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Do you know the appropriate diagnosis codes for gallstones and related procedures?

While many patients with gallstones do not have any signs or symptoms, a symptomatic patient typically needs surgery to remove their gallbladder. For gastroenterology coders, understanding the many codes associated with diagnosing and treating gallstones helps create a smooth process for coding gallbladder-related procedures.

Brush up on the ICD-10-CM codes for diagnosing gallstones and the CPT^庐 codes for gallbladder removal surgery with this review.

Know the Basics of Cholelithiasis, AKA Gallstones

Gallstones are made of hardened bile deposits inside the gallbladder. Cholesterol stones are the most common type of gallstones, but patients may also have pigmented stones composed of bilirubin, or mixed stones made from both bilirubin and cholesterol.

Gallstones are common; between 10 and 15 percent of American adults will develop gallstones at some point in their lifetime. Women, older adults, and people with a family history of gallstones have a higher risk of developing the calculi compared to the general population.

If a stone blocks the bile duct, the blockage may cause upper right abdominal pain that can radiate into the back, as well as jaundice, nausea, vomiting, and itching.

The main treatment for symptomatic cholelithiasis (gallstones) is cholecystectomy (gallbladder removal). About one in four people with gallstones will require surgery to manage their condition. Surgeons may choose a laparoscopic or open approach for cholecystectomy.

Learn How to Code a Cholelithiasis Diagnosis

Use K80.- (Cholelithiasis) from the ICD-10-CM code set for a gallstone diagnosis. The K80.- code set includes:

• K80.0- (Calculus of gallbladder with acute cholecystitis)
• K80.1- (Calculus of gallbladder with other cholecystitis)
• K80.2- (Calculus of gallbladder without cholecystitis)
• K80.3- (Calculus of bile duct with cholangitis)
• K80.4- (Calculus of bile duct with cholecystitis)
• K80.5- (Calculus of bile duct without cholangitis or cholecystitis)
• K80.6- (Calculus of gallbladder and bile duct with cholecystitis)
• K80.7- (Calculus of gallbladder and bile duct without cholecystitis)
• K80.8- (Other cholelithiasis)

You should choose the most applicable code from the K80.- code category depending on the information available in the patient鈥檚 record. Each code in the category includes more specific options that describe factors like whether the patient does or does not have an obstruction or whether the condition is acute or chronic.

For example, if a patient鈥檚 record states they have gallstones with chronic cholecystitis (gallbladder inflammation) and an obstruction, use K80.11 (Calculus of gallbladder with chronic cholecystitis with obstruction). Keep in mind that cholecystitis can occur without cholelithiasis. In those cases, refer to the K81.- (Cholecystitis) code category.

If a patient has retained gallstones after their gallbladder removal surgery, do not use the K80.- code set. Instead, assign K91.86 (Retained cholelithiasis following cholecystectomy).

Grasp the CPT^庐 Codes Relevant to Gallbladder Surgery

The 47400-47999 CPT^庐 code range covers surgical procedures on the biliary tract. Refer to the code range that best fits the procedure type.

• 47400-47480 covers incision procedures on the biliary tract
• 47490-47544 covers introduction procedures on the biliary tract
• +47550-47556 covers endoscopy procedures on the biliary tract
• 47562-47579 covers laparoscopic procedures on the biliary tract
• 47600-47715 covers excision procedures on the biliary tract
• 47720-47900 covers repair procedures on the biliary tract
• 47999 covers other procedures on the biliary tract

For example, for laparoscopic gallbladder removal, use 47562 (Laparoscopy, surgical; cholecystectomy). If the provider injected dye during the procedure to view the biliary ducts via X-ray, use 47563 (鈥� cholecystectomy with cholangiography). Use 47564 (鈥� cholecystectomy with exploration of common duct) if the provider explored the common bile duct to examine it for stones and ensure bile can pass freely.

Remember These Cholecystectomy Coding Tips

A physician may identify multiple diagnoses during gallbladder surgery. It is crucial that coders report all diagnoses listed in the surgical record and watch out for cases where providers perform other procedures alongside a cholecystectomy.

Look at one possibility for when coders would need to list multiple diagnoses or procedures during a cholecystectomy:

Scenario: A provider performs an open appendectomy on a patient with acute appendicitis with localized peritonitis. During this procedure, the surgeon discovers that the patient has gallbladder inflammation, necessitating gallbladder removal. The provider also explores the common bile duct to check for stones and ensure bile can pass freely. In doing so, the provider discovers a gallstone blocking the duct.

In this scenario, the coder needs to include the following when coding the procedure:

• 44950 (Appendectomy)
• K35.30 (Acute appendicitis with localized peritonitis, without perforation or gangrene)
• 47610 (Cholecystectomy with exploration of common duct)
• K80.43 (Calculus of bile duct with acute cholecystitis with obstruction)

When in doubt, refer to the 47400-47999 CPT^庐 code range and the K80.- and K81.- lists in the ICD-10-CM code set to see which diagnosis best fits the patient.

Michelle Falci, BA, M Falci Communications LLC