ICD-10 Coding for Absence of Gallbladder(Z90.5, Q44.0)
Complete ICD-10-CM coding and documentation guide for Absence of Gallbladder. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Absence of Gallbladder
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z90.5 | Acquired absence of gallbladder | Use when the gallbladder is absent due to surgical removal. |
|
| Q44.0 | Congenital agenesis, aplasia, and hypoplasia of gallbladder | Use when congenital absence is confirmed by imaging. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for absence of gallbladder
Essential facts and insights about Absence of Gallbladder
Primary ICD-10-CM Codes for absence of gallbladder
Decision Criteria
clinical Criteria
- History of gallbladder surgery
Applicable To
- Post-cholecystectomy status
Excludes
- Congenital absence of gallbladder (Q44.0)
Clinical Validation Requirements
- Documented history of cholecystectomy
- Imaging showing surgical clips
Code-Specific Risks
- Misuse when congenital absence is present
Coding Notes
- Ensure surgical history is documented.
Q44.0 - Congenital agenesis, aplasia, and hypoplasia of gallbladder
Use when congenital absence is confirmed by imaging.
Applicable To
- Congenital absence of gallbladder
Excludes
- Acquired absence of gallbladder (Z90.5)
Clinical Validation Requirements
- Imaging confirmation (e.g., MRCP)
- No surgical history
Coding Notes
Confirm with imaging and absence of surgical history.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Right upper quadrant pain
R10.11Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Absence of Gallbladder to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.5.
Impact
Clinical: Misdiagnosis risk, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Ensure detailed imaging reports, Verify surgical history
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Verify surgical history and use Q44.0 if congenital.
Impact
Using Z90.5 for congenital cases or vice versa.
Mitigation Strategy
Implement thorough documentation review processes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Absence of Gallbladder, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Absence of Gallbladder
Use these documentation templates to ensure complete and accurate documentation for Absence of Gallbladder. These templates include all required elements for proper coding and billing.
Congenital Agenesis Confirmation
Specialty: RadiologyRequired Elements
- Imaging modality used
- Confirmation of absence
- Exclusion of ectopic gallbladder
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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