ICD-10 Coding for Cholecystectomy(K81.0, Z90.5)
Complete ICD-10-CM coding and documentation guide for Cholecystectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cholecystectomy
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K81.0 | Acute cholecystitis | Use when acute inflammation of the gallbladder is documented. |
|
| Z90.5 | Acquired absence of gallbladder | Use for follow-up visits after gallbladder removal. |
|
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 cholecystectomy
Essential facts and insights about Cholecystectomy
Primary ICD-10-CM Codes for cholecystectomy
Decision Criteria
clinical Criteria
- Presence of acute symptoms and imaging findings
Applicable To
- Acute inflammation of gallbladder
Excludes
- Chronic cholecystitis (K81.1)
Clinical Validation Requirements
- WBC >12,000
- CRP >10 mg/dL
- Ultrasound showing gallbladder wall thickening >4mm
Code-Specific Risks
- Misclassification as chronic cholecystitis
Coding Notes
- Ensure documentation specifies acute nature.
Z90.5 - Acquired absence of gallbladder
Use for follow-up visits after gallbladder removal.
Applicable To
- Status post cholecystectomy
Excludes
- Presence of gallbladder (K80-K81)
Clinical Validation Requirements
- Operative report confirming gallbladder removal
Coding Notes
Document as 'status post cholecystectomy'.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Acquired absence of gallbladder
Z90.5Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Chronic cholecystitis
K81.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cholecystectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K81.0.
Impact
Clinical: Ambiguity in treatment provided, Regulatory: Non-compliance with documentation standards, Financial: Potential denial of claims
Mitigation Strategy
Use structured templates, Review operative notes for completeness
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Reserve Z90.5 for postoperative encounters only.
Impact
High risk of coding errors between laparoscopic and open procedures
Mitigation Strategy
Regular training and audits of operative reports
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 Cholecystectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cholecystectomy
Use these documentation templates to ensure complete and accurate documentation for Cholecystectomy. These templates include all required elements for proper coding and billing.
Acute cholecystitis requiring cholecystectomy
Specialty: General SurgeryRequired Elements
- Indication for surgery
- Surgical approach
- Intraoperative findings
- Postoperative care
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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