ICD-10 Coding for Cholelithiasis Unspecified(K80.9)
Complete ICD-10-CM coding and documentation guide for Cholelithiasis Unspecified. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cholelithiasis Unspecified
K80-K87Primary Range
Diseases of gallbladder, biliary tract, and pancreas
This range includes all conditions related to gallstones and their complications.
Key Information: ICD-10 code for cholelithiasis unspecified
Essential facts and insights about Cholelithiasis Unspecified
Primary ICD-10-CM Code for cholelithiasis unspecified
Decision Criteria
clinical Criteria
- Gallstones confirmed by imaging without complications
documentation Criteria
- Absence of specific location or complication in documentation
Applicable To
- Gallstones without further specification
Clinical Validation Requirements
- Ultrasound confirming gallstones without signs of inflammation or obstruction
- Normal liver function tests
Code-Specific Risks
- Risk of undercoding if complications are present but not documented
Coding Notes
- Ensure documentation specifies absence of complications for accurate coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Abdominal pain, unspecified
R10.9Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cholelithiasis Unspecified to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K80.9.
Impact
Clinical: Misrepresentation of patient condition, Regulatory: Potential audit issues, Financial: Incorrect billing and reimbursement
Mitigation Strategy
Ensure imaging reports are reviewed and documented, Train staff on documentation requirements
Impact
Reimbursement: Potential underpayment due to incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Document and code specific complications such as cholecystitis or choledocholithiasis.
Impact
Using K80.9 when more specific codes apply
Mitigation Strategy
Review documentation for specific details on stone location and complications.
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 Cholelithiasis Unspecified, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cholelithiasis Unspecified
Use these documentation templates to ensure complete and accurate documentation for Cholelithiasis Unspecified. These templates include all required elements for proper coding and billing.
Primary Care Visit
Specialty: Family MedicineRequired Elements
- Patient history
- Symptom description
- Imaging results
- Clinical assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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