ICD-10 Coding for Gallbladder Disease(K80.0, K80.10, K80.2)
Complete ICD-10-CM coding and documentation guide for Gallbladder Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gallbladder Disease
K80-K81Primary Range
Diseases of gallbladder, including cholelithiasis and cholecystitis
This range covers all primary conditions related to gallbladder disease, including gallstones and inflammation.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K80.0 | Acute cholecystitis with gallstones | Use when acute inflammation and gallstones are documented. |
|
| K80.10 | Chronic cholecystitis with gallstones | Use when chronic symptoms and gallstones are documented. |
|
| K80.2 | Gallstones without cholecystitis | Use when gallstones are present without signs of inflammation. |
|
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 gallbladder disease
Essential facts and insights about Gallbladder Disease
Primary ICD-10-CM Codes for gallbladder disease
Decision Criteria
clinical Criteria
- Presence of acute symptoms and imaging confirmation
Applicable To
- Acute calculous cholecystitis
Excludes
- Chronic cholecystitis (K81.1)
Clinical Validation Requirements
- RUQ pain with fever
- Positive Murphy's sign
- Ultrasound showing gallstones and wall thickening
Code-Specific Risks
- Misclassification if chronic cholecystitis is present
Coding Notes
- Ensure documentation specifies 'acute' and presence of gallstones.
K80.10 - Chronic cholecystitis with gallstones
Use when chronic symptoms and gallstones are documented.
Applicable To
- Chronic calculous cholecystitis
Excludes
- Acute cholecystitis (K80.0)
Clinical Validation Requirements
- Recurrent biliary pain
- Imaging showing gallstones without acute inflammation
Coding Notes
Documentation must clearly indicate chronicity.
K80.2 - Gallstones without cholecystitis
Use when gallstones are present without signs of inflammation.
Applicable To
- Cholelithiasis without inflammation
Excludes
- Cholecystitis (K80.0, K80.10)
Clinical Validation Requirements
- Asymptomatic stones found on imaging
Coding Notes
Ensure documentation specifies absence of inflammation.
Differential 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 Gallbladder Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K80.0.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Increased audit risk., Financial: Potential for denied claims.
Mitigation Strategy
Use specific terms like 'acute' or 'chronic'.
Impact
Reimbursement: Potential for reduced reimbursement due to lack of specificity., Compliance: Increased audit risk for unspecified coding., Data Quality: Decreased data quality and accuracy.
Mitigation Strategy
Ensure documentation specifies presence or absence of cholecystitis and obstruction.
Impact
High audit risk when using unspecified codes for gallbladder disease.
Mitigation Strategy
Ensure detailed documentation supports specific code selection.
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 Gallbladder Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gallbladder Disease
Use these documentation templates to ensure complete and accurate documentation for Gallbladder Disease. These templates include all required elements for proper coding and billing.
Laparoscopic Cholecystectomy
Specialty: SurgeryRequired Elements
- Procedure details
- Findings
- Pathology results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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