ICD-10 Coding for Gallbladder Removal(K80.20, Z90.5)
Complete ICD-10-CM coding and documentation guide for Gallbladder Removal. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gallbladder Removal
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K80.20 | Calculus of gallbladder with acute cholecystitis without obstruction | Use when acute cholecystitis is present without obstruction. |
|
| Z90.5 | Acquired absence of gallbladder | Use to indicate the absence of gallbladder post-surgery. |
|
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 removal
Essential facts and insights about Gallbladder Removal
Primary ICD-10-CM Codes for gallbladder removal
Decision Criteria
clinical Criteria
- Acute cholecystitis without obstruction
Applicable To
- Gallstones with acute cholecystitis
Excludes
- Chronic cholecystitis (K81.1)
Clinical Validation Requirements
- WBC >12,000
- RUQ pain
- Ultrasound showing gallstones
Code-Specific Risks
- Misclassification if obstruction is present
Coding Notes
- Ensure documentation specifies absence of obstruction.
Z90.5 - Acquired absence of gallbladder
Use to indicate the absence of gallbladder post-surgery.
Applicable To
- Status post cholecystectomy
Clinical Validation Requirements
- Operative report confirming gallbladder removal
Coding Notes
Ensure operative report is available.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cholecystostomy status
Z98.51Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Calculus of gallbladder with acute cholecystitis with obstruction
K80.61Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gallbladder Removal to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K80.20.
Impact
Clinical: Lack of evidence for procedure performed., Regulatory: Potential audit failure., Financial: Loss of reimbursement for additional procedure.
Mitigation Strategy
Verify documentation before coding, Educate surgical teams on documentation requirements
Impact
Reimbursement: Incorrect reimbursement due to duplicate coding., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate procedural data.
Mitigation Strategy
Code only the open cholecystectomy procedure.
Impact
Coding both laparoscopic and open procedures when conversion occurs.
Mitigation Strategy
Educate coders on correct coding practices for conversions.
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 Removal, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gallbladder Removal
Use these documentation templates to ensure complete and accurate documentation for Gallbladder Removal. These templates include all required elements for proper coding and billing.
Laparoscopic cholecystectomy
Specialty: General SurgeryRequired Elements
- Indications for surgery
- Procedure details
- Findings
- Complications
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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