ICD-10 Coding for History of Cholecystectomy(Z90.5, Z98.51)
Complete ICD-10-CM coding and documentation guide for History of Cholecystectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of 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 |
|---|---|---|---|
| Z90.5 | Acquired absence of gallbladder | Use when documenting the history of gallbladder removal without current complications. |
|
| Z98.51 | Presence of cholecystostomy drain | Use when a cholecystostomy drain is actively present. |
|
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 history of cholecystectomy
Essential facts and insights about History of Cholecystectomy
Primary ICD-10-CM Codes for history of cholecystectomy
Decision Criteria
clinical Criteria
- Absence of gallbladder confirmed by imaging
documentation Criteria
- Operative note detailing cholecystectomy
Applicable To
- History of cholecystectomy
Excludes
- Presence of cholecystostomy drain (Z98.51)
Clinical Validation Requirements
- Operative note confirming cholecystectomy
- Imaging studies showing absence of gallbladder
Code-Specific Risks
- Incorrectly using when a drain is present
Coding Notes
- Ensure documentation specifies 'status post cholecystectomy' with date.
Z98.51 - Presence of cholecystostomy drain
Use when a cholecystostomy drain is actively present.
Applicable To
- Cholecystostomy tube present
Excludes
- Absence of gallbladder (Z90.5)
Clinical Validation Requirements
- Documentation of active cholecystostomy drain
Coding Notes
Ensure documentation specifies the presence of the drain.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Cholecystectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.5.
Impact
Clinical: Inaccurate patient history, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Use specific phrases like 'status post cholecystectomy', Include dates and methods
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify current presence of the drain before coding.
Impact
Improper sequencing of codes can lead to audit flags.
Mitigation Strategy
Ensure primary codes are sequenced correctly before 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 History of Cholecystectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Cholecystectomy
Use these documentation templates to ensure complete and accurate documentation for History of Cholecystectomy. These templates include all required elements for proper coding and billing.
Post-Cholecystectomy Follow-Up
Specialty: General SurgeryRequired Elements
- Date of cholecystectomy
- Surgical method
- Current status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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