ICD-10 Coding for History of Gallstones(Z87.79, K80.20)
Complete ICD-10-CM coding and documentation guide for History of Gallstones. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Gallstones
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z87.79 | Personal history of other diseases of the digestive system | Use when documenting a resolved history of gallstones, typically after cholecystectomy. |
|
| K80.20 | Calculus of gallbladder without cholecystitis, without obstruction | Use for active gallstone disease without complications. |
|
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: How do you code a history of gallstones?
Essential facts and insights about History of Gallstones
Primary ICD-10-CM Codes for history of gallstones
Decision Criteria
clinical Criteria
- Patient has undergone cholecystectomy and is asymptomatic.
documentation Criteria
- Medical record includes past diagnosis and treatment details.
Applicable To
- History of gallstones
Excludes
- Current gallstone disease (K80-K80.9)
Clinical Validation Requirements
- Documentation of previous gallstone diagnosis and treatment
- Absence of current symptoms or active disease
Code-Specific Risks
- Incorrectly coding active gallstone disease as history
Coding Notes
- Ensure documentation clearly states the gallstones are resolved.
K80.20 - Calculus of gallbladder without cholecystitis, without obstruction
Use for active gallstone disease without complications.
Applicable To
- Gallstones without inflammation or blockage
Excludes
- Resolved gallstone history (Z87.79)
Clinical Validation Requirements
- Current imaging showing gallstones
- Symptoms of biliary colic
Coding Notes
Ensure current symptoms and imaging support active disease coding.
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 History of Gallstones to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z87.79.
Impact
Clinical: Inaccurate patient history, Regulatory: Non-compliance with documentation standards, Financial: Potential claim denials
Mitigation Strategy
Verify surgical records, Update patient history regularly
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify current symptoms and imaging before coding as history.
Impact
Coding active gallstones as history can lead to audit issues.
Mitigation Strategy
Ensure thorough documentation and verification of current status.
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 Gallstones, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Gallstones
Use these documentation templates to ensure complete and accurate documentation for History of Gallstones. These templates include all required elements for proper coding and billing.
Post-Cholecystectomy Follow-Up
Specialty: GastroenterologyRequired Elements
- Surgical history
- Current symptom status
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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