Cracking the Code
Coding Cholelithiasis
Cholelithiasis is the presence of one or more gallstones (calculi) in the gallbladder. The codes describe a calculus of the gallbladder with different types of cholecystitis, e.g., acute, chronic, or both, or without cholecystitis and with or without obstruction. The obstruction is usually a calculus that has lodged in the neck of the gallbladder or the cystic duct. Code selection identifies the presence or absence of an obstruction.
About 80% of people with gallstones are asymptomatic. The remainder has symptoms ranging from a characteristic type of pain (biliary colic) to cholecystitis to life-threatening cholangitis. Biliary colic is the most common symptom.
We may see combination coding when supported by documentation while coding Cholelithiasis content. We can find guidelines for combination coding in the I.B.9 in the FY2023 ICD-10-CM Guidelines.
Q: 32-year-old female patient presents with abdominal pain. The physician performs an abdominal ultrasound and discovers the patient has gallstones and inflammation of the gallbladder. What is the appropriate ICD-10-CM code(s)?
A: K80.10. Rationale: The patient is diagnosed with gallstones (cholelithiasis) and gallbladder inflammation (cholecystitis). If you are using your ICD-10-CM coding book, in our Alphabetic Index, we search for Cholecystitis/with calculus, stones in/gallbladder; and we are referred to: “see Calculus gallbladder, with cholecystitis.” We then look up Calculus/gallbladder/with cholecystitis. Now, we are directed to K80.10. As always, we want to verify this code selection in our Tabular List. Code K80.10 is a combination code for both cholelithiasis and cholecystitis and as a result, only one code is reported.
Reference: FY 2023 ICD-10-CM Guidelines, Merck Manual