Learn about Cholelithiasis Unspecified (ICD-10-CM diagnosis code C), also known as gallstones or biliary calculi. This resource provides information on clinical documentation, medical coding, healthcare best practices, and diagnostic criteria for Cholelithiasis Unspecified. Find details on symptoms, treatment options, and relevant medical terminology for accurate and efficient healthcare documentation and coding.
Also known as
Disorders of gallbladder, biliary tract
Covers gallstones, cholecystitis, and other biliary diseases.
Symptoms and signs involving abdomen and pelvis
Includes abdominal pain, nausea, and other related symptoms.
Diseases of liver
Liver conditions that may be associated with biliary issues.
Follow this step-by-step guide to choose the correct ICD-10 code.
Are the gallstones symptomatic?
Yes
With cholecystitis?
No
Code as K80.20 (Asymptomatic gallstones are usually found during investigations for other issues and are coded as biliary colic, though asymptomatic.)
When to use each related code
| Description |
|---|
| Gallstones present, type unspecified. |
| Gallstones in the gallbladder. |
| Gallstones obstructing the bile duct. |
Coding C74.90 lacks specificity. CDI should query for stone location (gallbladder, bile duct) to ensure accurate code assignment (e.g., C74.10, C74.20).
Documentation may indicate cholecystitis (inflammation) alongside stones. Failing to code the cholecystitis (e.g., K80.00) leads to undercoding and lost revenue.
Patients may have both cholelithiasis and biliary dyskinesia. Accurate coding of both (e.g., K83.80) is crucial for proper reimbursement and quality reporting.
Q: What are the most effective diagnostic imaging modalities for differentiating between symptomatic and asymptomatic cholelithiasis (gallstones) in a patient presenting with right upper quadrant pain?
A: Differentiating between symptomatic and asymptomatic cholelithiasis in a patient with right upper quadrant (RUQ) pain requires careful consideration of clinical presentation and imaging findings. While abdominal ultrasound is often the initial imaging modality due to its availability and cost-effectiveness, it may not always be definitive in correlating gallstones with the patient's symptoms. Cholescintigraphy (HIDA scan) offers functional assessment of gallbladder emptying and can help identify cystic duct obstruction, a key factor in symptomatic cholelithiasis causing biliary colic. In cases where ultrasound and HIDA scan are inconclusive, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) can provide detailed anatomical visualization of the biliary tree and surrounding structures, helping to identify subtle abnormalities or complications. Consider implementing a tiered imaging approach starting with ultrasound and escalating to more advanced modalities like MRCP or EUS based on initial findings and clinical suspicion. Explore how incorporating these imaging modalities can improve diagnostic accuracy and guide appropriate management strategies for patients with suspected cholelithiasis and RUQ pain.
Q: How do I manage a patient with incidentally discovered asymptomatic cholelithiasis (gallstones) during an abdominal ultrasound performed for unrelated reasons?
A: The management of incidentally discovered asymptomatic cholelithiasis often involves watchful waiting, as the majority of these cases remain asymptomatic throughout the patient's life. Current guidelines generally recommend against prophylactic cholecystectomy in asymptomatic individuals. However, certain factors may warrant closer monitoring or consideration of intervention. These include patients with diabetes, those with sickle cell anemia, individuals with porcelain gallbladder, or patients with large gallstones (>3cm). It's crucial to educate the patient about potential symptoms of biliary colic and the need to seek medical attention should they develop. Learn more about the risks and benefits of prophylactic cholecystectomy in specific patient populations and consider implementing a shared decision-making approach to tailor management to the individual patient's circumstances.
Patient presents with symptoms suggestive of cholelithiasis unspecified, also known as gallstones or biliary calculi. Presenting complaint includes intermittent right upper quadrant pain, possibly radiating to the right shoulder or back, described as sharp, cramping, or dull. Symptoms may be associated with fatty food ingestion, and the patient reports experiencing nausea, vomiting, and dyspepsia. Physical examination may reveal tenderness in the right upper quadrant, Murphy's sign, or a palpable gallbladder. Differential diagnoses include biliary colic, cholecystitis, choledocholithiasis, and other gastrointestinal disorders. Diagnostic workup may include abdominal ultrasound, computed tomography (CT) scan, magnetic resonance cholangiopancreatography (MRCP), and liver function tests (LFTs). Treatment options for symptomatic cholelithiasis may include watchful waiting, lifestyle modifications such as dietary changes, cholecystectomy (laparoscopic or open), and medical dissolution therapy. Patient education on gallbladder disease, gallstone prevention, and postoperative care will be provided. ICD-10 code K80.20 will be used for cholelithiasis unspecified. This diagnosis impacts medical billing and coding for reimbursement purposes. Follow-up care and monitoring will be scheduled as needed.