Patient presents with a history of cholecystectomy.  The patient reports prior removal of their gallbladder.  The date of the cholecystectomy was documented as [Date of Cholecystectomy] and performed via [Laparoscopic, Open, or other method].  The indication for the cholecystectomy was [Indication for cholecystectomy, e.g., symptomatic cholelithiasis, cholecystitis, biliary colic, gallbladder polyps, etc.].  The operative report from the original procedure indicates [Pertinent findings from operative report, e.g., number and size of stones, presence of inflammation, any complications].  The patient's current symptoms, if any, are [Current symptoms] and are [Related or unrelated to prior cholecystectomy].  Physical examination of the abdomen is [Description of abdominal exam, e.g., soft, non-tender, no masses, surgical scar present in the right upper quadrant].  Post-cholecystectomy syndrome is [Considered or ruled out] based on the patient's presentation.  Assessment: Status post cholecystectomy.  Plan: [Plan for ongoing care, e.g., monitoring, further workup if indicated, dietary recommendations]. This documentation supports ICD-10 code Z90.49 (Personal history of other surgical operations).  Consider CPT codes for evaluation and management services based on the complexity of the encounter (e.g., 99213, 99214).  Differential diagnoses considered included [Differential diagnoses, if applicable].