Find information on status post cholecystectomy diagnosis, including clinical documentation tips, ICD-10 and CPT codes, postoperative care, common complications, and long-term management. Learn about biliary colic, gallbladder removal surgery, and cholecystitis for accurate medical coding and healthcare documentation. This resource offers guidance for physicians, coders, and other healthcare professionals dealing with post-cholecystectomy patients.
Also known as
Other postprocedural disorders of digestive
Covers complications following digestive system procedures, including cholecystectomy.
Acquired absence of other organs
Indicates the absence of an organ, such as the gallbladder after cholecystectomy.
Disorders of gallbladder, biliary tract
While not post-op specific, can be used with Z90.49 to detail prior gallbladder conditions.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there a current complication?
Yes
What is the complication?
No
Is status post cholecystectomy stated as the reason for encounter?
When to use each related code
| Description |
|---|
| Normal post-cholecystectomy state |
| Postcholecystectomy syndrome |
| Bile duct injury post-cholecystectomy |
This patient presents status post cholecystectomy. The patient underwent laparoscopic cholecystectomy for symptomatic cholelithiasis and biliary colic. Preoperative diagnosis included gallbladder stones, gallbladder disease, and chronic cholecystitis. The operative report indicates successful removal of the gallbladder without complications. Postoperative course has been unremarkable. The patient denies fever, chills, nausea, vomiting, or right upper quadrant pain. Surgical site is healing well, with no signs of infection, erythema, or drainage. Bowel sounds are present and active. Diet has been advanced as tolerated. Current medications include postoperative pain management with acetaminophen and ibuprofen as needed. The patient demonstrates understanding of discharge instructions, including wound care, activity restrictions, and dietary recommendations. Follow-up appointment is scheduled in two weeks for routine postoperative evaluation and surgical site assessment. Differential diagnosis at this time includes postoperative pain, surgical site infection, and bile leak, though none are suspected at this time. The patient’s prognosis is excellent. ICD-10 code Z90.49, Personal history of other specified aftercare following surgery, is appropriate for this encounter.