Find information on symptomatic cholelithiasis diagnosis, including clinical documentation, medical coding, ICD-10 codes (K80), biliary colic, gallstones, cholecystitis, and ultrasound findings. Learn about healthcare best practices for documenting and coding symptomatic gallbladder disease for accurate reimbursement and patient care. This resource provides guidance for physicians, clinicians, and medical coders on properly documenting and coding symptomatic cholelithiasis.
Also known as
Diseases of the biliary tract
Covers gallbladder, bile duct, and other biliary conditions.
Symptoms and signs involving the 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.
With cholecystitis?
When to use each related code
| Description |
|---|
| Gallstones with symptoms |
| Asymptomatic gallstones |
| Biliary colic |
Coding K80.0 (Cholelithiasis without cholecystitis) when documentation supports symptomatic cholelithiasis (K80.2) leads to undercoding and lost revenue.
Failing to capture complicating diagnoses like acute cholecystitis (K81.0) or biliary colic (K80.8) with symptomatic cholelithiasis impacts reimbursement and severity.
Insufficient documentation of symptoms related to gallstones can lead to denials for K80.2. CDI can query for symptom clarification.
Patient presents with symptomatic cholelithiasis, confirmed by abdominal ultrasound demonstrating the presence of gallstones within the gallbladder. The patient reports classic biliary colic, characterized by episodic, intense right upper quadrant or epigastric pain, often radiating to the right shoulder or back. Pain episodes are typically triggered by fatty meals and may be accompanied by nausea, vomiting, and dyspepsia. Physical examination reveals tenderness in the right upper quadrant upon palpation. Differential diagnoses considered include acute cholecystitis, biliary dyskinesia, peptic ulcer disease, and pancreatitis. Laboratory findings, including liver function tests and complete blood count, are within normal limits, ruling out acute cholecystitis and other complications. The patient's current symptoms warrant a cholecystectomy, which has been discussed with the patient, including risks and benefits. Surgical consultation has been obtained and the procedure is scheduled. Patient education provided on postoperative care and dietary modifications. ICD-10 code K80.20 (Calculus of gallbladder without cholecystitis) is assigned. The patient's prognosis is excellent with surgical intervention.