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How to Document Cholecystitis Using ICD-10 and CPT Codes

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Cholecystitis is an inflammation of the gallbladder – a small, pear-shaped organ on the right side of your abdomen. The article provides an overview about the ICD-10 diagnosis codes and CPT procedure codes for correctly documenting this disorder.

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How to Document Cholecystitis Using ICD-10 and CPT Codes

  1. 1. www.outsourcestrategies.com 918-221-7769 How to Document CHOLECYSTITIS Using ICD-10 & CPT Codes Cholecystitis is an inflammation of the gallbladder – a small, pear-shaped organ on the right side of your abdomen. The article provides an overview about the ICD- 10 diagnosis codes and CPT procedure codes for correctly documenting this disorder. www.outsourcestrategies.com 918-221-7769 8596 E. 101st Street, Suite H, Tulsa, OK 74133
  2. 2. www.outsourcestrategies.com 918-221-7769 Cholecystitis is an inflammation of the gall bladder that normally occurs due to an obstruction of the cystic or bile duct by gall stones arising from the gallbladder (cholelithiasis). If left untreated, this condition can lead to life- threatening complications such as perforation of the gallbladder, gallbladder rupture, nausea, fibrosis and shrinking of the gallbladder, tissue death and gangrene and secondary bacterial infections. Gastroenterologists can rely on medical coding outsourcing companies to report cholecystitis diagnosis and treatment accurately. According to the National Institutes of Health,80 percent of cholecystitis cases are related to gallstones that are usually formed from cholesterol and a pigment known as bilirubin (a chemical found in bile) or a mix of the two which gets formed in the gall bladder. The cystic duct is the main opening of the gallbladder. Treatment for cholecystitis often involves gallbladder removal surgery (also called cholecystectomy). Causes and Symptoms Chronic inflammation in the gallbladder can be caused by gall stones, bile duct blockage, tumor, infection and blood vessel problems. In most cases, cholecystitis signs and symptoms can occur after a heavy or fatty meal. One of the main symptoms associated with this condition is a sudden sharp pain in the upper right-hand side of your abdomen, which spreads towards your right shoulder or back. Some of the additional symptoms include -  Tenderness on the upper-right hand side of the abdomen  Nausea and vomiting  High fever  Sweating  Loss of appetite
  3. 3. www.outsourcestrategies.com 918-221-7769  Yellowing of the skin and the whites of the eyes (jaundice)  A bulge in the abdomen  Abdominal cramping and bloating Symptoms of this condition may vary widely from one person to another. A typical cholecystitis attack can last for 2-3 days and the pain will last for about 30 minutes. Medical Codes for Cholecystitis As the symptoms of cholecystitis are similar to that of other conditions, physicians will conduct an evaluation of previous medical history of the patient and conduct a detailed physical exam to rule out other conditions. For patients who experience severe abdominal pain, physicians may carry out a simple physical test called Murphy’s sign. As part of the procedure, patients will be asked to breathe in deeply with your physician’s hand pressed on your stomach, just above your rib cage. Patients, who suffer from cholecystitis, will experience sudden pain when the gallbladder gets pressed by the physician. If any of the symptoms suggest that patients suffer from acute cholecystitis, physicians will recommend several additional tests such as abdominal ultrasound, endoscopic ultrasound, Magnetic resonance cholangiopancreatography (MRCP), computerized tomography (CT) scans and blood tests to check for gallstones or other signs of a problem with your gallbladder. In addition, Hepatobiliary nuclear imaging (that uses a radioactive tracer) to diagnose conditions that affect the gall bladder, liver and ducts will be performed. Treatment for cholecystitis involves pain medications, antibiotics (to fight infections), fluid injections and oral dissolution therapy using medications to help dissolve gallstones. Surgery will be recommended for acute cholecystitis due to a high rate of recurrence
  4. 4. www.outsourcestrategies.com 918-221-7769 from inflammation related to gallstones. Gallbladder removal surgery (also called cholecystectomy) can be performed by open abdominal excision or laparoscopically. general surgery medical coding involves using the specific diagnosis and procedure codes for reporting cholecystitis on your medical claims. ICD-10-CM codes K81 - Cholecystitis  K81.0 - Acute cholecystitis  K81.1 - Chronic cholecystitis  K81.2 - Acute cholecystitis with chronic cholecystitis  K81.9 - Cholecystitis, unspecified K82 - Other diseases of gallbladder  K82.0 - Obstruction of gallbladder  K82.1 - Hydrops of gallbladder  K82.2 - Perforation of gallbladder  K82.3 - Fistula of gallbladder  K82.4 - Cholesterolosis of gallbladder  K82.8 - Other specified diseases of gallbladder CPT Codes  47562 - Laparoscopy, surgical; cholecystectomy  47563 - Laparoscopy, surgical; cholecystectomy with cholangiography  47564 - Laparoscopy, surgical; cholecystectomy with exploration of common duct ICD-10 Procedure Codes  0FT40ZZ - Resection of Gallbladder, Open Approach
  5. 5. www.outsourcestrategies.com 918-221-7769  0FT44ZZ - Resection of Gallbladder, Percutaneous Endoscopic Approach In order to meet the tasks of accurate and timely medical billing and claims submission, general surgery practices providing treatment for cholecystitis can outsource their medical tasks to an experienced medical billing company that offers the services of AAPC-certified coding specialists. Reports from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD) suggest that about 20 million Americans have gall stones. It is estimated that about 700,000 individuals undergo cholecystectomy annually in the United States. Even though it’s not always possible to prevent cholecystitis, you can reduce the risk of getting gallstones. Adopting a healthy lifestyle by incorporating a balanced diet, reducing the intake of high-cholesterol foods and losing body weight (if obese) can reduce the formation of gallstones.

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