Gastroenterology Coding Alert

Hint: Don’t code separately if the condition occurs with cholelithiasis or choledocholithiasis.

When your gastroenterologist arrives at a diagnosis of cholecystitis, you will need know chronicity details to report this accurately when ICD-10 becomes effective Oct. 1, 2014.

Note Reporting Options in ICD-9

When your gastroenterologist makes a diagnosis of cholecystitis, you currently note whether the condition is acute, chronic, or acute on chronic to choose the right code. Based on chronicity, you have the following code choices to report a diagnosis of cholecystitis using ICD-9 coding system:

575.0 — Acute cholecystitis

575.1 — Other cholecystitis

575.1 in ICD-9 expands using a fifth digit into the following three codes:

575.10 — Cholecystitis unspecified

575.11 — Chronic cholecystitis

575.12 — Acute and chronic cholecystitis

Reminder: If your gastroenterologist makes a diagnosis of acute cholecystitis with cholelithiasis or choledocholithiasis, you will have to choose 574.0 (Calculus of gallbladder with acute cholecystitis) and 574.3 (Calculus of bile duct with acute cholecystitis) and not mention the diagnosis of cholecystitis separately. Similarly, you will have to report 574.1 (Calculus of gallbladder with other cholecystitis) and 574.4 (Calculus of bile duct with other cholecystitis) for a diagnosis of chronic cholecystitis with cholelithiasis or choledocholithiasis.

Watch for Minor Descriptor Changes in ICD-10

When ICD-10 codes come into effect, a diagnosis of cholecystitis is made using K81 (Cholecystitis). Again, as in ICD-9 codes, K81 will further expand into the following four codes depending on the chronicity of the condition:

K81.0 — Acute cholecystitis

K81.1 — Chronic cholecystitis

K81.2 — Acute cholecystitis with chronic cholecystitis

K81.9 — Cholecystitis, unspecified

As in ICD-9 codes, a diagnosis of cholecystitis with cholelithiasis or choledocholithiasis should not be reported using K81.-. Instead, you will have to use the appropriate K80.- codes that are used to report a diagnosis of cholelithiasis or choledocholithiasis depending on chronicity and obstruction.

Find These Details in Documentation

Some symptoms that you are most likely to encounter in the patient documentation in a patient suffering from cholecystitis include pain in right upper abdominal area (R10.11, Right upper quadrant pain), nausea, vomiting (R11.2, Nausea with vomiting, unspecified) and fever (F50.9, Fever, unspecified). Your gastroenterologist might record tachycardia, pain and tenderness in the right upper quadrant, and palpable gallbladder in the right upper quadrant upon physical examination.

Based on symptoms and observations made during the physical examination, your gastroenterologist will order for an x-ray along with performing ultrasound examination to check for the presence of gallstones and to check for cholecystitis. He might also order for studies such as a hepatobiliary scintigraphy along with blood tests and urine analysis to check for presence of bile duct obstruction and to rule out other conditions.

Your gastroenterologist might also perform an endoscopic retrograde cholangiopancreatography (ERCP), especially if there is the suspicion of gallstones or obstruction of the common bile duct. Based on what procedure your gastroenterologist performs, you will have to report the appropriate ERCP code [such as 43264 (Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts) if he removes calculi from the biliary duct].

Example: Your gastroenterologist assesses a 45-year-old male patient with complaints of severe and constant pain in the upper abdominal area for the past two days. The patient also complains of fever along with nausea and vomiting during the same period. He also complains of pain radiating to the right shoulder area.

Upon examination, your gastroenterologist notes fever and tachycardia. He also notes pain in the right upper quadrant (RUQ) with a palpable tender mass in the RUQ.

Since the history and symptoms of the patient along with observations made upon physical examination is suggestive of gallstones and inflammation of the gallbladder, your gastroenterologist orders lab tests for WBC counts, ALT, AST, alkaline phosphatase and biluribin levels. He also orders for non-contrast radiography along with ultrasound examination that shows results suggestive of cholecystitis without any signs of calculi in the gallbladder or the bile duct.

Concerned about a possible bile duct obstruction from an unseen gallstone, he also performs an ERCP to visualize the bile ducts. He notes that there is no calculi obstructing the bile duct. You report the procedure with 43260 (Endoscopic retrograde cholangiopancreatography (ERCP) diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). You report the diagnosis with K81.0 if you are using ICD-10 codes and 575.0 if you’re using ICD-9 coding system.