Gastroenterology Coding Alert

Hint: Use different code sets when calculi are present in gall bladder and the biliary duct.

When reporting a diagnosis of cholelithiasis using ICD-10 codes, you’ll base your code selection on presence or absence of cholecystitis, chronicity and on the presence and absence of obstruction. If this seems familiar, that’s because this is how you currently select your ICD-9 codes.

ICD-9: When your clinician diagnoses cholelithiasis, you begin your code choice with 574 (Cholelithiasis). Depending on if your clinician identifies cholecystitis, 574 will expand into the following three choices:

• 574.0 -- Calculus of gallbladder with acute cholecystitis
• 574.1 -- Calculus of gallbladder with other cholecystitis
• 574.2 -- Calculus of gallbladder without mention of cholecystitis

All these three above mentioned codes expand using a 5^th digit expansion into another two codes depending on the presence or absence of obstruction. For example, 574.0 expands into the following code choices depending on the presence or absence of obstruction:

• 574.00 -- Calculus of gallbladder with acute cholecystitis without obstruction
• 574.01 -- Calculus of gallbladder with acute cholecystitis with obstruction

Reminder: You have to use the above mentioned choices when your clinician identifies calculi in the gallbladder. If the calculi are found in the biliary duct, you would use the code ranges, 574.7x-574.9x again depending on the chronicity of cholecystitis and on the presence or absence of obstruction.“Gallstones may occur in the gallbladder and bile duct at the same time so these sets of codes are not mutually exclusive and in some patients you might correctly choose a code from both,” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT^® Advisory Panel.

ICD-10: When you begin to use ICD-10 codes, 574 that you use in ICD-9 to identify a diagnosis of cholelithiasis crosswalks to K80 (Cholelithiasis). As in ICD-9, depending on the presence or absence of cholecystitis, you have three code choices:

• K80.0 -- Calculus of gallbladder with acute cholecystitis
• K80.1 -- Calculus of gallbladder with other cholecystitis
• K80.2 -- Calculus of gallbladder without cholecystitis

Again, as in ICD-9, K80.0 and K80.2 expand further into two code choices depending on the presence or absence of obstruction. For example, K80.2 expands into the following code choices:

• K80.20 -- Calculus of gallbladder without cholecystitis without obstruction
• K80.21 -- Calculus of gallbladder without cholecystitis with obstruction

Caveat: Unlike in ICD-9, K80.1 expands into six code choices depending on chronicity of the cholecystitis and on the presence or absence of obstruction. This allows you to accurately choose a code that helps identify the condition more appropriately. So, the six codes that K80.1 expands into include:

• K80.10 -- Calculus of gallbladder with chronic cholecystitis without obstruction
• K80.11 -- Calculus of gallbladder with chronic cholecystitis with obstruction
• K80.12 -- Calculus of gallbladder with acute and chronic cholecystitis without obstruction
• K80.13 -- Calculus of gallbladder with acute and chronic cholecystitis with obstruction
• K80.18 -- Calculus of gallbladder with other cholecystitis without obstruction
• K80.19 -- Calculus of gallbladder with other cholecystitis with obstruction

Note: As in ICD-9, if your gastroenterologist identifies cholelithiasis and choledocholithiasis, you have other code choices to report the condition. In such a case, again depending on the presence or absence of obstruction and on chronicity of identified cholecystitis, you have to report either of K80.6_ (Calculus of gallbladder and bile duct with cholecystitis) or K80.7_ (Calculus of gallbladder and bile duct without cholecystitis).

Focus on These Basics Briefly

Documentation spotlight: 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, nausea, vomiting and fever. Your gastroenterologist might record tachycardia, pain and tenderness in the right upper quadrant, and palpable gallbladder in the right upper quadrant upon physical examination.

Tests: Based on symptoms and observations made during the physical examination, your gastroenterologist may order an ultrasound examination to check for the presence of gallstones and to check for cholecystitis. He might also order other studies including a hepatobiliary scintigraphy along with blood tests to check for presence of bile duct obstruction and to rule out other conditions.

Depending on the results of preliminary tests 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 43265 (Endoscopic retrograde cholangiopancreatography [ERCP];with destruction of calculi, any method [e.g., mechanical, electrohydraulic, lithotripsy]) if he performed destruction of the calculus/calculi.

Example: Your gastroenterologist reviews a 60-year-old female patient with complaints of dull and intense pain in the right upper abdominal area that seems to be radiating to the shoulder on the same side. The patient complains that the pain seemed to begin postprandially and seems to take about an hour or so to resolve spontaneously with no medication. She also informs your clinician that the pain is not being relieved by using the toilet. She also says that she has been feeling feverish and has some had some episodes of nausea and vomiting. The patient has a previous documented history of gallstones.

Upon examination, your gastroenterologist notes fever and tachycardia. He also notes pain in the right upper quadrant (RUQ) with positive Murphy’s sign.

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 bilirubin levels. He also orders for non-contrast radiography along with ultrasound examination that shows results suggestive of cholecystitis with calculi in the gallbladder and possibly in the bile duct.

He also performs an ERCP to visualize the bile ducts and remove any gallstones. He notes that there is no calculi obstructing the bile duct but identifies a large floating calculus which he destroys with a mechanical lithotripter after a sphincterotomyallowing the debris to escape.

What to report: You report the sphincterotomy and destruction procedure of the calculi with 43262 (Endoscopic retrograde cholangiopancreatography[ERCP]; with sphincterotomy/papillotomy) and 43265. You report the diagnosis with K80.62 (Calculus of gallbladder and bile duct with acute cholecystitis without obstruction) if you are using ICD-10 codes and 574.00 (Calculus of gallbladder with acute cholecystitis without mention of obstruction)along with574.30 (Calculus of bile duct with acute cholecystitis without mention of obstruction) if you’re using the ICD-9 coding system.