ICD-10 Coding for Bile Duct Dilation Secondary to Cholecystectomy(K91.5, K83.1)
Complete ICD-10-CM coding and documentation guide for Bile Duct Dilation Secondary to Cholecystectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bile Duct Dilation Secondary to Cholecystectomy
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K91.5 | Postcholecystectomy syndrome | Use when symptoms are present without evidence of obstruction or stones. |
|
| K83.1 | Obstruction of bile duct | Use when obstruction is confirmed by imaging. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bile duct dilation after cholecystectomy
Essential facts and insights about Bile Duct Dilation Secondary to Cholecystectomy
Primary ICD-10-CM Codes for dilation bile duct secondary to cholecystectomy
Decision Criteria
clinical Criteria
- Presence of symptoms without obstruction
Applicable To
- Asymptomatic bile duct dilation post-cholecystectomy
Excludes
- Obstruction due to stones (K80.5)
Clinical Validation Requirements
- Persistent right upper quadrant pain
- Nausea
- Abnormal liver function tests without obstruction
Code-Specific Risks
- Using without symptoms
- Missing secondary codes for obstruction
Coding Notes
- Ensure symptoms are documented if using K91.5.
K83.1 - Obstruction of bile duct
Use when obstruction is confirmed by imaging.
Applicable To
- Bile duct obstruction post-cholecystectomy
Excludes
- Obstruction due to stones (K80.5)
Clinical Validation Requirements
- CBD dilation >10 mm on imaging
- Elevated bilirubin or ALP
Coding Notes
Document imaging findings clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dilation of CBD with intraluminal device
0F798DZDocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bile Duct Dilation Secondary to Cholecystectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K91.5.
Impact
Clinical: Misrepresentation of patient condition., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific measurements, Link symptoms to findings
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure symptoms are documented or use K83.1 if obstruction is present.
Impact
Lack of documented symptoms when coding K91.5.
Mitigation Strategy
Ensure symptoms are clearly documented in patient records.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bile Duct Dilation Secondary to Cholecystectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bile Duct Dilation Secondary to Cholecystectomy
Use these documentation templates to ensure complete and accurate documentation for Bile Duct Dilation Secondary to Cholecystectomy. These templates include all required elements for proper coding and billing.
Post-cholecystectomy bile duct dilation
Specialty: GastroenterologyRequired Elements
- Patient symptoms
- Imaging findings
- Procedure details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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