ICD-10 Coding for Status Post Cholecystectomy(Z90.5, Z48.01, K91.5)
Complete ICD-10-CM coding and documentation guide for Status Post Cholecystectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Status Post Cholecystectomy
Z90.5Primary Range
Acquired absence of gallbladder
Used to indicate the anatomical status of the patient post-cholecystectomy.
Encounter for surgical aftercare following surgery on the digestive system
Used for postoperative care visits following cholecystectomy.
Postcholecystectomy syndrome
Used when the patient presents with symptoms related to postcholecystectomy syndrome.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z90.5 | Acquired absence of gallbladder | Use when documenting the anatomical status of a patient who has had a cholecystectomy. |
|
| Z48.01 | Encounter for surgical aftercare following surgery on the digestive system | Use for visits specifically for postoperative care following cholecystectomy. |
|
| K91.5 | Postcholecystectomy syndrome | Use when the patient presents with symptoms directly related to postcholecystectomy syndrome. |
|
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 status post cholecystectomy
Essential facts and insights about Status Post Cholecystectomy
Primary ICD-10-CM Codes for status post cholecystectomy
Decision Criteria
documentation Criteria
- Documented surgical history of cholecystectomy
Applicable To
- Status post cholecystectomy
Excludes
- Postcholecystectomy syndrome (K91.5)
Clinical Validation Requirements
- Surgical history confirming cholecystectomy
- Absence of gallbladder noted in imaging or surgical report
Code-Specific Risks
- Incorrectly using as primary code for postoperative care
Coding Notes
- Z90.5 is typically used as a secondary code to indicate the absence of the gallbladder.
Z48.01 - Encounter for surgical aftercare following surgery on the digestive system
Use for visits specifically for postoperative care following cholecystectomy.
Applicable To
- Postoperative care following cholecystectomy
Excludes
- Complications of surgical procedures (K91.5)
Clinical Validation Requirements
- Documentation of postoperative care activities such as wound care or drain management
Coding Notes
Z48.01 should be the primary code for postoperative care visits.
K91.5 - Postcholecystectomy syndrome
Use when the patient presents with symptoms directly related to postcholecystectomy syndrome.
Applicable To
- Symptoms related to gallbladder removal
Excludes
- General abdominal pain not linked to surgery
Clinical Validation Requirements
- Symptoms such as RUQ pain, fatty stool, or bile duct issues post-surgery
Coding Notes
K91.5 should be used as the primary code when symptoms are directly linked to the cholecystectomy.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Status Post Cholecystectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.5.
Impact
Clinical: May lead to inadequate patient care follow-up., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Use specific language to describe postoperative care activities, Ensure all relevant details are included in the patient's record
Impact
Reimbursement: Incorrect coding can lead to denied claims for postoperative care., Compliance: Non-compliance with coding guidelines for postoperative care., Data Quality: Inaccurate representation of patient care in medical records.
Mitigation Strategy
Use Z48.01 for postoperative care visits and Z90.5 as a secondary code.
Impact
Inadequate documentation of postoperative care can lead to audit issues.
Mitigation Strategy
Ensure thorough documentation of all care activities and patient symptoms.
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 Status Post Cholecystectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Status Post Cholecystectomy
Use these documentation templates to ensure complete and accurate documentation for Status Post Cholecystectomy. These templates include all required elements for proper coding and billing.
Postoperative Follow-Up Visit
Specialty: General SurgeryRequired Elements
- Patient's current symptoms
- Details of postoperative care provided
- Any complications or new symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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