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 & 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.
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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

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 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

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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

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 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.