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2025 ICD-10-CM code K82.A2

Perforation of gallbladder in cholecystitis.

Code first the underlying cholecystitis (K81.-) or cholelithiasis with cholecystitis (K80.-).

Medical necessity for treatment of a perforated gallbladder in cholecystitis is established by the presence of acute symptoms, such as severe abdominal pain, fever, and signs of infection. The perforation itself represents a serious complication requiring immediate medical intervention.

The physician is responsible for diagnosing the perforation and cholecystitis, typically through imaging studies and physical examination, and determining the appropriate course of treatment, which may include surgery or other interventions.

In simple words: A hole has developed in the gallbladder due to inflammation.

Perforation of the gallbladder occurring during the course of cholecystitis.

Example 1: A patient with a history of gallstones presents with severe abdominal pain, fever, and a positive Murphy's sign. Imaging reveals a perforation in the gallbladder wall, confirming a diagnosis of cholecystitis with perforation., A patient undergoing a laparoscopic cholecystectomy for acute cholecystitis is found to have a small perforation in the gallbladder during the procedure., An elderly patient with chronic cholecystitis develops a sudden worsening of symptoms, including increased pain and sepsis. Imaging reveals a perforation of the gallbladder, requiring emergency surgery.

Documentation should include evidence of cholecystitis, such as imaging findings (ultrasound, CT scan), laboratory results, and physical examination findings. The perforation should also be clearly documented in imaging reports.

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