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2025 ICD-10-CM code K80.4

Calculus of the bile duct with cholecystitis.

Always code the level of severity (acute, chronic) and presence of complications accurately.

Medical necessity for treatment is established based on the presence of symptomatic cholecystitis and/or choledocholithiasis (stones in the bile duct).Symptoms can range from mild discomfort to severe pain and life-threatening complications.Treatment aims to alleviate symptoms and prevent potential complications such as cholangitis, pancreatitis, or sepsis.

The clinical responsibility for this diagnosis lies with gastroenterologists, surgeons, and other physicians involved in the diagnosis and management of biliary tract disorders. This involves ordering appropriate imaging studies (e.g., ultrasound, CT scan, MRCP), performing endoscopic procedures (e.g., ERCP), and managing surgical intervention (e.g., cholecystectomy, choledocholithotomy) where necessary.

IMPORTANT:If cholangitis is present, code K80.3 should also be used.If complications such as gangrene or perforation of the gallbladder occur, additional codes (K82.A1, K82.A2) should be added.A bile duct fistula (K83.3) should also be coded if present.

In simple words: This code means there are stones in the bile duct, and the gallbladder is inflamed.The gallbladder is a small organ that stores bile, a fluid that helps digest fats.Inflammation is swelling and irritation. Additional codes might be needed if there are serious complications.

K80.4, Calculus of bile duct with cholecystitis, refers to the presence of stones in the bile duct accompanied by inflammation of the gallbladder.This diagnosis encompasses various presentations, including acute and chronic cholecystitis, and may require additional codes for complications like gangrene of the gallbladder (K82.A1), perforation of the gallbladder (K82.A2), or bile duct fistula (K83.3).The presence of cholangitis should be coded separately (K80.3).

Example 1: A 60-year-old female presents with right upper quadrant pain, fever, and jaundice. Imaging reveals gallstones in the common bile duct and inflammation of the gallbladder. The diagnosis is K80.4 (Calculus of bile duct with cholecystitis)., A 45-year-old male with a history of gallstones undergoes an ERCP during which gallstones are removed from the common bile duct. Post-procedure, he is diagnosed with acute cholecystitis. The diagnosis is K80.4 (Calculus of bile duct with cholecystitis) along with additional codes for the procedure and the acute inflammation., A 72-year-old female is admitted with severe abdominal pain and elevated inflammatory markers.Laparoscopic cholecystectomy reveals gangrenous cholecystitis and stones in the bile duct.The final diagnosis includes K80.4 (Calculus of bile duct with cholecystitis) and K82.A1 (Gangrene of gallbladder).

Detailed history and physical examination documenting symptoms (e.g., RUQ pain, fever, jaundice). Imaging studies showing the presence of gallstones in the bile duct (e.g., ultrasound, CT scan, MRCP).Laboratory findings demonstrating inflammation (e.g., elevated white blood cell count, liver function tests).

** This code is used for both acute and chronic cholecystitis in conjunction with bile duct stones.The presence of obstruction should be specified with additional fifth digits.Always ensure complete documentation to support the diagnosis and justify the medical necessity for procedures performed.

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