2025 ICD-10-CM code K81.0
(Active) Effective Date: N/A Revision Date: N/A Diseases of the gallbladder, biliary tract, and pancreas - Cholecystitis Diseases of the digestive system Feed
Acute cholecystitis is an inflammation of the gallbladder, often caused by gallstones.
Modifiers may be applicable to further specify the procedure or service provided.
Medical necessity for treatment of acute cholecystitis is established by the presence of symptoms consistent with the diagnosis, confirmed by imaging and laboratory findings.The severity of symptoms and risk of complications influence the choice of treatment, either medical management or surgical intervention.
The clinical responsibility for managing acute cholecystitis involves diagnosis through history, physical exam, and imaging; managing symptoms with medication and fluids; and determining the need for surgical intervention.Post-operative care, if surgery is performed, is also the physician's responsibility.
In simple words: Acute cholecystitis is a sudden inflammation of your gallbladder, a small organ that stores bile.This usually happens because a gallstone blocks the tube leading out of the gallbladder.It can cause severe pain in your upper right abdomen, nausea, vomiting, and fever. Doctors may use medicine, fluids, or surgery to treat it.
Acute cholecystitis refers to a sudden inflammation of the gallbladder, a small organ beneath the liver that stores bile.The most common cause is gallstones obstructing the cystic duct, leading to bile accumulation and inflammation. Other causes include infections or trauma. Symptoms can include severe right upper quadrant pain, nausea, vomiting, fever, and jaundice.Diagnosis typically involves physical examination, blood tests, and imaging studies (ultrasound, CT scan). Treatment often includes medication, intravenous fluids, and sometimes surgery (cholecystectomy) to remove the gallbladder.
Example 1: A 55-year-old female presents with sudden onset of severe right upper quadrant pain radiating to her right shoulder blade.She also reports nausea and vomiting. Ultrasound reveals acute cholecystitis with gallstones. She is admitted to the hospital for intravenous fluids, pain management, and a scheduled cholecystectomy., A 70-year-old male with a history of chronic cholecystitis experiences an exacerbation of his symptoms, including worsening pain and fever.Laboratory tests show leukocytosis and elevated inflammatory markers.He is treated with antibiotics and supportive care.His condition improves, and he is discharged with instructions to follow up with his gastroenterologist., A 30-year-old female presents with acute cholecystitis without gallstones.Further investigation reveals an infection. She is treated with antibiotics and close monitoring.Symptoms resolve, and she is discharged without surgical intervention.
Detailed history and physical examination findings; results of laboratory tests (complete blood count, liver function tests, inflammatory markers); imaging studies (ultrasound, CT scan if necessary); operative report if surgery is performed; pathology report if applicable.
** Accurate coding requires careful documentation of the clinical presentation, diagnostic findings, and treatment provided.Consider the possibility of associated conditions such as cholelithiasis, which may require additional coding.
- Payment Status: Active
- Specialties:Surgery, Gastroenterology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center