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2025 ICD-10-CM code K91.5

Postcholecystectomy syndrome is a complication that can occur after gallbladder removal surgery.

Appropriate coding requires careful documentation of the symptoms and any investigations performed to exclude other diagnoses.The clinical picture should support the diagnosis of PCS.If other significant conditions are identified concurrently, these should also be coded.

Modifiers may be applicable depending on the specific circumstances and procedures performed during evaluation and treatment.Consult relevant coding guidelines for appropriate modifier use.

Medical necessity for the diagnosis and management of PCS is established by the presence of persistent or new-onset symptoms referable to the biliary tract after a cholecystectomy, and when other causes have been ruled out. Treatment is medically necessary to relieve symptoms and improve patient quality of life.

The clinical responsibility for managing PCS involves a thorough history, physical examination, and appropriate investigations to determine the cause of the symptoms and implement suitable management strategies.This may involve gastroenterology, surgery, or other specialists depending on the findings.

IMPORTANT:No alternate codes specifically noted, however, depending on the specific symptoms and underlying cause other codes might be applicable.

In simple words: Postcholecystectomy syndrome means you're having problems after your gallbladder was removed.This could include stomach pain, indigestion, nausea, or vomiting that didn't go away after the surgery.

Postcholecystectomy syndrome (PCS) encompasses a variety of symptoms that persist or develop after a cholecystectomy (gallbladder removal).These symptoms can include persistent abdominal pain, dyspepsia (indigestion), nausea, vomiting, and biliary-type pain. The etiology of PCS is often unclear, and it may be related to residual gallstones, sphincter of Oddi dysfunction, or other factors.Diagnosis typically involves a thorough clinical evaluation, imaging studies (e.g., ultrasound, endoscopic retrograde cholangiopancreatography [ERCP]), and exclusion of other possible causes.

Example 1: A 55-year-old female patient undergoes a laparoscopic cholecystectomy.Post-operatively, she experiences persistent right upper quadrant pain, nausea, and intermittent vomiting.Imaging studies are negative for retained gallstones.Diagnosis of PCS is made based on clinical presentation and exclusion of other causes.Management focuses on symptomatic relief with medication., A 62-year-old male patient has a cholecystectomy for symptomatic cholelithiasis.Several months later he develops recurrent biliary-type pain. ERCP reveals sphincter of Oddi dysfunction, which is treated with endoscopic sphincterotomy. The PCS diagnosis is related to the sphincter of Oddi dysfunction., A 48-year-old female patient presents with persistent epigastric pain and dyspepsia six weeks post cholecystectomy.Further investigation reveals no retained stones, and an upper endoscopy rules out peptic ulcers.The diagnosis of PCS is made, and the patient is treated with medication and lifestyle modifications.The pain persists, and she is ultimately referred to a pain management specialist.

Detailed surgical notes from the cholecystectomy, documentation of post-operative symptoms (including timing and severity), results of any imaging studies (ultrasound, ERCP, CT), results of other investigations (e.g., blood tests, endoscopy), and documentation of treatments and their effects.

** The diagnosis of PCS is often challenging, requiring a thorough evaluation to exclude other potential causes of post-cholecystectomy symptoms.Close collaboration between surgeons and gastroenterologists is often needed for optimal management.

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