Count On a Calculus Code for a Gallstone Diagnosis
Question: I have a record of an encounter with a patient who presented to the emergency department (ED) with abdominal pain and bloating. The gastroenterologist captured a history and physical examination and then performed an abdominal ultrasound of the right upper quadrant (RUQ). After interpreting the images, the provider diagnosed the patient with gallstones and ordered laparoscopic cholecystectomy, which they performed later that day. I’m new to gastroenterology coding and I’m not sure what codes to assign — can you help? Nebraska Subscriber Answer: Sure! You’ll need two CPT® codes and one ICD-10-CM code to code this encounter. Assign 76705 (Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)) to report the RUQ abdominal ultrasound. Then, you’ll use 47562 (Laparoscopy, surgical; cholecystectomy) to code the laparoscopic cholecystectomy. Next, you’ll assign K80.20 (Calculus of gallbladder without cholecystitis without obstruction) to report the gallstones. You’ll search for “calculus” in the ICD-10-CM code book Alphabetic Index when searching for gallstones. Code K80.20 represents the presence of gallstones without inflammation nor obstruction in the gallbladder. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
