Clinical History: Abdominal Pain, Vomiting, Cholelithiasis.
Gross Description: 6.0 x 3.8 cm apparent gallbladder received. The cystic duct is patent. The lumen contains yellow-brown bile admixed with multiple friable, black calculi that vary in greatest dimension from 0.1 to 0.8 cm. The wall thickness measures up to 0.4 cm, and is focally thickened and fibrotic. Representative sections of the cystic duct and body are submitted in blocks A and B.
Microscopic Diagnosis: Acute and chronic cholecystitis with cholelithiasis.
What diagnosis codes are assigned?
Per the ICD-9-CM and ICD-10-CM Coding Guidelines for Acute and Chronic Conditions, “If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetical Index at the same indentation level, code both and sequence the acute (subacute) first.”
In ICD-10 the Tabular List categorizes Cholelithiasis with acute and/or chronic cholecystitis without obstruction as follows:
- K80.00 – Calculus of gallbladder with acute cholecystitis without obstruction
- K80.10 – Calculus of gallbladder with chronic cholecystitis without obstruction
- K80.12 – Calculus of gallbladder with acute and chronic cholecystitis without obstruction
Since ICD-10 provides one code (K80.12) that encompasses both the acute and chronic conditions, only one code is required, as it represents the highest level of specificity.
Coding in ICD-9 requires two codes for this scenario because there is no single code that encompasses both acute and chronic cholecystitis with cholelithiasis. The Alphabetic Index for Cholelithiasis separates the subentries of acute and chronic cholecystitis at the same indentation level. Therefore, both the acute and chronic codes are required, and sequence acute first.
2012 ICD-9-CM Manual (American Medical Association)
2014 Draft ICD-10-CM Manual (Optum)