About Us
iRCM is an industry leader with innovative technology and an expert team. We are a complete Revenue Cycle Management solution that streamlines reimbursements and delivers remarkable results.
Contact Info
iRCM is an industry leader with innovative technology and an expert team. We are a complete Revenue Cycle Management solution that streamlines reimbursements and delivers remarkable results.
Accurate documentation and ICD-10 coding of cholecystectomy procedures are vital for clinical outcomes reporting, payer compliance, and surgical audit transparency.
For general surgeons, hepatobiliary specialists, and gastroenterologists, understanding the coding logic behind ICD-10-CM and ICD-10-PCS ensures precise alignment between operative documentation and hospital data systems.
This guide consolidates CMS updates, ICD-10-PCS code definitions, and clinical documentation pearls for open, laparoscopic, and robotic cholecystectomy, including postoperative and aftercare coding.
Condition | ICD-10-CM Code | Description |
Calculus of the gallbladder without cholecystitis | K80.20 | Gallstones in the gallbladder, no inflammation |
Calculus of the gallbladder with acute cholecystitis | K80.00 | Gallstones with acute inflammation |
Chronic cholecystitis without calculus | K81.1 | Non-calculous chronic inflammation |
Other disorders of the gallbladder | K82.8 | Polyps, cysts, cholesterolosis |
Ensure documentation differentiates acute vs chronic cholecystitis, and presence/absence of stones, as this directly affects K80 vs K81 code selection.
Code | Description | Use |
Z48.815 | Aftercare following surgery on the digestive system | Routine post-op visits (wound care, drain review) |
Code | Description | Clinical Context |
Z90.49 | Acquired absence of the gallbladder | Past cholecystectomy; anatomical absence |
Z90.5 (legacy) | Acquired absence of the gallbladder | Older system variant still accepted by some EMRs |
Code | Condition | Comment |
K91.5 | Post-cholecystectomy syndrome | Biliary dyspepsia, retained CBD stone, sphincter of Oddi dysfunction |
ICD-10-PCS employs seven-character alphanumeric codes detailing surgical section, body system, root operation, body part, approach, device, and qualifier.
Some key codes
Code | Description |
0FT40ZZ | Resection of Gallbladder, Open Approach |
0FB40ZZ | Excision of Gallbladder, Open Approach |
Code | Description |
8E0W4CZ | Robotic-Assisted Procedure of the Trunk Region, Percutaneous Endoscopic Approach |
8E0W0CZ | Robotic-Assisted Procedure of the Trunk Region, Open Approach |
This dual-code combination accurately reflects a da Vinci-assisted LC and meets CMS 2025 guidance.
From one source:
Surgeons should ensure that operative notes include:
Scenario | Code | Explanation |
Post-surgical follow-up | Z48.815 | Routine checkups after cholecystectomy |
History of cholecystectomy | Z90.49 | Past removal, no active disease |
Post-surgery complications | K91.5 | Symptomatic biliary disturbance |
Failure to update post-conversion status — not documenting “converted from laparoscopic to open.”
Category | Code(s) | Description |
Diagnosis (CM) | K80.20 · K81.1 · K91.5 | Cholelithiasis · Cholecystitis · Post-cholecystectomy syndrome |
Aftercare | Z48.815 | Post-surgical aftercare |
History/Absence | Z90.49 | Acquired absence of the gallbladder |
Laparoscopic (PCS) | 0FT44ZZ · 0FB44ZZ | Laparoscopic cholecystectomy |
Open (PCS) | 0FT40ZZ · 0FB40ZZ | Open cholecystectomy |
Robotic (PCS) | 8E0W4CZ · 8E0W0CZ | Robotic-assisted procedure codes |
Robotic cholecystectomy offers improved ergonomics and precision for difficult cases (e.g., dense adhesions, obesity).
From a documentation standpoint, include robotic console utilization and patient-side docking in the operative note.
ICD-10-PCS recognizes the robotic assistance under code 8E0W4CZ, in conjunction with 0FT44ZZ, to fully describe the technique.
Reference: CMS ICD-10-PCS 2025 Official Guidelines, Section B3.1b.
Proper ICD-10 coding supports:
For specialized clinicians, ICD-10 coding is not just administrative; it’s an extension of surgical documentation quality.
By clearly defining approach, extent, and postoperative course, surgeons enable coders to apply the correct ICD-10-PCS and ICD-10-CM codes, ensuring data accuracy, appropriate DRG assignment, and regulatory compliance.
iRCM is an industry leader with innovative technology and an expert team. We are a complete Revenue Cycle Management solution that streamlines reimbursements and delivers remarkable results.
