Gallstones are stones or lumps that tend to develop in the gall bladder or bile duct when digestive fluid or substances harden. A small, pear-shaped organ, the gall bladder is located on the upper right side of the abdomen (just below the liver). It holds a digestive fluid called “bile” that is released into your small intestine. These stones range in size (small like a grain of sand to as large as a golf ball). In some cases, people develop just one gallstone, while others develop many gallstones at the same time. The condition often involves no symptoms and therefore do not require any specific treatment. However, in some cases, if these stones get trapped inside the opening (duct) of the gallbladder; it can cause a sudden, intense pain in the tummy that usually lasts between 1 – 5 hours. Symptomatic gallstones usually require gallbladder removal surgery. On the other hand, asymptomatic gallstones typically do not require any treatment. However, following a low-fat, high-fiber diet can help prevent the condition in the long run. Billing and coding for gastroenterology conditions can be challenging. Specialists treating this condition can partner with a reliable gastroenterology medical coding company to streamline their medical billing process.

Reports suggest that about 20 million Americans have gallstones. It is not exactly clear what factors exactly cause gallstones. The condition may occur – when your bile contains too much cholesterol or bilirubin or when the gallbladder doesn’t empty correctly. If the gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones. There are two different types of gallstones that can form in the gall bladder. Cholesterol gallstones often appear yellow in color. Pigment gallstones are dark brown or black in color that form when your bile contains too much bilirubin. Factors that may increase the risk of this condition include – being female, being overweight or obese, eating a high-fat, high cholesterol diet, and a family history of gallstones and diabetes.

Symptoms of Gallstones

In most cases, patients may not experience any specific symptoms at all. This is because gallstones stay in the gallbladder and cause no problems. Chronic pain is one of the primary symptoms associated with the condition. Pain may occur suddenly and may get worse quickly. Pain can occur on the right side of the body, just below the ribs (between the shoulder blades) and may last for several hours to a few minutes. Other associated symptoms include –

  • Pain on the right-hand side of the body, just below the ribs
  • Back pain between the shoulder blades
  • Nausea and vomiting
  • Sweating
  • Restlessness
  • Jaundice (a yellow tint to the skin and eyes)
  • Chest pain

The condition can also cause acute cholecystitis – a more serious condition when the gallbladder is actually inflamed. This generally occurs when a stone blocks off the cystic duct, which increases the pressure within the gallbladder. The condition may require antibiotics, hospitalization and even urgent surgery.

How to Diagnose and Treat Gallstones?

Initial diagnosis of the condition generally begins with a physician performing a detailed physical examination. This involves checking the patient’s eyes and skin for visible changes in color. A yellowish tint may be a visible sign of jaundice, the result of too much bilirubin in the body. A wide variety of diagnostic tests may be performed. Top imaging tests include – Abdominal Ultrasound and Endoscopic ultrasound (EUS), oral cholecystography, a hepatobiliary iminodiacetic acid (HIDA) scan, Computerized tomography (CT), Magnetic resonance cholangiopancreatography (MRCP) or Endoscopic retrograde cholangiopancreatography (ERCP). Gallstones detected using ERCP can be easily removed during the procedure. In addition to these imaging tests, blood tests may be performed to measure the amount of bilirubin in the blood. These tests help identify any specific type of infection, jaundice, pancreatitis or other complications caused by gallstones.

Generally, majority of people with this condition do not show any specific symptoms and hence do not need any treatment. The physician will determine whether any specific treatment is required based on the symptoms and the results of the diagnostic tests performed. They may recommend patients to remain alert for symptoms of gallstone complications like chronic pain in the upper right abdomen.

Treatment for this condition may be required only if the condition causes gall bladder inflammation, blockage of the bile duct or movement of the bile duct into the intestines. Treatment modalities for this condition include – cholecystectomy (surgery to remove the gall bladder), Endoscopic retrograde cholangiopancreatolography and Lithotripsy. Medications to dissolve gallstones are another option; but the stones in the gall bladder are likely to reoccur once the medications are stopped. Medications are generally not prescribed and are mainly reserved for people who cannot undergo surgery. Gastroenterologists, general surgeons or other physician specialists who diagnose and treat different types of gallstones must carefully document the diagnostic tests and other procedures performed using the correct medical codes. Medical billing and coding services provided by medical billing companies can help physicians use the correct codes for their medical billing process.

ICD-10 Codes

K80 Cholelithiasis

  • K80.0 Calculus of gallbladder with acute cholecystitis
  • K80.1 Calculus of gallbladder with other cholecystitis
  • K80.2 Calculus of gallbladder without cholecystitis
  • K80.3 Calculus of bile duct with cholangitis
  • K80.4 Calculus of bile duct with cholecystitis
  • K80.5 Calculus of bile duct without cholangitis or cholecystitis
  • K80.6 Calculus of gallbladder and bile duct with cholecystitis
  • K80.7 Calculus of gallbladder and bile duct without cholecystitis
  • K80.8 Other cholelithiasis

K81 Cholecystitis

  • K81.0 Acute cholecystitis
  • K81.1 Chronic cholecystitis
  • K81.2 Acute cholecystitis with chronic cholecystitis
  • K81.9 Cholecystitis, unspecified

K82 Other diseases of gallbladder

  • K82.0 Obstruction of gallbladder
  • K82.1 Hydrops of gallbladder
  • K82.2 Perforation of gallbladder
  • K82.3 Fistula of gallbladder
  • K82.4 Cholesterolosis of gallbladder
  • K82.8 Other specified diseases of gallbladder
  • K82.9 Disease of gallbladder, unspecified
  • K82.A Disorders of gallbladder in diseases classified elsewhere
  • K82.A1 Gangrene of gallbladder in cholecystitis
  • K82.A2 Perforation of gallbladder in cholecystitis

CPT Codes

  • 47562 (laparoscopic cholecystectomy without cholangiography)
  • 47563 (laparoscopic cholecystectomy with cholangiography)
  • 47564 (laparoscopic cholecystectomy with exploration of the common bile duct)
  • 47600 (cholecystectomy without cholangiography)
  • 47605 (cholecystectomy with cholangiography)
  • 47610 (cholecystectomy with exploration of the common bile duct)

Maintaining a healthy weight and following a balanced diet is crucial to reduce the risk of developing this condition. Discussing with the physician in detail about weight loss and cholesterol management is also a big part of preventing gallstones.
For accurate and timely billing and claims submission, healthcare practices can outsource their medical coding tasks to a reliable medical billing and coding company that provides the services of AAPC-certified coding specialists.