Gall Stones – Causes, Treatment Options and ICD-10 Coding

by | Published on Dec 22, 2020 | Podcasts, Medical Coding (P) | 0 comments

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Based in the United States, Outsource Strategies International (OSI) is an experienced medical billing service company that provides quality medical billing and coding services for various specialties.

In today’s podcast, Meghann Drella, one of our Senior Solutions Managers, discusses coding for gallstones and also provides an overview of the causes, symptoms and treatment options for the condition.

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Hello and welcome to our podcast series. My name is Meghann Drella and I am a Senior Solutions Manager here at Outsource Strategies International. Today, I will be discussing Coding Gall Stones – An Overview of the Symptoms and Treatment.

0:13 – Gallstones – A General Overview

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 does 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.

1:08 – Causes of Gallstones

Reports suggest that about 20 million Americans have gallstones. It’s 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 correctly or often enough, bile may become very concentrated, contributing to the formation of gallstones.

1:32 – Two Types 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.

1:45 – Risk Factors of Gallstones

Factors that may increase the risk of this condition include being female, overweight or obese, eating a high-fat, high cholesterol diet, and a family history of gallstones and diabetes.

1:55 – Signs and Symptoms

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 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, and 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.

2:48 – Diagnosis and Treatment

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 also performed. 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, the majority of people with this condition do not show any specific symptoms and hence don’t 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 that patients 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 surgery to remove the gall bladder), Endoscopic retrograde, 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.

4:16 – Preventing Gallstones

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.

I hope this helps but always remember that documentation as well as a thorough knowledge of the payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank you for joining me and stay tuned for my next podcast.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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