ICD Code K91.86

ICD code K91.86 is a medical classification used to describe the condition of retained cholelithiasis following a cholecystectomy. This means that gallstones remain in the bile ducts after the surgical removal of the gallbladder, which can lead to complications such as pain, infection, or jaundice. This code is used by healthcare providers to document and communicate this specific postoperative complication for billing and treatment purposes.

1. Post-Cholecystectomy Status: The patient must have undergone a cholecystectomy, which is the surgical removal of the gallbladder.

2. Presence of Gallstones: There must be evidence of retained gallstones, which are stones that remain in the bile ducts after the gallbladder has been removed.

3. Biliary Colic: The patient may experience episodes of severe abdominal pain, typically in the upper right quadrant, which can radiate to the back or shoulder.

4. Jaundice: The patient may present with yellowing of the skin and eyes, indicating a possible obstruction in the bile duct due to retained stones.

5. Cholangitis: Symptoms of infection such as fever, chills, and abdominal pain may indicate inflammation of the bile duct system.

6. Abnormal Liver Function Tests: Elevated liver enzymes, bilirubin, or alkaline phosphatase levels in blood tests may suggest bile duct obstruction or liver involvement.

7. Imaging Confirmation: Diagnostic imaging such as an ultrasound, MRCP (Magnetic Resonance Cholangiopancreatography), or ERCP (Endoscopic Retrograde Cholangiopancreatography) should confirm the presence of retained stones in the bile ducts.

8. Recurrent Symptoms: The patient may have recurrent symptoms similar to those experienced before the cholecystectomy, indicating the presence of retained stones.

9. Biliary Obstruction: Clinical signs of bile duct obstruction, such as dark urine and pale stools, may be present.

10. Consultation with a Specialist: A gastroenterologist or surgeon may be involved in confirming the diagnosis and planning further management.

For the ICD code K91.86, which pertains to retained cholelithiasis following cholecystectomy, the relevant CPT codes that may be applicable for treatment include:

1. 47562 - Laparoscopy, surgical; cholecystectomy.

2. 47563 - Laparoscopy, surgical; cholecystectomy with cholangiography.

3. 47564 - Laparoscopy, surgical; cholecystectomy with exploration of common duct.

4. 47600 - Cholecystectomy without cholangiography.

5. 47605 - Cholecystectomy with cholangiography.

6. 47610 - Cholecystectomy with exploration of common duct.

7. 43264 - Endoscopic retrograde cholangiopancreatography (ERCP) with removal of stone(s) from biliary/pancreatic duct(s).

8. 43265 - ERCP with destruction of calculi.

9. 47570 - Laparoscopy, surgical; cholecystectomy with exploration of common duct and removal of calculus.

These CPT codes are typically used in procedures that address complications such as retained stones after a cholecystectomy. It is important for healthcare providers to select the appropriate CPT code based on the specific procedure performed to ensure accurate billing and reimbursement.

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