ICD-10 Code for History of Cholecystectomy
The ICD-10 code for a history of cholecystectomy (gallbladder removal) is Z90.49 (Acquired absence of other specified parts of digestive tract).
Code Details
The appropriate coding for a patient with a prior cholecystectomy falls under the Z-code category for personal history of procedures:
- Z90.49: Acquired absence of other specified parts of digestive tract
- This is the specific code used to document that a patient has had their gallbladder surgically removed
- It indicates the anatomical absence of the organ due to prior surgical intervention
Clinical Context
This code is used when:
- Documenting past surgical history during encounters for unrelated conditions
- The absence of the gallbladder is relevant to current clinical decision-making
- Evaluating patients for conditions where prior cholecystectomy status matters (e.g., evaluating abdominal pain, considering biliary pathology)
Important Coding Considerations
When coding encounters related to cholecystectomy complications or sequelae, different codes apply:
- Active bile duct injuries would use K91.5 (Postcholecystectomy syndrome) or specific injury codes
- Post-surgical complications require their own specific ICD-10 codes based on the nature of the complication
The Z90.49 code is purely for documenting the historical fact of gallbladder removal, not for active complications or current surgical procedures. For the actual cholecystectomy procedure itself, CPT codes (47562-47564 for laparoscopic, 47600 for open) are used alongside diagnosis codes for the indication (e.g., K80.x codes for cholelithiasis).