Coding, Classification and Reimbursement

Retained gallstone

  • 1.  Retained gallstone

    Posted 01-10-2019 09:53
    ​Patient presented with RUQ abdominal pain.  Had history of a Lap cholecystectomy 14 years ago.  Found to have an abscess with what looked like a gallstone in the abdominal wall.  An I&D of the abscess was performed with removal of the retained gallstone from within the subcutaneous tissue.

    Can either the retained gallstone (K91.86) or the abdominal wall abscess (L02.211) be assigned as principal diagnosis?

    Appreciate any suggestions!

    Paula Scheiderich, RHIT
    Clinical Documentation Improvement
    Oneida Healthcare Center

  • 2.  RE: Retained gallstone

    Posted 01-13-2019 21:54
    I don't have access to an encoder at the moment, but I would look at the procedure codes to determine if either would qualify as the principal procedure for this encounter.  If both procedures are weighted equally then I would tend more to using the abscess as the pdx because I imagine the patient was also on antibiotics?  If so, from an intensity of care aspect, the I&D combined with ongoing antibiotics would support the abscess as PDX unless additional care was also given for the retained gallstone.  If, however, the gallstone also received additional care and both conditions were treated and monitored equally then this qualifies as a situation of both dx qualifying as pdx which means either could be sequenced first.

    Hope this makes sense.  I would be interested in seeing what other's recommend.

    Alicia Kellogg, RHIT
    Inpatient Coder

  • 3.  RE: Retained gallstone

    Posted 01-14-2019 08:40

    It does.  Thanks for your input Alicia.



    Paula Scheiderich, RHIT

    Clinical Documentation Integrity

    Oneida Health

    315 363-6000 Ext. 1084