Retained cholelithiasis following cholecystectomy

This code signifies the presence of gallstones in the biliary tract after the gallbladder has been surgically removed (cholecystectomy). These retained stones can be located in the common bile duct, hepatic ducts, or cystic duct remnant, leading to symptoms such as pain, jaundice, or cholangitis.

Apply this code when documentation explicitly states the presence of cholelithiasis in a patient who has previously undergone cholecystectomy. This typically occurs when stones are discovered post-operatively, either immediately or years later, often identified via imaging studies like ERCP or MRCP.

• Ensure documentation clearly specifies "retained" or "post-cholecystectomy" gallstones to differentiate from pre-operative cholelithiasis.
• Do not confuse with codes for cholelithiasis with cholecystitis if the gallbladder is no longer present.
• Sequence this code as a primary diagnosis when it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity impacting treatment.