Calculus of bile duct w/o cholangitis or cholecyst w/o obst

This code describes the presence of gallstones within the bile duct (choledocholithiasis) without any associated inflammation of the bile ducts (cholangitis) or gallbladder (cholecystitis), and without causing a blockage of the bile flow. It indicates the presence of stones in the common bile duct or hepatic ducts that are not currently causing obstructive symptoms or infection.

Use this code when diagnostic imaging (e.g., ultrasound, MRI, ERCP) confirms the presence of calculi in the bile duct, and the patient does not exhibit signs or symptoms of cholangitis (fever, jaundice, abdominal pain) or cholecystitis (RUQ pain, Murphy's sign). Documentation should clearly state the location of the calculus and explicitly rule out obstruction and inflammation.

• Ensure documentation specifies "without obstruction" and "without cholangitis or cholecystitis" to accurately assign this code.
• Do not use this code if there is any mention of obstruction, inflammation, or infection; a more specific code would be required.
• Consider sequencing this code as a primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it is an incidental finding or a co-morbidity.