Perforation of gallbladder

This code signifies a hole or rupture in the wall of the gallbladder that is not caused by inflammation of the gallbladder (cholecystitis). This perforation can lead to the leakage of bile into the abdominal cavity, potentially causing peritonitis. It represents a serious complication requiring immediate medical intervention.

Use this code when documentation clearly indicates a perforation of the gallbladder without an associated diagnosis of cholecystitis. This might be seen in cases of trauma, gallstone erosion without inflammation, or spontaneous rupture. The physician's notes should explicitly state "perforation of gallbladder" and exclude any mention of cholecystitis as the cause.

• Always review documentation to confirm the absence of cholecystitis; if cholecystitis is present, refer to the Excludes1 note.
• Ensure the documentation specifies the perforation is of the gallbladder, not other abdominal organs.
• Consider sequencing with codes for any resulting complications, such as peritonitis.