Perforation of gallbladder in cholecystitis

This code signifies a hole or rupture in the gallbladder wall that has occurred as a complication of cholecystitis, which is inflammation of the gallbladder. This perforation allows bile to leak into the abdominal cavity, potentially leading to peritonitis or abscess formation. It represents a severe and acute complication requiring urgent medical intervention.

Use this code when documentation explicitly states a perforation of the gallbladder in the context of cholecystitis. This typically occurs in cases of acute cholecystitis that have progressed to a complicated stage. Look for terms like "gangrenous cholecystitis with perforation," "ruptured gallbladder due to inflammation," or "perforated cholecystitis" in operative reports, pathology reports, or physician notes.

• Always sequence this code after the underlying cholecystitis code (e.g., K81.0, K81.1) if the cholecystitis is still active and being treated.
• Do not confuse this with a traumatic perforation of the gallbladder, which would be coded differently (e.g., S36.114-).
• Ensure documentation clearly links the perforation to the cholecystitis; if the cause of perforation is unclear, further physician query may be necessary.