Perforation of gallbladder

This code signifies a hole or rupture in the wall of the gallbladder. This can lead to the leakage of bile into the abdominal cavity, causing peritonitis and other severe complications. It is often a consequence of acute cholecystitis or gallstone impaction.

Apply this code when documentation explicitly states a perforation or rupture of the gallbladder. This typically occurs in cases of severe acute cholecystitis, gangrenous cholecystitis, or following trauma. Supporting documentation includes operative reports, pathology findings, and imaging reports confirming the perforation.

• Differentiate from gangrene of the gallbladder without perforation, which is a distinct condition.
• Always sequence this code after the underlying cause, such as acute cholecystitis, if applicable.
• Look for specific terms like "perforated," "ruptured," or "hole in gallbladder wall" in the physician's notes.