Home Health ICD-9/ICD-10 Alert

Question: We have a patient who had a thoracentesis due to pleural effusion. Congestive heart failure (CHF) is an underlying condition, and the effusion is recurrent. Should I report V58.74 for aftercare following surgery of the respiratory system as my primary diagnosis, or should I code for the pleural effusion? 

Washington Subscriber

Answer: Pleural effusion is an integral part of congestive heart failure and included in code 428.0 (Congestive heart failure, unspecified). In left heart failure, there is usually some accumulation of fluid in the pleural space. Ordinarily the pleural effusion is minimal and does not require treatment other than the treatment of the underlying cause.

However, at times the effusion may require therapeutic thoracentesis or chest tube drainage. In such cases, you may report the pleural effusion (511.9) as an additional diagnosis since the condition was specifically evaluated or treated.

Aftercare to the thoracentesis site is probably not the focus of your care with such an unstable patient. Code the congestive heart failure (428.0) followed by the pleural effusion (511.9).