Question: We have a patient with a history of COPD, CHF, HPTN, atrial fibrillation, coronary artery disease and chronic renal failure. The patient developed shortness of breath and was treated at our local hospital for a spontaneous left pneumothorax with insertion of chest tubes. Chest tubes were removed,and the patient was discharged with home care skilled nursing ordered to assess respiratory status and tube incision site. The pneumothorax is resolved. How should we code this patient?
Minnesota Subscriber
Answer: Report V55.8 (Attention to artificial openings, other specified artificial openings) for the thoracostomy, then 496 (Chronic airway obstruction, not elsewhere classified) or 491.21 (Obstructive chronic bronchitis, with [acute] exacerbation), followed by the other diagnoses in order of importance. You may also want to add the history code for respiratory diseases V12.69 (Other diseases of respiratory system).