Pulmonology Coding Alert

Hint: Use same ICD-10 code if the diagnosis is hemopneumothorax.

When your pulmonologist diagnoses hemothorax, you’ll be pleased to know that there is a very specific code for this condition in ICD-10 code unlike the generalized code that you had to use in ICD-9.

ICD-9:  You will currently report a diagnosis of hemothorax with 511.89 (Other specified forms of effusion, except tuberculous). You will use the same diagnosis code if your pulmonologist diagnoses other types of effusion that do not have a specific code. In addition to using 511.89 for a diagnosis of hemothorax, you also report the same code if the diagnosis is encysted pleurisy, hemopneumothorax, hydropneumothorax, or hydrothorax.

Exclusions: You cannot report 511.89 if the cause of the hemothorax is traumatic. This is reported using 860.2 (Traumatic hemothorax without open wound into thorax) or 860.3 (Traumatic hemothorax with open wound into thorax) or with 860.4-860.5. You also cannot use this diagnosis code if the patient has tuberculosis. In such a case scenario, you will report the diagnosis of pleurisy with 012.0 (Tuberculous pleurisy).

ICD-10: Unlike in ICD-9, a diagnosis of hemothorax has a specific code in ICD-10. So, if your clinician diagnoses the condition, you will use J94.2 (Hemothorax). You will use the same diagnosis code if your clinician’s diagnosis is hemopneumothorax. In ICD-9, you would use 511.89 if the diagnosis was hemothorax, hemopneumothorax, encysted pleurisy, hydropneumothorax, or hydrothorax. In ICD-10, you have separate codes for all these conditions:

J90 (Pleural effusion, not elsewhere classified) is used for a diagnosis of encysted pleurisy

J94.8 (Other specified pleural conditions) is used if the diagnosis is hydropneumothorax or hydrothorax.

Exclusions: As in ICD-9, you cannot report J94.2 if the cause for the hemothorax is traumatic. In such a case, you will use either S27.1XX- (Traumatic hemothorax…) or S27.2XX- (Traumatic hemopneumothorax…). You will have to use a 7^th character to denote the following:

• A = Initial encounter (i.e., S27.1XXA or S27.2XXA)
• D = Subsequent encounter (i.e., S27.1XXD or S27.2XXD)
• S = Sequela (i.e., S27.1XXS or S27.2XXS)

Focus on These Basics Briefly

Documentation spotlight: Your pulmonologist will arrive at a diagnosis of hemothorax based on a thorough history, medical examination, signs and symptoms and the findings of blood tests, diagnostic tests and chest x-rays.

Some of the signs and symptoms that you are more likely to encounter in the documentation of a patient diagnosed with hemothorax will include dyspnea, and chest pain that is often exacerbated with deep inspiration. Your clinician might note the presence of hemoptysis especially in cases where the hemothorax has occurred as a complication to malignancy.

Upon examination, your pulmonologist might note the presence of signs of anemia. He will also note decreased breath sounds and dullness to percussion. He might also note the presence of asymmetrical chest expansion with delayed expansion on the affected side.

Tests: Your clinician will derive a blood sample to check for blood count, platelet counts, hematocrit value clotting factors and to check for any bacterial or viral cause for the accumulation of blood in the pleural space. Your pulmonologist will also order for chest x-rays or other imaging studies such as ultrasonography or a CT scan. In most cases, these imaging studies will help your clinician diagnose the condition.

When there is presence of any fluids in the pleural space, the most immediate intervention that your pulmonologist will employ is to insert a chest tube to drain out the fluid. If your clinician suspects the presence of blood, then the fluid drained out is sent for analysis. Your clinician will compare the hematocrit values of the fluid to the hematocrit value obtained from the blood sample to help confirm the presence of blood in the pleural space.

Example: Your pulmonologist is called to evaluate a patient in the ER with complaints of increasing dyspnea and chest pain. The patient has a history of a coagulapathy for which he is under medications for the past year or so. Your pulmonologist observes that the patient is alert and when he queries the patient, the patient says that he developed a mild dry cough that later almost disappeared but then his symptoms of dyspnea began to set in and it began to increase to a point that he had severe trouble breathing. He also complained that he had some amount of chest discomfort that seems to increase when he breathed in.

Upon examination, your pulmonologist observed paleness of the extremities and some amount of cyanosis. He admitted the patient and withdrew a blood sample and sent it to the lab for various analysis such as blood count, differential counts, platelet count, bleeding time, clotting time and hematocrit value. He also ordered for a chest x-ray.

He also noted dullness on percussion and decreased breath sounds. The patient documentation also included presence of asymmetrical chest expansion with delayed expansion on the affected side that made your pulmonologist think of effusion.

After observation of the patient’s x-rays, your pulmonologist observed accumulation of fluid. He inserted a chest tube and drained out the fluid and sent it to the lab for analysis. The chest tube was secured in place.  He compared the hematocrit values of the drained out fluid and the circulating hematocrit and arrived at a diagnosis of hemothorax.

What to report: You report the evaluation of the patient with 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…). You report the chest tube insertion with 32556 (Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance). You report the diagnosis of hemothorax using 511.89 if you are using ICD-9 codes and J94.2 if you are using ICD-10 codes.