Pulmonology Coding Alert

Tip: Watch for fistula as in the ICD-9 codes.

Your work as a pulmonology coder might expose you to see a number of different infections of the lungs and the pleural cavity, leading to a diagnosis of pyothorax (empyema). For this reason, you need to be well informed about how to report pyothorax (empyema) when ICD 10 codes come into effect.

When your pulmonologist makes a diagnosis of pyothorax (empyema), you will often see the following in the documentation of the patient:

Symptoms such as fever (R50.9, Fever, unspecified); cough (R05, Cough); shortness of breath (R06.02, Shortness of breath); pain in the area of the chest (R07.1, Chest pain on breathing); and sweating (R61, Generalized hyperhidrosis).

Your pulmonologist will order for a chest x-ray or a CT scan of the chest to check what is causing the symptoms as well as ascertain the changes in breath sounds that he will encounter during examination of the patient.

"Standard 2-view chest x-ray remains the first study for evaluating empyema," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. "Ultrasonography may show small volumes of pleural fluid. It may also provide information about viscosity or quickly demonstrate septa in the pleural fluid collection. Chest CT provides the most information. CT imaging identifies fluid, loculation, and thickening of the pleural membranes. CT and ultrasonography are also used in the placement of drainage catheters."

If the chest x-ray or the CT scan shows signs of pus accumulation in the pleural space, your pulmonologist will perform a thoracentesis to drain the pus from the pleural space. You will report this procedure with 32422 (Thoracentesis with insertion of tube, includes water seal (e.g., for pneumothorax), when performed [separate procedure]).

The removed fluid is then sent to the laboratory for culture and to check if the accumulated fluid is exudative (caused due to an infection such as pneumonia) or transudative (caused due to organ failure).

If the results of the fluid return back as exudative, your pulmonologist confirms a diagnosis of pyothorax (empyema). "Chest tubes for pleural empyema have a tendency to become clogged by the thick pus. Your pulmonologist may consult a surgeon for placement of one or more large-bore chest tubes to assist with drainage and prevent further complications," adds Pohlig.

Reporting Pyothorax with ICD-9 Codes

When your pulmonologist confirms a diagnosis of pyothorax, you need to look further in the documentation to check if there is a mention of a fistula in the patient's notes. Based on the presence or absence of a fistula, pyothorax (empyema) is reported with ICD-9 codes as mentioned below:

• 510.0 -- Empyema with fistula. This code includes bronchocutaneous fistula, bronchopleural fistula, hepatopleural fistula, mediastinal fistula, pleural fistula, thoracic fistula and any condition classifiable to 510.9 with fistula
• 510.9 -- Empyema without fistula. This code includes abscess of pleura, abscess of thorax, empyema (chest, lung or pleura), fibrinopurulent pleurisy, purulent pleurisy, pyopneumothorax, septic pleurisy, seropurulent pleurisy and suppurative pleurisy.

Observe Fistula Descriptor Changes in ICD-10 Codes

When ICD-10 codes come into effect, you will report a diagnosis of pyothorax (empyema) on the same basis that you were using for ICD-9 codes, i.e. you look for presence or absence of a fistula in the documentation of the patient. Based on this, you will report pyothorax with ICD-10 codes as expanded below:

• J86.0 -- Pyothorax with fistula
• J86.9 -- Pyothorax without fistula

Note that the descriptor in ICD-9 says "empyema" whereas the descriptor in ICD-10 says "pyothorax". This is the only difference although the terms "empyema" and "pyothorax" represent the same condition and the terms are often used interchangeably. Apart from this, there are no other changes of note between the ICD-9 and ICD-10 codes.

Example: A 63-year-old male patient presents to your pulmonologist's office with complaints of severe cough and shortness of breath. He also complains of intermittent fever for the past few days, although the temperature recorded presently is near normal. Upon auscultation, your pulmonologist notes dull breath sounds and dull percussion note.

Your pulmonologist then orders a chest x-ray. Upon visualizing the x-ray, your pulmonologist confirms the presence of fluid in the pleural space and proceeds to perform a thoracentesis. The aspirated fluid is then sent to the laboratory for analysis.

Based on the laboratory findings, your pulmonologist confirms a diagnosis of pyothorax. Your pulmonologist does not mention the presence of a fistula in the documentation. You report the diagnosis with J86.9.