Pulmonology Coding Alert

Question: The diagnosis for one of the patients admitted to our facility was anasarca with pleural effusion. I was going to code the diagnosis with 514 but do I also need to code the pleural effusion with a separate code?

Mississippi Subscriber

Answer: For facility billing, before reporting a diagnosis of anasarca with pleural effusion, you will have to delve deep into the cause for the massive edema before you report the diagnosis.

If the edema is as a result of congestive heart failure (CHF), any pleural effusion that is present but doesn’t require direct treatment will not need to be reported separately. Pleural effusion is an integral part of CHF. You should not automatically assign the code unless the physician determines or documents that it has become "clinically significant"). The presence of a pleural effusion alone requires more investigation before appropriately assigning the code.

For example, a patient with CHF can be admitted with pleural effusion that is so massive that respiratory symptoms are a mainstay of the presentation and the physician directly treats the effusion by performing a thoracentesis or insertion of a chest tube. It is appropriate to assign the pleural effusion with a secondary code. Never assign pleural effusion as the principal diagnosis in CHF cases.

Remember that professional/physician billing differs. Assigning the primary dx of pleural effusion is required to support the need for the thoracentesis or chest tube. Also concurrent care rules require each specialty physician to identify the primary condition being managed. Therefore, the cardiologist and the pulmonologist should not both assign CHF as their primary dx. The cardiologist will likely assign CHF as his/her primary dx on the claim form while the pulmonologist will assign pleural effusion as the primary dx on his/her claim form to distinguish the services.

Facility Coding Considerations: If a CHF patient has pleural effusion caused by something other than CHF, the circumstances of admission will determine the assignment of the code for pleural effusion.

The other causes for anasarca include renal failure or liver failure. In the case of these conditions, pleural effusion is not an integral part of the disease. You should assign and sequence a code based on the circumstances of admission. If the circumstance of admission revolves around the presence of pleural effusion necessitating treatment with thoracentesis or insertion of a chest tube, you will have to report the pleural effusion separately.