Pulmonology Coding Alert

Question: I have a report from a physician in our practice from their encounter with a patient. The patient is experiencing cough, chest pain, shortness of breath, and a fever. The physician ordered a CT scan and found increased fluid in the patient’s pleural space. The patient was diagnosed with bronchopleural fistula.

What code should I use to document the diagnosis?

Georgia Subscriber

Answer: Bronchopleural fistula is an additional synonym listed under J86.0 (Pyothorax with fistula). Pyothorax occurs when pus enters the pleural cavity between the membrane covering the lung and the membrane lining the thoracic cage. The other synonyms listed with J86.0 include Bronchocutaneous fistula, Hepatopleural fistula, Mediastinal fistula, Pleural fistula, and Thoracic fistula.

Pyothorax most commonly occurs when an infection spreads from an inflamed lung to the pleural membrane. The patient may also experience different forms of tuberculosis or a lung abscess because of the infection. A fistula happens when two hollow spaces, such as organs, intestines, or blood vessels, form an abnormal connection. This can occur due to surgery, injury, infection, or inflammation.

Additionally, the code features an instruction to include the appropriate code from B95-B97 to identify the infectious agent.

Parent Code note: The parent code J86 (Pyothorax) features an Excludes1 note that doesn’t allow you to code J86.0 with J85.- (Abscess of lung and mediastinum) or A15.6 (Tuberculous pleurisy).