Pulmonology Coding Alert

Question: I have documentation that lists the patient’s diagnosis as pulmonary edema, but the documentation doesn’t say whether the condition is acute or chronic.

What ICD-10-CM code should I use to report pulmonary edema?

Texas Subscriber

Answer: If the documentation doesn’t have more information specifying the diagnosis, then you’ll assign J81.1 (Chronic pulmonary edema) to report the patient’s diagnosis. Code J81.1 carries a synonym of Pulmonary edema NOS, which correlates with the information listed in the provider’s documentation. Code J81.0 (Acute pulmonary edema) does not feature a “not otherwise specified” synonym, making that code the incorrect choice.

Pulmonary edema is a condition where an abnormal amount of fluid buildup occurs in the alveolar sacs of the lungs. This fluid buildup can result in shortness of breath and reduced oxygenation of the patient’s blood. If a patient is experiencing pulmonary edema, they may present symptoms such as:

• Orthopnea (shortness of breath while lying down)
• Air hunger
• Wheezing, gurgling, or grunting sounds while breathing
• Shortness of breath causing an inability to speak in full sentences

Important: When assigning a code from J81.- (Pulmonary edema), remember to use an additional code to reflect the patient’s exposure to, dependence on, or use of tobacco.