Pulmonology Coding Alert

Hint: Identify underlying cause with additional code for secondary spontaneous pneumothorax.

For your pulmonologist’s spontaneous pneumothorax diagnoses, base your code choice on whether the condition is primary (occurring due to no other cause) or secondary (if the condition has occurred due to some other respiratory condition).

ICD-9: For  spontaneous pneumothorax diagnoses under ICD, you will begin your choice  with 512.8 (Other pneumothorax and air leak). Then, depending on whether your clinician identifies the pneumothorax as primary or secondary, you will have to use these two expansions to 512.8 to choose the appropriate ICD-9 code for the condition:

• 512.81 (Primary spontaneous pneumothorax)
• 512.82 (Secondary spontaneous pneumothorax)

Caveat: You cannot use 512.8x to report the diagnosis of pneumothorax if it has occurred due to a congenital condition (770.2) or has occurred due to trauma (860.0-860.1, 860.4-860.5) or tuberculous disease (011.7). Also, if your clinician’s diagnosis is secondary spontaneous pneumothorax, you’ll have to first report the condition that has contributed to the development of the pneumothorax.

ICD-10: When you begin using ICD-10 codes, 512.8 that you use to identify a diagnosis of spontaneous pneumothorax crosswalks to J93.1 (Other spontaneous pneumothorax). As in ICD-9, J93.1 again expands to two codes to help you specifically identify primary and secondary pneumothorax. The two codes that J93.1 expands into include:

• J93.11 (Primary spontaneous pneumothorax)
• J93.12 (Secondary spontaneous pneumothorax)

Reminder: The list of inclusions and guidelines that you follow while reporting the diagnosis of spontaneous pneumothorax while using ICD-9 is similar to the list of inclusions and guidelines that you will follow for ICD-10 codes. So, you don’t use J93.1- if your clinician’s diagnosis of pneumothorax has occurred due to a congenital cause (P25.1); trauma (S27.0); or tuberculous disease (A15.-). In addition, you cannot use J93.1- if the pneumothorax has occurred post-operatively (J95.811) or for a diagnosis of post-operative air leak (J95.812). Also, if your clinician’s diagnosis is pyopneumothorax, you will have to use J86.- instead of J93.1-.

As in ICD-9, when your clinician diagnoses secondary spontaneous pneumothorax, you will have to first report the underlying condition that has resulted in the occurrence of pneumothorax.

Check These Basics Briefly

Documentation spotlight: Your pulmonologist will arrive at a diagnosis of spontaneous pneumothorax based on a thorough history, medical examination, signs and symptoms and based on the findings of blood tests and diagnostic tests such as CT scans and chest x-rays and ultrasonography.

Some of the signs and symptoms that your pulmonologist might note in a patient suffering from spontaneous pneumothorax might include dyspnea, acute stabbing type of chest pain that often radiates to the shoulder on the affected side, and your clinician might note that the pain increases with the inhalation. Your clinician might also note that the patient complains of cough, fatigue and anxiety.

Upon examination, your pulmonologist might note signs of tachypnea, decreased lung sounds, presence of crackles or wheezing sounds on auscultation, and presence of hyperresonance on percussion. In some cases, your clinician might note asymmetric lung expansion with shift of trachea and the mediastinum to the unaffected side.

Tests: Based on history, signs and symptoms and physical findings, if your pulmonologist suspects a diagnosis of spontaneous pneumothorax, your pulmonologist will order for imaging tests such as a chest x-ray or a CT scan to ascertain the diagnosis. Your clinician might also ask for ultrasonography to help arrive at the diagnosis of the condition.

He might also opt to obtain an arterial blood sample to check for arterial blood gases to see if there is any hypoxia or hypercarbia. This will help in confirming the diagnosis and your clinician will also be able to assess the severity of the pneumothorax.

Example: Your pulmonologist recently reviewed a 35-year-old male patient who was admitted in the emergency department of the hospital after developing right-sided chest pain and severe shortness of breath. The patient also was suffering from bouts of coughing with no sputum production.

Upon questioning, the patient told your clinician that the pain was severe and came in bouts and seemed to be traveling all the way onto the right shoulder area. The patient said he had no previous symptoms of any respiratory problems. He provided a history of smoking for about 15 years.

On examination, your clinician noted the signs of tachypnea and tachycardia. He noted that there was no shift of the trachea or mediastinum. Upon auscultation, your clinician noted absence of breath sounds with presence of fine crackles on the right side while breath sounds on the left side seemed normal.

Suspecting pneumothorax, your clinician withdrew an arterial blood sample that was sent to the lab for blood gas analysis. He also ordered for a chest x-ray and performed an ultrasound examination of the affected areas.

Based on the history, signs and symptoms, and interpretations of blood gas analysis and diagnostic imaging studies, your clinician confirms a diagnosis of primary spontaneous pneumothorax.

What to report: You report the evaluation of the patient with 99222 (Initial hospital care, per day, for the evaluation and management of a patient…). You report the diagnosis using J93.11 if you are using ICD-10 codes or use 512.81 if you’re using ICD-9 codes.