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re; subcutaneous emphysema

  1. #1
    Default re; subcutaneous emphysema
    Medical Coding Books

    I would like to know how you would code subcutaneous emphysema. Report states subcutaneous emphysema, but if you go to the icd 9 book it takes you to 958.7 (traumatic) or theres another option of coding 518.1. Which one would you code? Because for me i don't feel comfortable coding 958.7 because it's not stating it's traumatic.

    Thank you,

  2. #2
    Rochester, NY
    Usually I see this on a post procedure chest x-ray and I code 998.81. I would choose the 518.1 if trauma is not indicated in the report and this is not post surgery. Can you get more information from the physician to make a final decision?
    Thanks, Jill

  3. #3
    Default re; subcutaneous emphysema
    Hi Jill,

    Thanks for your reply but here is the report ;

    CT chest, noncontrast

    Indication: Pneumothorax and subcutaneous emphysema, reinsertion of
    small caliber chest tube with Heimlich valve
    Spiral CT of the chest was obtained without contrast. There is a right
    pneumothorax of approximately 50% with extensive subcutaneous

    The skin was marked, then prepped and draped in the usual sterile
    fashion. Local anesthetic was injected through the chest wall. A small
    incision was made to allow for passage of the Heimlich valve catheter.

    The catheter was introduced and its position within the pleural space
    was confirmed. Suction was applied. There was partial reinflation of
    the right lung, and approximately 250 cc of serous fluid was removed.

    The Heimlich valve appeared to be working However, the lung did not
    completely expand on followup CT.

    Heimlich valve replacement with incomplete reexpansion of the right
    lung. Extensive subcutaneous and mediastinal air is noted.

    Severe bilateral interstitial and airspace disease

    Thank you,

  4. Default
    I would use the 998.81 in this case.

  5. #5
    Default re;
    Thank you very much!

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