Coding Tip: Reporting Pleural Effusion with Congestive Heart Failure

by Jun 10, 2016Industry News, Medical Coding Tips0 comments

This Coding Tip was updated on 12/10/2018

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

When is it appropriate to report J91.8 as an SDX in a patient with CHF?

Pleural Effusion is common in patients with Congestive Heart Failure. This is usually minimal and requires no additional treatment than that given for the heart failure. Pleural Effusion should not be coded when only found as a radiological finding without the physician concurring with the finding and addressing it by one of the methods below.

Pleural Effusion (PE) may be reported as an additional secondary diagnosis code when associated with heart failure when the effusion is specifically evaluated or treated. This instruction did not change from ICD-9 to ICD-10 coding.

If additional x-rays are required to monitor the PE or special x-rays, such as decubitus views, are ordered to confirm the diagnosis the PE would be reported as an SDX code.  If the patient requires thoracentesis or chest tube drainage for therapeutic treatment of the PE then it would be appropriate to report as an SDX code.

References: Coding Clinic, Second Quarter ICD-10-2015 Pages: 15-16 Effective with discharges: July 6, 2015

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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