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ICD-10 Coding for Pneumothorax(J93.11, J93.12, S27.0XXA, J95.811)

Complete ICD-10-CM coding and documentation guide for Pneumothorax. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Collapsed lungPTXair leak syndrome

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Related ICD-10 Code Ranges

Complete code families applicable to Pneumothorax

J93Primary Range

Pneumothorax and air leak

This range includes all types of pneumothorax, including spontaneous, traumatic, and postprocedural.

S27

Injury of other and unspecified intrathoracic organs

This range includes traumatic pneumothorax codes.

J95

Postprocedural respiratory disorders

This range includes postprocedural pneumothorax.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
J93.11Primary spontaneous pneumothoraxUse for pneumothorax occurring spontaneously without underlying lung disease.
  • Chest X-ray or CT showing pneumothorax
  • No history of underlying lung disease
J93.12Secondary spontaneous pneumothoraxUse for pneumothorax occurring in the presence of underlying lung disease.
  • Chest X-ray or CT showing pneumothorax
  • Documentation of underlying lung disease
S27.0XXATraumatic pneumothorax, initial encounterUse for pneumothorax resulting from trauma.
  • Trauma history
  • Imaging showing pneumothorax
J95.811Postprocedural pneumothoraxUse for pneumothorax occurring as a complication of a medical procedure.
  • Procedure report linking pneumothorax to procedure

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for primary spontaneous pneumothorax

Essential facts and insights about Pneumothorax

The ICD-10 code for primary spontaneous pneumothorax is J93.11, used when no underlying lung disease is present.

Primary ICD-10-CM Codes for pneumothorax

J93.11
Primary spontaneous pneumothorax
Billable Code

Decision Criteria

clinical Criteria

  • No underlying lung disease present

documentation Criteria

  • Explicit documentation of spontaneous pneumothorax

Applicable To

  • Spontaneous pneumothorax without underlying lung disease

Excludes

Clinical Validation Requirements

  • Chest X-ray or CT showing pneumothorax
  • No history of underlying lung disease

Code-Specific Risks

  • Misclassification if underlying lung disease is present

Coding Notes

  • Ensure documentation specifies absence of underlying lung disease.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Shortness of breath

R06.02
Use if shortness of breath is documented but not integral to pneumothorax.

Personal history of nicotine dependence

Z87.891
Use if patient has a history of smoking.

Fracture of rib(s), initial encounter

S22.3XXA
Use if rib fractures are present.

Other specified postprocedural states

Z98.89
Use if additional postprocedural conditions are present.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Secondary spontaneous pneumothorax

J93.12
Presence of underlying lung disease such as COPD or cystic fibrosis.

Primary spontaneous pneumothorax

J93.11
No underlying lung disease present.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Pneumothorax to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code J93.11.

Impact

Clinical: Lack of specificity can affect treatment decisions., Regulatory: May lead to coding audits and denials., Financial: Potential loss of reimbursement for specific conditions.

Mitigation Strategy

Always specify type and laterality when possible., Query provider for missing details.

Impact

Clinical: Inaccurate patient records., Regulatory: Non-compliance with coding standards., Financial: Incorrect DRG assignment affecting reimbursement.

Mitigation Strategy

Ensure encounter type is documented in the medical record., Educate staff on importance of 7th character usage.

Impact

Reimbursement: Incorrect DRG assignment can lead to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data affecting patient records and statistics.

Mitigation Strategy

Ensure 'A' is used for initial encounters and 'D' for subsequent encounters.

Impact

Reimbursement: Potential denial of claims due to lack of documentation., Compliance: Violation of coding standards., Data Quality: Misleading data on procedural complications.

Mitigation Strategy

Require explicit provider documentation linking pneumothorax to the procedure.

Impact

Use of unspecified codes when specific details are available.

Mitigation Strategy

Encourage detailed documentation and provider queries.

Impact

Misuse of encounter type characters leading to incorrect coding.

Mitigation Strategy

Regular training on 7th character guidelines.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Pneumothorax, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Pneumothorax

Use these documentation templates to ensure complete and accurate documentation for Pneumothorax. These templates include all required elements for proper coding and billing.

Primary spontaneous pneumothorax

Specialty: Pulmonology

Required Elements

  • Patient demographics
  • Onset and nature of symptoms
  • Imaging results
  • Absence of underlying lung disease

Example Documentation

42M with sudden-onset pleuritic chest pain. CXR shows 25% right apical pneumothorax without mediastinal shift. No history of lung disease or trauma. Final Diagnosis: Primary spontaneous pneumothorax (J93.11).

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has pneumothorax.
Good Documentation Example
Patient presents with sudden-onset chest pain. CXR confirms 30% right pneumothorax. No history of lung disease. Diagnosis: Primary spontaneous pneumothorax.
Explanation
The good example provides detailed clinical context and imaging confirmation, supporting the diagnosis.

Postprocedural pneumothorax

Specialty: Surgery

Required Elements

  • Procedure details
  • Imaging results
  • Complication statement

Example Documentation

Pneumothorax occurred during ultrasound-guided lung biopsy. Chest tube placed under fluoroscopy. Documented as complication of procedure (J95.811).

Examples: Poor vs. Good Documentation

Poor Documentation Example
Pneumothorax after procedure.
Good Documentation Example
Pneumothorax occurred during thoracentesis, confirmed by CXR. Documented as a complication of the procedure.
Explanation
The good example specifies the procedure and confirms the complication with imaging.

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