CHF and Pleural Effusion

lolly1024lolly1024
in Clinical & Coding

I have a question: At my institution, we typically do not capture the pleural effusions noted and documented with a CHF exacerbation unless a pleural tap was completed as it stands now. The 2015 coding clinic states it is acceptable to report pleural effusion J91.8...if the condition requires either therapeutic intervention or diagnostic testing. All of our CHF exacerbations get at least one chest xray. Is that enough "diagnostic testing" to code the secondary condition? What does everyone else do with pleural effusions and chf exacerbation?

Comments

  • afloyd24afloyd24
    We have come to an agreement at our facility that if there is a thoracentesis, a left lateral decubitus cxr OR any other imaging with the indication for the test listed as pleural effusion to code it.  If the physician states the pleural effusion and then restates after a follow up cxr something to the effect of "cxr shows decreasing pleural effusion" showing that he is following it, we code it. 
  • hooter1964hooter1964
    Agree with afloyd24!
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