Pleural effusion

Patient admitted with new onset AF.  Also c/o some chest pain.  D-dimer was elevated.  Chest CT was done showing small bilateral pleural effusions.  Pleural effusion was documented by the attending and likely felt to be related to the AF.  No further workup was done.  If coded, pleural effusion would be only CC.  I feel the diagnosis should not be coded as it does not meet secondary diagnosis.  If you feel this should be coded and can you please explain you're thoughts on why.  . 

Comments

  • I would not unless there were repeat CXR to monitor it.
  • Thank you for your thoughts.
  • PE associated with pulmonary disease and certain cardiac conditions, such as CHF is 'almost' always integral to the underlying disease and is usually addressed by treatment of the underlying condition.  It may  be considered for reporting if/when 'addressed separately, with additional diagnostic studies, such as radiological studies and or diagnostic or therapeutic thoracentesis or chest-tube drainage.  It needs to be 'investigated/treatment' in a manner not typical.  One would code it if cause not know, or if malignant. 


    Paul Evans, RHIA, CCDS

  • In this situation, I would probably query especially since it would be my only CC.  The fact that he noted it specifically in his progress notes would be my queue.  (I would not query if it was only noted in a radiology summary report that was pulled into the progress notes)   I would just ask if it was an incidental finding on the chest CT or if there was any clinical significance that required monitoring, treating or evaluating.  
  • edited February 7
    Patient admitted with new onset AF.  Also c/o some chest pain.  D-dimer was elevated.  Chest CT was done showing small bilateral pleural effusions.  Pleural effusion was documented by the attending and likely felt to be related to the AF.  No further workup was done.  If coded, pleural effusion would be only CC.  I feel the diagnosis should not be coded as it does not meet secondary diagnosis.  If you feel this should be coded and can you please explain you're thoughts on why.  . 


    Q: What is causing the effusions as AF with CHF would cause the effusions rather than Atrial Fibrillation alone, and the original post states the effusions are in the setting of atrial fibrillation w/o mention of any other condition.

     Are the effusions resolving with treatment of the etiology? 

    The fact these are termed 'small' indicates they may not necessarily be clinically significant.  Given the quote states these are documented,  it may be most appropriate to pose a query that would address to clinical significance.   (How is the condition impacting medical-decision making, treatment, diagnostic efforts, nursing care)? 

    If a review indicates the conditions required to meet the UHDDS definition of a reportable condition are not present, it should not be coded.  From the description that these are small, I would not pursue unless there is evidence these are being specifically addressed as mentioned by others on this topic.

    You may also find that coding will not code 'small' plueral effusions unless there is a basis for coding them separately.

    Coding pleural effusions that occur in the setting of conditions known to cause them is the exception rather than rule - there are exceptions, however

    Year:1991
    Issue:Third Quarter
    Title: Pleural Effusion with Congestive Heart Failure
    Body: 

    VOLUME 8        THIRD QUARTER

    NUMBER 3        1991, Page 19

     

    Pleural Effusion with Congestive Heart Failure

     

    Question: Is pleural effusion an integral part of congestive heart failure and included in code 428.0, or should an additional code be assigned? Could the code for pleural effusion ever be the principal diagnosis when associated with congestive heart failure?

     

    Answer: The congestive heart failure (428.0) would always be the principal diagnosis; in some instances the pleural effusion may be reported as an additional diagnosis.

     

    Pleural effusion is commonly seen with congestive heart failure with or without pulmonary edema. The pulmonary veins and lymphatics drain the pleural space and return fluid to the heart. In left heart failure, which results in elevated pressures in the venous system, there is usually some accumulation of fluid in the pleural space. Ordinarily the pleural effusion is minimal and is not specifically addressed other than by more aggressive treatment of the underlying congestive heart failure. In this situation it should not be reported unless the coder is directed to do so by the physician.

     

    Pleural effusion documented only as an x-ray finding without the physician having made such a diagnosis should not be reported. Occasionally, however, special x-rays such as decubitus views are required to confirm the presence of pleural effusion or diagnostic thoracentesis may be performed to identify its etiology. In other cases, it may be necessary to address the effusion by therapeutic thoracentesis or chest tube drainage. In any of these situations, it is acceptable to report pleural effusion (511.9) as an additional diagnosis since the condition was specifically evaluated or treated, but reporting is not required.

     

    Paul Evans, RHIA, CCDS

  • I'd not code the pleural effusion, even though it is stated  in the notes, unless there is additional supporting information in the medical record.  The original question states 'no further work up was done'.

    PE

  • Thank you for you're input.
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