air leak with pneumothorax
Patient admitted with spontaneous pneumothorax. Small bore chest tube placed and attached to wall suction. Repeat imaging revealed pneumothorax was larger. Pigtail chest tube was changed to a larger one. Large air leak with position change noted today. Repeat chest x-ray is documented as stable and shows slightly smaller pneumothorax. MD notes if airleak does not resolve may need surgical intervention.
Not sure if the air leak is expected with pneumothorax. When is it appropriate to you use code J93.82 Other air leak?
Comments
It seems the pneumonthorax is large and was not adequately treated with initial efforts, and that further efforts are expended to fully treat the condition.
Paul
I agree with Paul that the air leak is a component of the pneumothorax and wouldn't be coded separately.
Erik J. Kilbo, RHIA, CCS, CPC-I, CDIP, CCDS
When you get a spontaneous pneuo it is not uncommon at all to pick up the hemovac and notice a massive amount of bubbling in the waterseal chamber, especially if the patient has a diagnosis like emphysema, cancer, etc.
For idiopathic spontaneous pneumo in a young healthy person, massive air leaks are somewhat less common and may merit further investigation. Doctor noted it was positional though which makes me think the air link is occurring adjacent to the insertion site of the tube (it was someone improved with a larger chest tube) rather than from some other pathophysiology. If it is just positional it may self seal.
If they have to do surgery i would recommend looking deep into the record to determine a patho for the pneumo beyond idiopathic.
Surgery is not a routinely required intervention for the typical idiopathic spontaneous pneumo in a young other wise healthy person.
Perhaps a surgical resident inserted the chest tube and butchered the insertion site??