Cracking the Code
Coding CHF with Pleural Effusion
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Pleural effusion is a typical disorder that is seen in patients who have congestive heart failure. It is an abnormal accumulation of fluid within the pleural space. If the physician completes therapeutic intervention or diagnostic testing for the pleural effusion, then it is acceptable to report it as a secondary diagnosis. If the physician does NOT specifically evaluate or treat the pleural effusion separately from the congestive heart failure, then it should NOT be reported as a secondary diagnosis.
Q: A patient is admitted into the inpatient setting with congestive heart failure and pleural effusion. The congestive heart failure is monitored with chest x-rays, and the physician also completes an additional lateral decubitus x-ray to assess the volume of pleural effusion. The patient’s final diagnosis is congestive heart failure with pleural effusion.
A: 150.9, heart failure, unspecified J91.8, pleural effusion in other conditions classified elsewhere (acceptable secondary diagnosis because of the additional x-ray to assess the volume)
Reference: AHA Coding Handbook Ch. 18: Diseases of the Respiratory System—Pleural Effusion Coding Clinic 2114 Quarter 2015, pg. 16: Heart failure with pleural effusion