Cracking the Code

Congestive Heart Failure with Pleural Effusion

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.

J91.8 is an acceptable secondary diagnosis because of the additional x-ray to assess the volume

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: I50.9, heart failure, unspecified
J91.8, pleural effusion in other conditions classified elsewhere
Reference: AHA Coding Handbook Ch. 18: Diseases of the Respiratory System—Pleural Effusion
Coding Clinic 2nd Quarter 2015, pg. 16: Heart failure with pleural effusion
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