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ICD-10 Coding for Spontaneous Pneumothorax(J93.11, J93.12, J93.9)

Complete ICD-10-CM coding and documentation guide for Spontaneous Pneumothorax. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Primary Spontaneous PneumothoraxSecondary Spontaneous PneumothoraxPTX

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Related ICD-10 Code Ranges

Complete code families applicable to Spontaneous Pneumothorax

J93Primary Range

Pneumothorax and air leak

This range includes all types of pneumothorax, including spontaneous, tension, and chronic pneumothorax.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
J93.11Primary spontaneous pneumothoraxUse when pneumothorax occurs without any underlying lung disease.
  • CXR or CT showing pneumothorax
  • Absence of underlying lung disease
  • No history of trauma
J93.12Secondary spontaneous pneumothoraxUse when pneumothorax is associated with an underlying lung condition.
  • CXR or CT showing pneumothorax
  • Documentation of underlying lung disease
J93.9Pneumothorax, unspecifiedUse when documentation does not specify primary or secondary nature.
  • CXR or CT showing pneumothorax
  • Lack of specific documentation

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for primary spontaneous pneumothorax

Essential facts and insights about Spontaneous Pneumothorax

The ICD-10 code for primary spontaneous pneumothorax is J93.11, used when there is no underlying lung disease.

Primary ICD-10-CM Codes for spontaneous pneumothorax

J93.11
Primary spontaneous pneumothorax
Billable Code

Decision Criteria

clinical Criteria

  • No underlying lung disease present

Applicable To

  • Spontaneous pneumothorax without underlying lung disease

Excludes

  • Secondary spontaneous pneumothorax (J93.12)

Clinical Validation Requirements

  • CXR or CT showing pneumothorax
  • Absence of underlying lung disease
  • No history of trauma

Code-Specific Risks

  • Incorrectly coding as J93.9 when primary nature is documented

Coding Notes

  • Ensure documentation specifies 'primary' and absence of lung disease.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Personal history of pneumothorax

Z87.891
Use to indicate a history of pneumothorax if recurrent.

Cystic fibrosis, unspecified

E84.9
Use to specify the underlying condition when applicable.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Secondary spontaneous pneumothorax

J93.12
Presence of underlying lung disease such as COPD or cystic fibrosis.

Primary spontaneous pneumothorax

J93.11
No underlying lung disease.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Spontaneous Pneumothorax to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code J93.11.

Impact

Clinical: May lead to inappropriate treatment, Regulatory: Non-compliance with coding guidelines, Financial: Potential for incorrect billing and reimbursement

Mitigation Strategy

Thorough patient history, Detailed imaging reports

Impact

Reimbursement: May lead to lower reimbursement rates, Compliance: Non-compliance with coding specificity requirements, Data Quality: Decreases accuracy of clinical data

Mitigation Strategy

Ensure documentation specifies primary or secondary nature

Impact

Risk of audits due to non-specific coding of pneumothorax

Mitigation Strategy

Ensure detailed documentation to support specific code selection.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Spontaneous Pneumothorax, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Spontaneous Pneumothorax

Use these documentation templates to ensure complete and accurate documentation for Spontaneous Pneumothorax. These templates include all required elements for proper coding and billing.

Emergency Department Presentation

Specialty: Emergency Medicine

Required Elements

  • Patient history
  • Imaging results
  • Diagnosis
  • Treatment plan

Example Documentation

Patient presents with sudden chest pain. CXR shows right-sided pneumothorax. No history of lung disease. Diagnosis: Primary spontaneous pneumothorax.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Pneumothorax, admit for chest tube.
Good Documentation Example
Primary spontaneous pneumothorax (J93.11) confirmed by CT; no underlying lung disease. Plan: VATS pleurodesis.
Explanation
The good example provides specific diagnosis and treatment plan, enhancing coding accuracy.

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