Reporting Pleural Effusion with Congestive Heart Failure

When is it appropriate to report pleural effusion as an SDX in a patient with CHF?

Pleural Effusion is common in patients with Congestive Heart Failure. This is usually minimal and requires no additional treatment than that given for the heart failure. Pleural Effusion should not be coded when only found as a radiological finding without the physician concurring with the finding and addressing it by one of the methods below.

Pleural Effusion (PE) may be reported as an additional secondary diagnosis code when associated with heart failure when the effusion is specifically evaluated or treated. This instruction did not change from ICD-9 to ICD-10 coding.

If additional x-rays are required to monitor the PE or special x-rays, such as decubitus views, are ordered to confirm the diagnosis the PE would be reported as an SDX code.  If the patient requires thoracentesis or chest tube drainage for therapeutic treatment of the PE, then it would be appropriate to report as an SDX code.

Examples:

• Patient presents in exacerbation of chronic diastolic congestive heart failure. Chest x-ray shows moderate sized pleural effusion. This cleared with the treatment for the acute congestive heart failure. In this case, pleural effusion would not be coded.
• Patient presents in exacerbation of chronic diastolic heart failure. Chest x-ray shows moderate sized pleural effusion. Thoracentesis was considered and scheduled, but the effusion cleared with IV diuresis. In this case, it would be appropriate to report the pleural effusion as an additional SDX. The condition was specifically evaluated.
  

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References: 

Coding Clinic, Second Quarter ICD-10-2015 Pages: 15-16 Effective with discharges: July 6, 2015

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.