How to Document Pneumothorax – A Lung Condition Affecting the Pleura

How to Document Pneumothorax – A Lung Condition Affecting the Pleura

Read the article to know more about pneumothorax the lung condition, and its associated medical codes.

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Pneumothorax occurs when air leaks into the space between the lungs (known as the pleural space) making it to collapse. This air pushes on the outside of your lungs and makes it collapse, putting pressure on the heart.

Also known as lung collapse, this condition can occur as a complete collapse or a collapse of only a portion of the lungs. Normally, air can find its way in to the pleural space when there is an open injury in your chest wall or a tear or rupture in your lung tissue, disrupting the pressure that keeps your lungs inflated. The lung condition can be caused by a blunt or acute chest injury, damage from underlying lung disease or certain medical procedures.

However, in some cases, the condition may occur with no visible causes.

Symptoms usually include sudden chest pain and shortness of breath. In most cases, a small pneumothorax may heal on its own. On the other hand, a collapsed lung that involves larger volumes of air can become fatal causing severe complications. Treatment for pneumothorax will depend on the severity of your condition and involve both surgical and non-surgical modalities. Diagnosing and documenting the various types of lung collapses is a challenging task for physicians. Clear and precise medical record documentation is essential for accurate coding and sequencing for cognitive disorders. With

proper documentation,

medical billing and coding

companies can enable physicians to select the correct diagnosis codes and file clean claims for appropriate reimbursement.

Types of Pneumothorax and Its Causes Pneumothorax can be of two basic types - traumatic pneumothorax and nontraumatic pneumothorax. Either of these types can lead to a tension pneumothorax-–which occurs when the air surrounding the lung increases in pressure. This type is common in cases of trauma and requires emergency

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medical treatment.

This is caused by a leak in the pleural space that

resembles a one-way valve.

Traumatic pneumothorax –This type occurs due to some type of trauma or injury (major or minor) to the chest or wall. The trauma can damage chest structures and cause air to leak into the pleural space. Some of the top injuries that cause traumatic pneumothorax include – 

Trauma to the chest from a motor vehicle accident



Medical procedures that can damage the lung, such as a central line placement, ventilator use, lung biopsies, or CPR



Broken ribs



A stab wound or bullet wound to the chest



A hard hit or injury to the chest from a contact sport, such as from a football tackle

Non - traumatic pneumothorax - This type of pneumothorax does not occur after injury, instead, it happens spontaneously. There are two major types of spontaneous pneumothorax - primary and secondary. Often affecting young males who are

tall

and thin, primary

spontaneous

pneumothorax (PSP) occurs in people who have no known lung disease.

Secondary spontaneous pneumothorax (SSP), on the other hand tends to occur in older people with known lung problems. Factors that can increase the risk of non-traumatic pneumothorax include – chronic obstructive pulmonary diseases (COPD), acute or chronic infection (such as tuberculosis or pneumonia), lung cancer, cystic fibrosis and asthma.

Understanding the Symptoms Sudden chest pain and shortness of breath are one of the main symptoms associated with the condition. The onset of symptoms normally occurs at www.outsourcestrategies.com

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rest and in some cases often appears at the time of chest trauma or injury, or shortly afterward. Other associated symptoms include – 

Turning blue, or cyanosis



Tightness in the chest



Severe tachycardia, or a fast heart rate



Breaking out in a cold sweat



A steady ache in the chest

Persons who have been previously diagnosed with a lung disease have more risks for this condition. Generally, men are far more likely to have a pneumothorax than women. Other additional risk factors include – smoking, genetics, history of lung diseases, mechanical ventilation and previous pneumothorax. Many people who have had one pneumothorax can have another, typically within one to two years of occurrence of the first.

Diagnosing and Treating Pneumothorax Diagnosis of this condition is based on the presence of air in the space around the lungs. Imaging tests like – an upright posteroanterior chest radiograph (chest X-ray), computerized tomography (CT) scan, orthoracic ultrasound imaging may be done to identify more detailed images of the condition. The goal of treatment is to relieve the pressure on your lung, allowing it to re-expand. In addition, the treatment may also help prevent reoccurrences.

The method of achieving these goals may depend on the severity of lung diseases and the overall health of the patient. It may also depend on the fact that whether patients have experienced this lung condition before and if so what symptoms they experienced. Treatment modalities for this condition may include both surgical and nonsurgical modalities like - observation, needle aspiration, chest tube insertion, non-surgical repair or surgery. www.outsourcestrategies.com

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Surgical treatment for pneumothorax may be required only in certain situations like – when a person has repeated spontaneous pneumothorax, when a large amount of air trapped in the chest cavity or other lung conditions. Surgery may be performed as a last option to close the air leak.

There are different types of surgery for pneumothorax. One option is a thoracotomy. During this surgery, the surgeon will create an incision in the pleural space to help them see the problem. Another option is thoracoscopy (also known as video-assisted thoracoscopic surgery (VATS). As part of this surgery, the surgeon will insert a tiny camera through your chest wall to view inside your chest area. A thoracoscopy procedure can help your surgeon decide on the treatment for your pneumothorax. The possibilities include sewing blisters closed, closing air leaks, or removing the collapsed portion of your lung (also called lobectomy).

Cardiologists, pulmonologists or other related specialists who happen to diagnose and treat different types of pneumothorax and its related symptoms rely on reputable medical billing outsourcing companies for accurate documentation. ICD-10 codes for diagnosing pneumothorax include – J93 - Pneumothorax and air leak 

J93.0 - Spontaneous tension pneumothorax



J93.1 - Other spontaneous pneumothorax  J93.11 - Primary spontaneous pneumothorax  J93.12 - Secondary spontaneous pneumothorax



J93.8 - Other pneumothorax and air leak  J93.81 - Chronic pneumothorax  J93.82 - Other air leak  J93.83 - Other pneumothorax



J93.9 - Pneumothorax, unspecified

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Many people who have had one pneumothorax can have another, typically within one to two years of the first. In simple terms, having one pneumothorax increases the odds for a second. In some cases, air may continue to leak if the opening in the lung won't close. Surgery may be performed to close the air leak. It is estimated that less than 5 percent of people who have undergone surgery in combination with pleurodesis to repair a pneumothorax have the chances of developing pneumothorax again.

The long term outlook of the condition may depend on the size of the pneumothorax, as well as the causes and treatment options. Generally, a small pneumothorax that does not cause significant symptoms can resolve with observation or minimal treatment. On the other hand, when the pneumothorax is large or occurs due to an underlying lung disease, treatment and recovery may become more complicated. However, a pneumothorax that continues to reoccur can be even more challenging to treat.

The support of an experienced and professional medical coding service provider can be invaluable to document pneumothorax properly. Coders in reliable medical billing and coding companies would ensure accurate reporting of diagnostic details. If the documentation is incomplete in any way, they will ask the physician for additional clarification, which in a way helps avoid denied and delayed claims.

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