Q&A: Reporting plural effusion with congestive heart failure

Q: At my institution, we typically do not capture the pleural effusions noted and documented with a congestive heart failure (CHF) exacerbation unless a pleural tap was completed. Coding Clinic states it is acceptable to report pleural effusion J91.8 if the condition requires either therapeutic intervention or diagnostic testing. All of our CHF exacerbations get at least one chest x-ray. Is that enough “diagnostic testing” to code the secondary condition?

A: There is coding guidance that if a condition is thought to be integral to another you would not code it. For example, a hyponatremia in syndrome of inappropriate antidiuretic hormone secretion (SIADH), or in your scenario, a pleural effusion and acute heart failure. The definition of integral is that which would occur in most, if not all, of the individuals with the specific underlying condition.

We would indeed be able to report the pleural effusion if the patient received care over and above that given to the normal patient, or if the provider was able to identify another etiology for the pleural effusion. For example, if it were an infectious effusion or due to malignancy, you would be able to report the diagnosis.

Treatment over and above normal for this patient with heart failure would include a thoracentesis. A simple chest x-ray would not allow reporting the effusion. But AHA Coding Clinic, third quarter, 1991, does support that if a decubitus chest x-ray is ordered this can allow reporting. A decubitus chest is an image from the side that is routinely used to assess effusions.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.