Q&A: Documenting pleural effusion and congestive heart failure

Q: Can you explain when to code pleural effusion as a secondary diagnosis when it is present with congestive heart failure?

A: Usually, pleural effusion is integral to congestive heart failure and isn’t coded as a secondary diagnosis. But, if the physician documents that the pleural effusion is clinically significant and required monitoring and further evaluation, then it can be reported as a secondary diagnosis.

But, in order to code this way, a coder would have to have some further evaluation documented, such as a decubitus chest x-ray, treatment by thoracentesis, or a chest tube. Most of the time, though, pleural effusion won’t be coded along with congestive heart failure.

Editor’s Note: Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, answered this question in the recent HCPro webinar Cardiovascular Coding: Achieve Success with the Latest ICD-10-CM/PCS Codes.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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