Find key information on malignant pleural effusion including diagnosis codes, ICD-10 codes, clinical documentation requirements, treatment options, and prognosis. Learn about the medical coding guidelines for malignant pleural effusion and best practices for healthcare professionals documenting this condition. This resource provides essential details on pleural fluid analysis, cytology, thoracentesis procedures, and management of malignant pleural effusions for accurate clinical documentation and appropriate medical billing.
Also known as
Pleural effusion
Abnormal fluid buildup around the lungs.
Malignant neoplasm of bronchus
Cancer originating in the bronchi of the lungs.
Secondary malignant neoplasm of pleura
Cancer that has spread to the pleura from another site.
Malignant neoplasms of thymus, heart
Cancers affecting the thymus, heart, and related structures.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pleural effusion due to a primary malignant neoplasm of the pleura (mesothelioma)?
Yes
Code C45.0 Malignant mesothelioma of pleura
No
Is the pleural effusion due to secondary malignancy?
When to use each related code
| Description |
|---|
| Malignant Pleural Effusion |
| Parapneumonic Effusion |
| Heart Failure Effusion |
Coding malignant pleural effusion without specifying laterality (right, left, or bilateral) can lead to claim rejections and inaccurate data reporting. Use ICD-10-CM coding guidelines for laterality documentation.
Discrepancy between documented primary malignancy and pleural effusion coding. Ensure ICD-10-CM codes accurately reflect the primary site for accurate cancer registry data and reimbursement.
Insufficient clinical documentation to support malignant pleural effusion diagnosis. Clear documentation of malignancy confirmation (cytology, biopsy) is crucial for accurate coding and compliance with medical necessity guidelines.
Patient presents with symptoms suggestive of malignant pleural effusion, including dyspnea, pleuritic chest pain, and cough. Physical exam reveals decreased breath sounds and dullness to percussion over the affected hemithorax. Imaging studies, including chest x-ray and pleural fluid analysis, are indicative of a malignant pleural effusion. Thoracentesis was performed, and cytology is pending. Differential diagnosis includes parapneumonic effusion, heart failure, and tuberculosis pleural effusion. Preliminary diagnosis of malignant pleural effusion is based on clinical presentation, imaging findings, and patient history of [primary malignancy, if known]. Plan includes further investigation to determine primary malignancy if not already established, including consideration of bronchoscopy, CT scan of the chest, abdomen, and pelvis, and possible pleural biopsy. Treatment options will be discussed with the patient upon confirmation of diagnosis and identification of primary malignancy, and may include palliative thoracentesis, pleurodesis, or placement of an indwelling pleural catheter. Patient education provided regarding the nature of malignant pleural effusions, potential complications, and treatment options. ICD-10 code J90 to be confirmed upon cytology results. CPT codes for thoracentesis (32554 or 32555) and subsequent procedures will be documented accordingly. Ongoing monitoring of respiratory status and symptomatic management will be provided. Referral to oncology and pulmonology is planned.