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2025 ICD-10-CM code J91

Pleural effusion in conditions classified elsewhere.

Do not use J91 for pleural effusion due to heart failure (I50.-) or systemic lupus erythematosus (M32.13), which are specifically excluded. When a respiratory condition affects multiple sites, code to the lower anatomic site, per ICD-10-CM guidelines.

Medical necessity for the treatment of pleural effusion is established by the underlying condition causing it. The documentation should support the medical necessity of the procedures performed to diagnose and treat both the effusion and the primary condition.

Clinicians should identify and document the underlying cause of the pleural effusion to ensure accurate coding.Thorough physical examination, imaging studies (like chest X-rays or CT scans), and laboratory tests may be necessary to determine the etiology and guide appropriate management.

In simple words: Fluid buildup around the lungs due to another medical problem.

Presence of excess fluid in the pleural space, the area between the lungs and the chest wall, arising from an underlying condition other than those specifically excluded.

Example 1: A patient with pneumonia develops a pleural effusion as a complication. The effusion is coded as J91, with an additional code for the pneumonia., A patient with a history of malignancy presents with shortness of breath and is found to have a large pleural effusion. If the effusion is confirmed to be malignant, it would be coded as J91.0 (malignant pleural effusion), along with code(s) for primary site and any associated metastasis., A patient with congestive heart failure develops pleural effusion (I50.-), a common complication of heart failure. This is different than J91 which excludes pleural effusion caused by heart failure.

Documentation should clearly specify the presence of pleural effusion, the underlying cause, and any associated symptoms or clinical findings. Diagnostic reports, such as chest X-rays or CT scans, should be included to confirm the diagnosis. If the effusion is determined to be malignant, pathology reports confirming the diagnosis of malignancy are essential.

** Distinguishing between J91 and specific effusion codes is crucial for accurate reporting and reimbursement. If the effusion is a direct result of another classified condition (other than exclusions), J91 is used. Use additional codes to identify exposure to tobacco smoke (Z77.22, P96.81, Z87.891, Z57.31), tobacco dependence (F17.-), or tobacco use (Z72.0) if applicable.

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