Primary spontaneous pneumothorax
ICD-10 J93.11 is a billable code used to indicate a diagnosis of primary spontaneous pneumothorax.
Primary spontaneous pneumothorax (PSP) is characterized by the sudden accumulation of air in the pleural space without any preceding trauma or underlying lung disease. It typically occurs in tall, young males aged 10 to 30 years, although it can affect individuals of any age. Clinically, patients may present with sudden onset chest pain and dyspnea, often exacerbated by physical activity. The anatomy involved includes the pleura, which is the membrane surrounding the lungs, and the alveoli, where gas exchange occurs. The disease progression can vary; while some patients may experience a self-limiting course, others may require medical intervention, such as needle decompression or chest tube placement, especially if the pneumothorax is large or symptomatic. Diagnostic considerations include a thorough history and physical examination, followed by imaging studies such as chest X-ray or CT scan to confirm the presence of air in the pleural space. Early recognition and appropriate management are crucial to prevent complications such as tension pneumothorax, which can be life-threatening.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
J93.11 specifically covers primary spontaneous pneumothorax, which occurs without any underlying lung disease or trauma. It is important to differentiate it from secondary spontaneous pneumothorax, which arises due to pre-existing lung conditions.
J93.11 should be used when the pneumothorax is confirmed to be primary and spontaneous, without any identifiable cause such as lung disease or trauma. If there is an underlying condition, J93.12 should be considered.
Documentation should include a detailed history of the patient's symptoms, physical examination findings, imaging results confirming the pneumothorax, and a statement indicating the absence of underlying lung disease.
