AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Quarter 3; Ask the Editor
Lung Decortication for Empyema
A patient, who is status post Collis gastroplasty and Nissen fundoplication, is diagnosed with empyema of the left chest for which lung decortication is performed. What is the appropriate root operation for lung decortication due to empyema? ...
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Article Overview
This short coding guidance article addresses a thoracic procedure performed in the setting of empyema and explains why the operative record may need clarification before coding can be finalized. It is aimed at coding professionals who work with inpatient procedure coding and need to interpret procedure documentation in a compliant way.
Why This Topic Matters
Procedure coding depends on accurate documentation of what was actually done. This article matters because incomplete operative detail can affect correct code assignment and may require provider clarification.
What You Will Learn
- The clinical and documentation context for a lung decortication case
- Why operative detail matters when procedure documentation is incomplete
- When physician clarification may be needed before selecting a code or root operation
- How thoracic procedure documentation can affect inpatient coding review
Who Should Read This
- Inpatient coders
- Clinical documentation improvement specialists
- Coding auditors
- Health information management professionals
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