AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 3; Ask the Editor

Malignant Pleural Effusion

A patient was admitted with recurrent malignant pleural effusion, and thoracentesis with placement of a PleurX™ catheter was performed. Pleural fluid cytology was positive for cancer cells. The patient has a past history of left breast cancer and at that time underwent a lumpectomy. More recently, she was diagnosed with invasive ductal carcinoma of the left breast ER/PR positive, HER2 negative, and had a bilateral mastectomy. The patient also has known metastases to the cervical lymph nodes, liver and bone, and is on adjuvant Tamoxifen therapy. Would it be appropriate to assign code J91.0, Malignant pleural effusion, as the principal diagnosis? The instructional note at code J91.0 directs “Code first the underlying neoplasm.” ...

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