Pyothorax without fistula

This code signifies the presence of pus within the pleural space, the area between the lung and the chest wall, without any abnormal connection or tract to other organs or the skin. It represents an infection leading to empyema, where purulent fluid accumulates in the pleura.

Apply this code when documentation clearly indicates empyema or pyothorax without mention of a fistula. This is typically supported by imaging reports (e.g., chest X-ray, CT scan) showing pleural effusion with characteristics of pus, and/or aspiration of purulent fluid from the pleural space.

• Differentiate from other pleural effusions; the key is the presence of pus.
• If a fistula is documented, a more specific code from the J86 category should be used.
• Always sequence this code after the underlying cause of the pyothorax, if known and documented (e.g., bacterial pneumonia).