Spontaneous tension pneumothorax

This code represents a life-threatening condition where air accumulates in the pleural space, causing the lung to collapse, and the pressure within the chest cavity shifts mediastinal structures, impairing cardiac function and venous return. It occurs without any preceding trauma or medical intervention, often due to a rupture of a bleb or bulla on the lung surface.

Use this code when documentation clearly indicates a pneumothorax that developed spontaneously and is specifically identified as a tension pneumothorax. This diagnosis is typically supported by findings such as tracheal deviation, hemodynamic instability, and absent breath sounds on the affected side, confirmed by imaging.

• Differentiate from traumatic or iatrogenic pneumothorax; this code is strictly for spontaneous origin.
• Ensure documentation specifies "tension" pneumothorax, as simple spontaneous pneumothorax has a different code.
• Consider sequencing this code as a principal diagnosis if it is the primary reason for the admission and treatment.