Secondary spontaneous pneumothorax

This code signifies a collapsed lung that occurs without an apparent external cause, in a patient with underlying lung disease. It represents a non-traumatic accumulation of air in the pleural space, secondary to a pre-existing pulmonary condition.

Use this code when documentation clearly indicates a spontaneous pneumothorax in a patient with a known lung pathology such as COPD, cystic fibrosis, or interstitial lung disease. The physician's notes should specify the spontaneous nature and the underlying pulmonary condition contributing to the collapse.

• Differentiate from primary spontaneous pneumothorax (J93.11), which occurs in individuals without underlying lung disease.
• Ensure the medical record explicitly states "secondary" and identifies the underlying lung condition.
• Sequence this code as the principal diagnosis when it is the reason for the encounter, followed by codes for the underlying lung disease.