Traumatic pneumohemothorax without mention of open wound into thorax

This code signifies the presence of both air (pneumothorax) and blood (hemothorax) in the pleural space, resulting from a non-penetrating chest injury. It indicates that the chest wall itself was not breached by an open wound, but internal trauma led to the accumulation of air and blood.

Apply this code when documentation clearly states a traumatic pneumohemothorax without an associated open chest wound. This typically follows blunt force trauma to the chest, such as from a motor vehicle accident or a fall, where imaging confirms both air and blood in the pleural cavity.

• Ensure documentation explicitly denies an open wound into the thorax; otherwise, a different code may be more appropriate.
• Always code the underlying cause of the trauma (e.g., E-code) in addition to this diagnosis.
• Distinguish from spontaneous pneumohemothorax, which is not trauma-induced.