Primary spontaneous pneumothorax

This code signifies the sudden onset of a collapsed lung in an individual without a history of lung disease or trauma. It results from the rupture of small air sacs (blebs) on the lung surface, allowing air to leak into the pleural space and compress the lung.

Apply this code when documentation clearly indicates a spontaneous pneumothorax in a patient with no underlying pulmonary pathology or recent injury. This diagnosis is often made clinically with confirmation by chest X-ray or CT scan.

• Differentiate from secondary spontaneous pneumothorax (J93.12), which occurs in patients with pre-existing lung disease.
• Ensure documentation specifies "primary" and "spontaneous" to support this code.
• Do not use for pneumothorax due to trauma, iatrogenic causes, or other specified etiologies.