Empyema with fistula

This code signifies the presence of a collection of pus within the pleural cavity (empyema) that has formed an abnormal connection or passageway (fistula) to another organ, the skin, or the bronchial tree. This condition often arises as a complication of pneumonia, trauma, or surgery, leading to persistent infection and drainage.

Assign this code when documentation clearly indicates both an empyema and the presence of a fistula, such as a bronchopleural fistula, pleurocutaneous fistula, or pleuroenteric fistula. This typically follows surgical intervention, prolonged infection, or significant chest trauma.

• Ensure the documentation explicitly states the presence of a fistula in addition to empyema; otherwise, a simple empyema code may be more appropriate.
• Investigate for an underlying cause of the empyema and fistula, such as a bacterial infection, and code it as a secondary diagnosis if applicable.
• Do not confuse with codes for empyema without fistula, as the presence of a fistula significantly alters the clinical picture and treatment.