Empyema without mention of fistula

This code represents the presence of pus within the pleural space, a condition known as empyema, where there is no documentation of an abnormal connection (fistula) to other organs or the skin. It signifies a localized collection of purulent material between the parietal and visceral pleura.

Use this code for patients diagnosed with empyema where the clinical documentation explicitly states the absence of a fistula. This is appropriate when imaging (e.g., CT scan) or surgical exploration confirms empyema without evidence of a bronchopleural, pleurocutaneous, or other type of fistula.

• Ensure documentation specifically negates the presence of a fistula; otherwise, a more specific code may be required.
• Do not use if a fistula is present; instead, select a code that includes fistula.
• Always sequence this code after the underlying cause of the empyema, if known (e.g., pneumonia, trauma).