Spontaneous tension pneumothorax

This code represents a pneumothorax that occurs without an apparent external cause (spontaneous) and where air accumulates in the pleural space under positive pressure, leading to a mediastinal shift and hemodynamic compromise (tension). It is a life-threatening condition requiring immediate intervention.

Use this code when documentation clearly indicates a spontaneous pneumothorax with features of tension, such as mediastinal shift, tracheal deviation, or hemodynamic instability. This diagnosis is typically made in an emergency setting based on clinical presentation and imaging findings.

• Differentiate from simple spontaneous pneumothorax, which lacks the tension component.
• Ensure documentation explicitly states "tension" or describes the physiological effects of tension (e.g., mediastinal shift, hypotension).
• Always sequence this code as the principal diagnosis when it is the primary reason for the encounter.