Traumatic pneumothorax without mention of open wound into thorax

This code signifies the presence of air in the pleural space resulting from a non-penetrating chest injury, such as blunt trauma. It specifically indicates that there is no associated external opening or communication between the outside environment and the thoracic cavity. The air accumulation causes partial or complete lung collapse.

Apply this code when documentation clearly states a pneumothorax occurred due to trauma, and there is no mention of an open wound to the chest. This is typically seen in cases of motor vehicle accidents, falls, or direct blows to the chest without skin laceration or penetration. The physician's notes should explicitly link the pneumothorax to a traumatic event and confirm the absence of an open wound.

• Differentiate from spontaneous pneumothorax, which arises without external trauma.
• Ensure documentation specifies "without open wound" to avoid miscoding with penetrating injuries.
• Sequence this code as a principal diagnosis if it is the primary reason for the encounter, or as a secondary diagnosis if another condition is being treated concurrently.