N95.1 - Menopausal and female climacteric states

Clinical Definition

An acute sanguineous (bloody) pleural effusion caused by trauma, including both blunt force injuries and penetrating wounds. Blood accumulates in the pleural space between the lung and chest wall.

Documentation Requirements

• Must document "hemothorax" specifically

• Specify laterality (right, left, or bilateral)

• Document acuity (acute, chronic, or acute on chronic)

• Indicate traumatic cause (e.g., motor vehicle accident, fall, stabbing)

• Document any associated injuries

• Include presence of active bleeding vs. resolved

• Note volume of blood if measured

• Document any interventions (chest tube, thoracentesis)

Common Synonyms

• Blood in chest cavity

• Bleeding around lungs

• Blood between lung and ribs

• Bloody chest fluid

• Post-trauma chest bleeding

Coding Conflicts

Excludes1:

• Hemopneumothorax (J94.2)

• Spontaneous hemothorax (J94.2)

• Non-traumatic hemothorax

Scribing.io Automation

Our AI scribe automatically:

• Detects mentions of blood in pleural space

• Tags trauma-related keywords

• Identifies laterality terms

• Links associated procedures

• Highlights acuity descriptors

• Captures quantitative measurements

• Flags when documentation is insufficient for code assignment

The system requires specific mention of "hemothorax" and a clear traumatic cause to assign this code correctly.