Q21.16

Clinical notes

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

• •This code describes an unspecified presentation. If the medical record documents a more specific detail (e.g. laterality, type, or affected site), a more specific sibling code should be used instead — see Related codes below.
• •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.

Associated MS-DRGs

Q21.16 can serve as the principal diagnosis for these Medicare Severity Diagnosis-Related Groups.

Informational only — actual DRG assignment also depends on procedures, complications/comorbidities (CC/MCC), discharge status, and payer-specific rules not reflected here.

• DRG 205Other Respiratory System Diagnoses with MCC
• DRG 206Other Respiratory System Diagnoses without MCC
• DRG 306Cardiac Congenital and Valvular Disorders with MCC
• DRG 307Cardiac Congenital and Valvular Disorders without MCC