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R91.8
ICD-10-CM
Ground Glass Opacity

Understand Ground Glass Opacity (GGO) with this comprehensive guide. Learn about GGO diagnosis, including differential diagnosis, CT findings, lung nodule management, and follow-up recommendations. Explore relevant medical coding and clinical documentation best practices for GGO, including ICD-10 codes, SNOMED CT, and appropriate terminology for accurate reporting. This resource provides valuable information for healthcare professionals, radiologists, pulmonologists, and medical coders seeking clarity on GGO diagnosis and documentation.

Also known as

GGO
Ground-glass opacities

Diagnosis Snapshot

Key Facts
  • Definition : Hazy lung area on CT scan, indicating possible inflammation or fluid.
  • Clinical Signs : Often asymptomatic, but can include cough, shortness of breath, and fever.
  • Common Settings : Infections, interstitial lung disease, and sometimes early-stage lung cancer.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R91.8 Coding
R07.8

Other respiratory signs and symptoms

Ground glass opacities can manifest as other respiratory issues.

J84.1

Other interstitial pulmonary diseases

GGOs may be associated with interstitial lung diseases.

J98.4

Other specified respiratory disorders

Ground glass opacity can fall under other respiratory disorders.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is GGO due to COVID-19?

  • Yes

    Code U07.1, COVID-19

  • No

    Is GGO related to vaping?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Ground Glass Opacity
Consolidation
Nodule

Documentation Best Practices

Documentation Checklist
  • Ground glass opacity size, density, and location documented.
  • Correlation with prior imaging and clinical context.
  • Consider and document differential diagnoses for GGO.
  • Management plan including follow-up or further workup.
  • ICD-10 code R91.8 (Other nonspecific abnormal findings on diagnostic imaging of lung)

Coding and Audit Risks

Common Risks
  • Nonspecific GGO Coding

    Coding GGO without specifying etiology (infection, inflammation, etc.) leads to inaccurate reporting and potential DRG misassignment.

  • GGO Size Documentation

    Lack of documented GGO size hinders accurate coding, impacting severity assessment and appropriate reimbursement.

  • Follow-up GGO Coding

    Inconsistent coding of resolving or persistent GGOs across encounters creates data integrity issues and impacts quality metrics.

Mitigation Tips

Best Practices
  • Document GGO size, density, location for accurate ICD-10 coding (R91.8).
  • Correlate GGO with clinical findings, history for CDI, risk adjustment.
  • Timely follow-up imaging crucial for GGO management, compliance guidelines.
  • Consider differential diagnosis for GGO (infection, inflammation) in documentation.
  • Multidisciplinary review for complex GGO improves diagnostic accuracy, coding.

Clinical Decision Support

Checklist
  • Verify size and location: Document precise measurements and anatomical location.
  • Assess for growth: Compare with prior imaging, note any changes in size or density.
  • Consider risk factors: Smoking history, occupational exposures, family history of lung cancer.
  • Evaluate for other findings: Look for nodules, lymphadenopathy, or pleural effusions.
  • Recommend follow-up: Schedule appropriate imaging based on Fleischner Society guidelines.

Reimbursement and Quality Metrics

Impact Summary
  • Ground Glass Opacity reimbursement hinges on accurate coding (ICD-10 J84.89, R91.8) and reporting for optimal claims processing.
  • GGO coding impacts quality metrics related to lung cancer screening, early detection, and treatment efficacy reporting.
  • Accurate GGO documentation affects hospital reimbursement for radiology services, pulmonology consultations, and potential biopsies.
  • Proper GGO coding and staging (size, location) are crucial for appropriate reimbursement under value-based care models.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Document GGO size/location
  • R/O infection, hemorrhage
  • Consider J98.8 for other
  • If multiple GGOs, code each
  • Specify 'ground glass opacity'

Documentation Templates

Patient presents with ground glass opacity (GGO) noted on chest CT scan.  The GGO finding was identified during a [reason for CT scan, e.g., routine lung cancer screening, evaluation of cough, follow-up for prior pneumonia].  The ground glass nodule measures [size] mm located in the [lobe] of the [right or left] lung.  Differential diagnosis includes infection, inflammation, pulmonary fibrosis, and lung cancer.  Patient denies symptoms of cough, shortness of breath, chest pain, hemoptysis, or fever.  Physical exam reveals clear lung sounds bilaterally.  Patient has a history of [relevant medical history, e.g., smoking, asbestos exposure, prior lung disease].  Current medications include [list medications].  Assessment includes pulmonary ground glass opacity, etiology undetermined.  Plan includes [mention of follow-up imaging, e.g., repeat CT scan in [timeframe], pulmonary function tests, consultation with pulmonology], further investigation to determine the etiology of the GGO, and discussion of risks and benefits of lung biopsy if indicated.  Patient education provided regarding the significance of ground glass opacities, the need for follow-up, and the importance of smoking cessation if applicable.  ICD-10 code R91.8 (other abnormal findings on diagnostic imaging of lung) may be considered depending on the clinical scenario.  CPT codes for the CT scan and any subsequent procedures will be documented separately.  Follow-up scheduled for [date].