Understand lung infiltrate diagnosis, clinical documentation, and medical coding. Find information on lung infiltrate symptoms, causes, treatment, and prognosis. Learn about related terms like pulmonary infiltrate, pneumonia, interstitial lung disease, and atelectasis. Explore resources for healthcare professionals, including ICD-10 codes, differential diagnosis, and radiology findings for lung infiltrates. This resource provides comprehensive information for accurate clinical documentation and appropriate medical coding related to lung infiltrates.
Also known as
Pneumonia, organism unspecified
Lung inflammation caused by various germs, not specifically identified.
Pneumonitis due to solids and liquids
Lung inflammation from inhaling foreign substances like food or chemicals.
Abnormal respiratory sounds
Covers various abnormal breathing sounds, often indicating lung issues like infiltrates.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the lung infiltrate due to a specific infectious agent?
Yes
Is it bacterial pneumonia?
No
Is it due to a non-infectious cause?
When to use each related code
Description |
---|
Lung Infiltrate |
Pneumonia |
Pulmonary Edema |
Coding J18.9 (Pneumonia, unspecified) without documented etiology or further specification like bacterial vs viral leads to lower reimbursement and audit risk.
Lack of clear clinical indicators and supporting documentation for lung infiltrate diagnosis may raise questions of medical necessity during audits, impacting payment.
Failing to document laterality (right, left, bilateral) when coding lung infiltrates can lead to coding errors and claim denials. CDI can query for this specificity.
Patient presents with signs and symptoms suggestive of a lung infiltrate. Presenting complaints include cough, shortness of breath (dyspnea), chest pain, and possible fever. On physical examination, the patient may exhibit tachypnea, diminished breath sounds, crackles or rales on auscultation, and potential signs of respiratory distress. The patient's medical history may include recent respiratory infection, aspiration risk, underlying lung disease such as COPD or asthma, or immunocompromised status. Differential diagnosis includes pneumonia, pulmonary edema, interstitial lung disease, and lung cancer. Chest X-ray or CT scan of the chest was ordered to evaluate for the presence, location, and extent of the infiltrate. Laboratory studies such as complete blood count (CBC) with differential, blood cultures, and inflammatory markers (e.g., CRP, ESR) may be indicated. Sputum cultures and arterial blood gas analysis may be performed as clinically necessary. Initial treatment plan includes addressing the underlying cause of the infiltrate, which may involve antibiotics for suspected pneumonia, diuretics for pulmonary edema, or supportive care such as oxygen therapy. Patient education focuses on medication adherence, respiratory hygiene, and follow-up care. Further investigation may be warranted based on the clinical course and response to initial treatment. Medical coding will be determined based on the final diagnosis. Diagnosis of lung infiltrate requires ongoing monitoring and reassessment.