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R91.8
ICD-10-CM
Lung Infiltrate

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

Pulmonary Infiltrate
Lung Opacity

Diagnosis Snapshot

Key Facts
  • Definition : Substance denser than air filling lung tissues, often fluid, pus, or blood.
  • Clinical Signs : Cough, shortness of breath, fever, chest pain, reduced oxygen levels.
  • Common Settings : Pneumonia, heart failure, tuberculosis, lung cancer, COVID-19.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R91.8 Coding
J18.0-J18.9

Pneumonia, organism unspecified

Lung inflammation caused by various germs, not specifically identified.

J69.0-J69.8

Pneumonitis due to solids and liquids

Lung inflammation from inhaling foreign substances like food or chemicals.

R09.0-R09.89

Abnormal respiratory sounds

Covers various abnormal breathing sounds, often indicating lung issues like infiltrates.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Lung Infiltrate
Pneumonia
Pulmonary Edema

Documentation Best Practices

Documentation Checklist
  • Document infiltrate location, size, and characteristics.
  • Specify if infiltrate is unilateral or bilateral.
  • Note associated symptoms (cough, fever, dyspnea).
  • Document related lab results and imaging findings.
  • Detail differential diagnosis considerations.

Coding and Audit Risks

Common Risks
  • Unspecified Infiltrate

    Coding J18.9 (Pneumonia, unspecified) without documented etiology or further specification like bacterial vs viral leads to lower reimbursement and audit risk.

  • Clinical Validation

    Lack of clear clinical indicators and supporting documentation for lung infiltrate diagnosis may raise questions of medical necessity during audits, impacting payment.

  • Laterality Missing

    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.

Mitigation Tips

Best Practices
  • Document infiltrate location, size, and characteristics for accurate ICD-10 coding.
  • Query physician for infiltrate etiology to improve CDI and support DRG assignment.
  • Review prior imaging for comparison and trending to ensure complete clinical picture.
  • Correlate clinical findings with imaging results for compliant medical necessity documentation.
  • Consider differential diagnoses and document rationale for chosen diagnosis for optimal HCC coding.

Clinical Decision Support

Checklist
  • Review CXR/CT: infiltrate location, size, characteristics
  • Correlate imaging with symptoms: fever, cough, dyspnea
  • Assess labs: WBC, CRP, procalcitonin for infection
  • Consider differentials: pneumonia, edema, malignancy
  • Document infiltrate findings, diagnostic plan, and rationale

Reimbursement and Quality Metrics

Impact Summary
  • Lung Infiltrate reimbursement hinges on accurate coding (J18.9, R91.8) and documentation specifying etiology.
  • Coding errors for lung infiltrate impact DRG assignment, affecting hospital reimbursement and quality metrics.
  • Proper documentation of infiltrate type (e.g., pneumonia, edema) improves coding accuracy and Case Mix Index.
  • Quality metrics like hospital-acquired pneumonia reporting are impacted by lung infiltrate diagnosis coding.

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 infiltrate location
  • Specify infiltrate type
  • Code underlying cause
  • Consider laterality code
  • Check J18 pneumonia codes

Documentation Templates

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.
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