Find comprehensive information on lung nodule diagnosis, including clinical documentation, medical coding (ICD-10, SNOMED CT), and healthcare guidelines. Learn about pulmonary nodule detection, evaluation, management, and the role of imaging (CT scan, X-ray) in identifying benign and malignant nodules. Explore resources for physicians, radiologists, and other healthcare professionals related to lung nodule assessment, differential diagnosis, and treatment options.
Also known as
Solitary pulmonary nodule
Abnormal spot seen on a lung X-ray or CT scan.
Respiratory disorders NOS
Unspecified respiratory conditions when more specific info is unavailable.
Chest pain on breathing
Pain in the chest area associated with breathing, possibly related to a nodule.
Other abnormal findings of lung field
Encompasses various unusual lung findings including multiple nodules.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the lung nodule solitary?
Yes
Is it granulomatous?
No
Are they multiple?
When to use each related code
Description |
---|
Lung Nodule |
Lung Mass |
Pulmonary Hamartoma |
Coding lung nodule without specifying laterality (right/left/bilateral) or characteristic (solitary/multiple) leads to inaccurate reporting and potential DRG misassignment.
Missing or inadequate documentation of nodule size impacts accurate code selection and may trigger clinical validation queries, delaying claims processing.
Confusing history of lung nodule with current presentation can lead to incorrect coding. Clearly differentiate active vs. resolved nodules for accurate diagnosis coding.
Patient presents with a pulmonary nodule, identified on chest imaging (CXR or CT scan), prompting further evaluation for lung cancer screening, solitary pulmonary nodule, or indeterminate pulmonary nodule. The patient's medical history includes [insert relevant history such as smoking history, family history of lung cancer, prior lung disease, occupational exposures e.g., asbestos, radon] and current symptoms include [insert symptoms if present e.g., cough, hemoptysis, dyspnea, chest pain]. Physical examination reveals [insert relevant findings e.g., clear lung sounds, normal respiratory effort, no palpable lymphadenopathy]. Nodule characteristics, including size, shape, margins, and location, were assessed via [imaging modality and specify e.g., CT scan with contrast, demonstrating a 5 mm, well-circumscribed, non-calcified nodule in the right upper lobe]. Differential diagnosis includes benign entities such as granuloma, hamartoma, and infectious nodule, as well as malignant possibilities such as lung adenocarcinoma, squamous cell carcinoma, and small cell lung cancer. Management plan includes [insert management plan e.g., serial CT surveillance, positron emission tomography (PET) scan, biopsy via bronchoscopy or needle aspiration, referral to pulmonology or thoracic surgery]. Patient education provided regarding lung nodule diagnosis, lung cancer risk factors, and the importance of follow-up. ICD-10 code R91.1 (abnormal findings on diagnostic imaging of lung) and CPT codes for imaging and procedures performed will be used for billing and coding. Further evaluation and management will be determined based on evolving clinical picture and radiographic findings.