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R91.1
ICD-10-CM
Lung Nodule

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

Pulmonary Nodule
Solitary Pulmonary Nodule

Diagnosis Snapshot

Key Facts
  • Definition : Small growth in the lung, often found incidentally on imaging.
  • Clinical Signs : Usually asymptomatic. May cause cough, shortness of breath, or hemoptysis if large.
  • Common Settings : Detected on chest X-ray, CT scan, or PET scan during routine checkups or investigations.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R91.1 Coding
R91.1

Solitary pulmonary nodule

Abnormal spot seen on a lung X-ray or CT scan.

J98.9

Respiratory disorders NOS

Unspecified respiratory conditions when more specific info is unavailable.

R07.1

Chest pain on breathing

Pain in the chest area associated with breathing, possibly related to a nodule.

R91.8

Other abnormal findings of lung field

Encompasses various unusual lung findings including multiple nodules.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Lung Nodule
Lung Mass
Pulmonary Hamartoma

Documentation Best Practices

Documentation Checklist
  • Lung nodule size, location, and characteristics documented
  • Method of detection (e.g., CT scan, X-ray) specified
  • Comparison with prior imaging, if available
  • Patient symptoms and risk factors for lung cancer noted
  • Follow-up plan or next steps for evaluation detailed

Coding and Audit Risks

Common Risks
  • Unspecified Nodule

    Coding lung nodule without specifying laterality (right/left/bilateral) or characteristic (solitary/multiple) leads to inaccurate reporting and potential DRG misassignment.

  • Size Documentation

    Missing or inadequate documentation of nodule size impacts accurate code selection and may trigger clinical validation queries, delaying claims processing.

  • History vs. Present

    Confusing history of lung nodule with current presentation can lead to incorrect coding. Clearly differentiate active vs. resolved nodules for accurate diagnosis coding.

Mitigation Tips

Best Practices
  • Thorough documentation using ICD-10 R91.8 for unspecified findings
  • Size, location, density noted per Fleischner guidelines for compliant CDI
  • Track prior scans for growth assessment and compliant billing (CPT 71250)
  • Standardized reporting using Lung-RADS for improved communication and HCC
  • MDM documentation reflects nodule management, justifying E/M code selection

Clinical Decision Support

Checklist
  • Confirm nodule size and location documented (ICD-10 R91.1)
  • Review prior imaging for comparison and stability (SNOMED CT-12345)
  • Assess patient risk factors: smoking, FH, asbestos (LOINC 72166-5)
  • Consider malignancy risk based on Fleischner criteria (RadLex 223409)
  • Document management plan: follow-up or workup (CPT 71250)

Reimbursement and Quality Metrics

Impact Summary
  • Lung Nodule reimbursement hinges on accurate coding (ICD-10 J98.9, R91.1) and appropriate imaging, impacting hospital revenue.
  • Quality metrics for lung nodule management include timely follow-up (NQF #0523) impacting hospital quality reporting and pay-for-performance.
  • Thorough documentation of nodule size, location, and characteristics improves coding specificity and reduces claim denials.
  • Accurate staging and management of lung nodules affect hospital case mix index (CMI) and overall resource utilization.

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
  • Code nodule size using imaging reports
  • Document nodule characteristics for specificity
  • Consider R91.8 for unspecified findings
  • Use Z80.7 for personal history of lung cancer
  • Code laterality when documented

Documentation Templates

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.