Find comprehensive information on Solitary Pulmonary Nodule diagnosis, including clinical documentation best practices, ICD-10 codes (R91.1, R91.8), medical coding guidelines, differential diagnosis considerations, and radiology findings for accurate reporting and reimbursement. Learn about lung nodule management, patient education resources, and the latest clinical research on solitary lung nodules. This resource supports healthcare professionals in proper documentation and coding of SPN for optimized patient care.
Also known as
Other ill-defined pulmonary findings
This code encompasses unspecified abnormalities found in the lungs.
Respiratory disorder, unspecified
Used for pulmonary conditions not classified elsewhere.
Abnormal findings on diagnostic imaging of lung
Covers unusual results from lung scans but lacks nodule specificity.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the solitary lung nodule incidental?
Yes
Nodule size specified?
No
Is the nodule benign?
Coding without specifying granuloma, benign, or malignant status creates audit risk and impacts DRG assignment. CDI should query for clarity.
Missing or inadequate size documentation hinders accurate code selection (R91.1 vs. R91.8) and impacts quality reporting. CDI must clarify.
Failing to code incidental solitary lung nodules (Z83.83) when found during unrelated imaging introduces HCC coding and billing compliance risks.
Patient presents with a solitary pulmonary nodule (SPN), incidentally discovered on chest imaging performed for [reason for imaging, e.g., cough evaluation, preoperative assessment]. The nodule measures [size in mm] and is located in the [location, e.g., right upper lobe, left lower lobe, etc.] exhibiting [description of nodule characteristics, e.g., smooth margins, spiculated margins, ground-glass opacity]. Patient denies symptoms of cough, hemoptysis, dyspnea, chest pain, or weight loss. Medical history is significant for [list relevant medical history, e.g., prior malignancy, smoking history, family history of lung cancer]. Physical examination reveals clear lung sounds bilaterally. Differential diagnosis includes benign etiologies such as granuloma, hamartoma, and inflammatory nodule, as well as malignant possibilities such as primary lung cancer and metastasis. Assessment includes consideration for Fleischner Society guidelines for management of incidental pulmonary nodules. Plan includes [management plan based on nodule size, characteristics, and patient risk factors, e.g., serial CT surveillance, positron emission tomography (PET) scan, biopsy, surgical resection]. Patient education provided regarding lung nodule evaluation, risks and benefits of different management strategies, and importance of follow-up. ICD-10 code R91.1 (abnormal findings on diagnostic imaging of lung) may be applicable pending definitive diagnosis. Lung cancer screening, pulmonary nodule workup, and lung nodule management are key components of this clinical encounter.