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R91.1
ICD-10-CM
Solitary Lung Nodule

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

Solitary Pulmonary Nodule
SPN

Diagnosis Snapshot

Key Facts
  • Definition : A single, small, round growth in the lung, typically less than 3 cm.
  • Clinical Signs : Often asymptomatic, may cause cough or shortness of breath if large.
  • Common Settings : Detected incidentally on chest X-rays or CT scans during routine checkups or other investigations.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R91.1 Coding
R91.8

Other ill-defined pulmonary findings

This code encompasses unspecified abnormalities found in the lungs.

J98.9

Respiratory disorder, unspecified

Used for pulmonary conditions not classified elsewhere.

R91.1

Abnormal findings on diagnostic imaging of lung

Covers unusual results from lung scans but lacks nodule specificity.

Code-Specific Guidance

Decision Tree for

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?

Documentation Best Practices

Documentation Checklist
  • Solitary lung nodule size, location, and characteristics documented
  • Comparison to prior imaging and growth assessment
  • Management plan: observation, biopsy, or resection documented
  • Patient risk factors for malignancy (smoking, family history) noted
  • ICD-10 code R91.1 (Solitary pulmonary nodule) or appropriate alternative

Coding and Audit Risks

Common Risks
  • Unspecified Nodule Type

    Coding without specifying granuloma, benign, or malignant status creates audit risk and impacts DRG assignment. CDI should query for clarity.

  • Size Documentation Lacking

    Missing or inadequate size documentation hinders accurate code selection (R91.1 vs. R91.8) and impacts quality reporting. CDI must clarify.

  • Incidental Finding Omission

    Failing to code incidental solitary lung nodules (Z83.83) when found during unrelated imaging introduces HCC coding and billing compliance risks.

Mitigation Tips

Best Practices
  • Document nodule size, location, and characteristics for accurate ICD-10-CM coding (R91.1)
  • Complete imaging workup per Fleischner Society guidelines for compliant billing and CDI
  • Timely follow-up imaging crucial for appropriate CPT coding and risk stratification
  • Integrate Lung-RADS assessment in documentation for improved communication and HCC coding
  • Multidisciplinary discussion of indeterminate nodules optimizes patient care and coding accuracy

Clinical Decision Support

Checklist
  • Confirm nodule size <3cm, documented in radiology report ICD-10 R91.1
  • Assess patient smoking history SNOMED CT 428041000124106 documented
  • Review prior imaging for nodule growth or change ICD-10 Z85.820
  • Evaluate patient risk factors for malignancy documented

Reimbursement and Quality Metrics

Impact Summary
  • Solitary Lung Nodule Reimbursement: CPT codes 32405, 71250, 71260 impact payments. Accurate coding crucial for maximizing reimbursement.
  • Coding Accuracy: ICD-10 R91.1 (Solitary Pulmonary Nodule) specificity affects DRG assignment and hospital case mix index.
  • Quality Metrics Impact: Nodule management, follow-up imaging adherence impacts quality reporting and value-based payments.
  • Hospital Reporting: Accurate nodule documentation, staging (TNM) influences hospital quality data, cancer registry reporting.

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 R91.1 for unspecified nodule
  • Document size, location, density
  • Consider J98.8 for other specified respiratory conditions
  • Rule out infections, granulomas
  • Review imaging reports for precise details

Documentation Templates

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.