ICD-10 Coding for Pulmonary Nodule(R91.1, R91.8, D02.2)
Complete ICD-10-CM coding and documentation guide for Pulmonary Nodule. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pulmonary Nodule
R91.0-R91.9Primary Range
Abnormal findings on diagnostic imaging of lung
This range includes codes for various types of pulmonary nodules and findings on lung imaging.
Carcinoma in situ of bronchus and lung
Used when a pulmonary nodule is confirmed as carcinoma in situ.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R91.1 | Solitary pulmonary nodule | Use when imaging confirms a single nodule in the lung. |
|
| R91.8 | Other nonspecific abnormal finding of lung field | Use for multiple nodules or when findings are non-specific. |
|
| D02.2 | Carcinoma in situ of bronchus and lung | Use when biopsy confirms carcinoma in situ. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for solitary pulmonary nodule
Essential facts and insights about Pulmonary Nodule
Primary ICD-10-CM Codes for pulm nodule
Decision Criteria
clinical Criteria
- Single nodule confirmed by imaging
Applicable To
- Single lung nodule
Excludes
- Multiple nodules (R91.8)
Clinical Validation Requirements
- CT scan showing a solitary nodule less than 3 cm
- Documentation of nodule size and location
Code-Specific Risks
- Incorrectly coding multiple nodules as solitary
Coding Notes
- Ensure documentation specifies nodule characteristics.
R91.8 - Other nonspecific abnormal finding of lung field
Use for multiple nodules or when findings are non-specific.
Applicable To
- Multiple lung nodules
Excludes
- Solitary nodule (R91.1)
Clinical Validation Requirements
- CT scan showing multiple nodules
- Documentation of nodule characteristics
Coding Notes
Document all nodule characteristics clearly.
D02.2 - Carcinoma in situ of bronchus and lung
Use when biopsy confirms carcinoma in situ.
Applicable To
- Pre-invasive lesions of lung
Excludes
- Invasive carcinoma (C34._)
Clinical Validation Requirements
- Biopsy report confirming carcinoma in situ
- Pathology report
Coding Notes
Ensure biopsy confirmation is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of nicotine dependence
Z87.891Personal history of other malignant neoplasm of bronchus and lung
Z85.118Encounter for screening for malignant neoplasms
Z12.2Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Pulmonary Nodule to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R91.1.
Impact
Clinical: Inadequate clinical assessment, Regulatory: Non-compliance with coding standards, Financial: Potential for denied claims
Mitigation Strategy
Use structured templates, Double-check imaging reports
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Potential audit risk, Data Quality: Inaccurate clinical data
Mitigation Strategy
Use R91.8 for multiple nodules.
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Misleading clinical data
Mitigation Strategy
Query provider for confirmation via biopsy or PET-CT.
Impact
Inadequate documentation of nodule characteristics
Mitigation Strategy
Implement structured reporting templates
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Pulmonary Nodule, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pulmonary Nodule
Use these documentation templates to ensure complete and accurate documentation for Pulmonary Nodule. These templates include all required elements for proper coding and billing.
Pulmonary Nodule Evaluation
Specialty: PulmonologyRequired Elements
- Nodule size in mm
- Location and laterality
- Morphology
- Growth rate
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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