ICD-10 Coding for Multiple Pulmonary Nodules(R91.8, D02.2, D49.1)
Complete ICD-10-CM coding and documentation guide for Multiple Pulmonary Nodules. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Multiple Pulmonary Nodules
R91-R94Primary Range
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
This range includes codes for abnormal findings in the lungs, such as multiple pulmonary nodules.
In situ neoplasms
This range includes codes for carcinoma in situ, which may be relevant if nodules are confirmed as carcinoma in situ.
Neoplasms of uncertain behavior
This range includes codes for nodules suspicious for malignancy but not yet confirmed.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R91.8 | Other nonspecific abnormal finding of lung field | Use when imaging shows multiple nodules without confirmed malignancy. |
|
| D02.2 | Carcinoma in situ of bronchus and lung | Use when biopsy confirms carcinoma in situ. |
|
| D49.1 | Neoplasm of unspecified behavior of respiratory system | Use when nodules are suspicious for malignancy but not confirmed. |
|
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 multiple pulmonary nodules
Essential facts and insights about Multiple Pulmonary Nodules
Primary ICD-10-CM Codes for pulmonary nodules multiple
Decision Criteria
clinical Criteria
- CT shows multiple nodules without malignancy confirmation.
documentation Criteria
- Documentation includes size, location, and number of nodules.
Applicable To
- Multiple nonspecific nodules without confirmed malignancy
Excludes
- Solitary pulmonary nodule (R91.1)
Clinical Validation Requirements
- CT showing ≥2 nodules in ≥1 lobes
- Documentation stating 'multiple,' 'bilateral,' or specifying ≥2 locations
Code-Specific Risks
- Confusion with solitary nodules
- Incorrectly upgrading to malignancy codes without confirmation
Coding Notes
- Ensure documentation specifies multiple nodules and their characteristics.
D02.2 - Carcinoma in situ of bronchus and lung
Use when biopsy confirms carcinoma in situ.
Applicable To
- Confirmed carcinoma in situ by biopsy
Clinical Validation Requirements
- Histology report confirming carcinoma in situ
Coding Notes
Ensure biopsy confirmation is documented.
D49.1 - Neoplasm of unspecified behavior of respiratory system
Use when nodules are suspicious for malignancy but not confirmed.
Applicable To
- Nodules suspicious for malignancy but not yet confirmed
Clinical Validation Requirements
- PET SUVmax >2.5
- Nodule growth ≥1.5 mm in 6 months
Coding Notes
Document suspicion criteria clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Multiple Pulmonary Nodules to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R91.8.
Impact
Clinical: Inadequate clinical assessment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use structured templates, Train staff on documentation requirements
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R91.8 for multiple nodules and ensure documentation specifies 'multiple.'
Impact
Risk of audit if documentation does not support multiple nodules.
Mitigation Strategy
Ensure all imaging reports specify multiple nodules and their characteristics.
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 Multiple Pulmonary Nodules, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Multiple Pulmonary Nodules
Use these documentation templates to ensure complete and accurate documentation for Multiple Pulmonary Nodules. These templates include all required elements for proper coding and billing.
Radiology Report for Multiple Nodules
Specialty: RadiologyRequired Elements
- Nodule count
- Size(s)
- Location(s)
- Density
- Morphology
- Comparison
- Fleischner Society criteria
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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