ICD-10 Coding for Solitary Lung Nodule(R91.1, D02.2)
Complete ICD-10-CM coding and documentation guide for Solitary Lung Nodule. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Solitary Lung Nodule
R91.0-R91.9Primary Range
Abnormal findings on diagnostic imaging of lung
This range includes codes for abnormal findings on imaging studies of the lung, including solitary pulmonary nodules.
Carcinoma in situ of bronchus and lung
Used when a biopsy confirms carcinoma in situ in a solitary pulmonary nodule.
Personal history of nicotine dependence
Relevant for documenting smoking history which is a risk factor for lung nodules.
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 a solitary nodule is detected on imaging without a confirmed diagnosis. |
|
| D02.2 | Carcinoma in situ of bronchus and lung | Use when biopsy confirms carcinoma in situ in a nodule. |
|
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 lung nodule
Essential facts and insights about Solitary Lung Nodule
Primary ICD-10-CM Codes for solitary lung nodule
Decision Criteria
clinical Criteria
- Imaging shows a solitary nodule without confirmed malignancy.
Applicable To
- Single lung nodule detected on imaging
Excludes
- Confirmed malignancy (C34.-)
Clinical Validation Requirements
- Imaging showing a solitary nodule less than 3 cm
- No prior malignancy diagnosis
Code-Specific Risks
- Confusion with R91.8 for multiple nodules
Coding Notes
- Ensure documentation specifies 'solitary' and includes nodule size.
D02.2 - Carcinoma in situ of bronchus and lung
Use when biopsy confirms carcinoma in situ in a nodule.
Applicable To
- Carcinoma in situ confirmed by biopsy
Excludes
- Invasive carcinoma (C34.-)
Clinical Validation Requirements
- Biopsy confirming carcinoma in situ
Coding Notes
Sequence after R91.1 if found during workup.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of nicotine dependence
Z87.891Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Solitary Lung 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 follow-up planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use structured templates for documentation., Ensure all imaging reports include nodule details.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate health records.
Mitigation Strategy
Use the appropriate cancer code (C34.-) instead.
Impact
Using R91.1 for multiple nodules or confirmed malignancy.
Mitigation Strategy
Regular training on code differentiation and documentation requirements.
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 Solitary Lung Nodule, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Solitary Lung Nodule
Use these documentation templates to ensure complete and accurate documentation for Solitary Lung Nodule. These templates include all required elements for proper coding and billing.
Initial detection of solitary lung nodule
Specialty: PulmonologyRequired Elements
- Nodule size and location
- Imaging modality used
- Patient history including smoking
- Follow-up recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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