2025 ICD-10-CM code R91.1
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90-R94) 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Solitary pulmonary nodule. This refers to a single, small abnormality in the lung, typically less than 3 cm in diameter, that is completely surrounded by normal lung tissue.
Medical necessity for services related to R91.1 stems from the need to evaluate and characterize the nodule to differentiate between benign and malignant etiologies. Further diagnostic testing is medically necessary when the nodule characteristics, patient history, or other risk factors raise suspicion for malignancy.The documentation should clearly articulate the reasons for further workup and justify the chosen diagnostic approach.
The clinical responsibility for R91.1 primarily lies with the physician ordering and interpreting the diagnostic imaging that revealed the solitary pulmonary nodule. This often involves pulmonologists, radiologists, and potentially thoracic surgeons or oncologists, depending on the subsequent findings and the patient's risk factors.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R00-R99: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedR90-R94: Abnormal findings on diagnostic imaging and in function studies, without diagnosis
In simple words: A solitary pulmonary nodule is a single spot found on a lung x-ray or CT scan.It's small, usually less than an inch across, and surrounded by healthy lung tissue. It may be harmless or a sign of something more serious, so doctors will usually want to do more tests to figure out what it is.
A solitary pulmonary nodule, also known as a coin lesion, is a single, well-defined, round or oval opacity found in the lung parenchyma on a radiograph, measuring up to 3 cm in diameter. It is not associated with other lung abnormalities like atelectasis, hilar adenopathy, or pleural effusion. This finding often requires further investigation to determine its nature (benign or malignant).
Example 1: A 55-year-old patient with a history of smoking undergoes a routine chest x-ray, which incidentally reveals a 1.5 cm, well-defined nodule in the right upper lobe.The patient is asymptomatic. The physician documents the finding as R91.1 and orders a follow-up CT scan to assess the nodule further. Subsequent investigation reveals that the nodule is benign (granuloma)., A 70-year-old patient with no significant past medical history presents with a persistent cough.A chest CT scan is performed, which identifies a 2 cm spiculated nodule in the left lower lobe.R91.1 is used as the preliminary diagnosis pending further investigation, including a biopsy. The biopsy subsequently confirms a diagnosis of lung cancer., During a pre-operative evaluation for an unrelated surgical procedure, a 40-year-old patient's chest x-ray shows a small, calcified nodule in the right lung. Given the calcification, which is often indicative of a benign process, the physician documents the finding as R91.1 and decides to monitor the nodule with periodic imaging surveillance.
Documentation for R91.1 should include the size, location, and characteristics of the nodule as observed on imaging (e.g., well-circumscribed, spiculated, calcified). Patient demographics, including age and smoking history, should be documented, along with pertinent medical history. The rationale for using R91.1, including the indeterminate nature of the nodule and the need for further investigation, should be clearly stated.If subsequent diagnostic procedures are performed, their results should also be documented.
** A solitary pulmonary nodule can be an incidental finding with various possible causes, ranging from benign granulomas and infections to malignant tumors. A thorough clinical evaluation, including imaging studies and potentially biopsy, is essential to determine the appropriate management strategy. Regular follow-up is often required, even for benign nodules, to monitor for any changes.
- Specialties:Pulmonology, Radiology, Thoracic Surgery, Oncology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Independent Clinic, Federally Qualified Health Center