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Question: One of our pulmonologists ordered a chest X-ray for a patient to evaluate their lungs. The report came back with “unspecified opacity” in the findings. What diagnosis codes should I use to report the findings?

California Subscriber

Answer: For the unspecified opacity finding of the chest X-ray, you’ll turn to Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99), in the ICD-10-CM code book. Within this chapter, the two code categories that you’ll examine to determine the most accurate code for this general finding are as follows:

• R91.- (Abnormal findings on diagnostic imaging of lung)
• R94.- (Abnormal results of function studies)

You’ll need a 4^th character to complete a code in the R91.- category. Assign code R91.1 (Solitary pulmonary nodule) when the provider identifies only one abnormal mass within the lung during the imaging test. Use R91.8 (Other nonspecific abnormal finding of lung field) when the physician does not specify the type of abnormality in the lung that is identified on the imaging test.

Under the R94.- category, you’ll find R94.2 (Abnormal results of pulmonary function studies). This code is designated for reporting results of the patient’s pulmonary function studies, such as vital capacity, ventilatory capacity, or spirometry, which are abnormal. You’ll use this code when the physician performs pulmonary function tests (PFTs) to assess the patient’s condition.

For the case you have presented, you’ll report R91.8 for the findings listed in the report. Of course, if the documentation presents a more specific diagnosis, then you’ll assign the appropriate codes to match the documented diagnosis.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC