Pulmonology Coding Alert

Question: I'm coding a chest X-ray with an indication of shortness of breath, productive cough, and chest pain. The physician doesn't report any definitive findings besides an opacity over the right lower lobe. The physician states that it may be a shadow. Is this enough to report as a diagnosis or should I send the claim back to the provider? What would the ICD-10 code be for a lung opacity?

Codify Subscriber

Answer: This is a tricky scenario without a definitive answer. If you search the ICD-10 index under "opacity," you won't find the term "lung" or any synonymous terminology. At this point, your options quickly wane in terms of utilization of the ICD-10 index. This is where implementing a set of universal coding guidelines can go a long way in your practice. "Lung opacity" is a fairly common finding when it comes to chest X-rays. Most practices will assign a diagnosis code to a non-indexable recurrent radiological finding such as this. The diagnosis "lung opacity" is most commonly coded as R91.8 (Other nonspecific abnormal finding of lung field), but check first with your supervisors before making any final coding determinations.

What makes this question a little more difficult than your typical "lung opacity" chest X-ray is the fact that the provider questions whether it may be a shadow. One of the first rules of diagnosis coding is that questionable diagnoses such as this one should be sent back to the provider for further clarification. However, the code description for R91.8 allows for some wiggle room as it pertains to an unclear diagnosis such as this. You may also use the sign/symptom that prompted the service (eg, sob, cough, chest pain) until a more definitive diagnosis becomes available.