Help with dx for Chest CT


Charlotte, NC
Best answers
History/Reason for procedure is restaging carcinoma of the lung status post right upper lobectomy.

The impression states nodule in the right lower lobe is unchanged from the previous examination.

No evidence for recurrence of tumor.

Would you code the cancer as 162.9 or V10.11? Would you include 518.89 for the nodule as a secondary or the primary diagnosis?

Thank you.
whatever the final impression states is final. only if there is no definitive impression rendered, we may go for symptoms in the clinical history.
When the final impression states nodule and no lung carcinoma, we should only assign 518.89 as the primary Dx, and History code if needed, as last dx, only.
v code

yes the primary dx should be v10.11 for thats the reason why pt is coming for and add the code for nodule.

v code is used because the carcinoma has already been excised add 518.89 for lung nodule because it was addressed.
Lavanyamohan is correct.

The nodule (definitive finding) would be listed primary.

"History of" codes are indicated in ICD-9 as unacceptable principal dx codes, therefore if needed would be coded secondary.
Just curious, given the same example does anyone use follow up codes or is this something specific to facilities? Our facility would have us code this out by doing it this way...

ADX V1011 (HX Lung) or V6759 (exam other FU), or V6709 (post surg)
PDX V6759 or v6709, 51889, V1011