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v1.0.0
ICD-10 Guide
DiagnosesAbnormal Computed Tomography Chest

Abnormal Computed Tomography Chest

ICD-10 Coding for Abnormal CT Chest Findings(R91.1, R93.8)

PRIMARY SPECIALTYRadiology
COMPLEXITYHigh
LAST UPDATED09/08/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Abnormal Computed Tomography Chest?
Essential facts and insights about Abnormal CT Chest Findings

Key Clinical Considerations:

  • Presence of abnormal findings on diagnostic imaging of lung
  • Unspecified abnormal findings on diagnostic imaging of lung

Clinical Information

Clinical Criteria & Documentation Requirements

  • Detailed description of the abnormal findings identified in the CT scan
  • Specific location and extent of the abnormality within the chest

Coding Guidelines

Usage Guidelines & Examples

  • R91.1 is used for abnormal findings on diagnostic imaging of lung, while R93.8 is used for other specified abnormal findings on diagnostic imaging of body structures
  • R91.1 should not be used if the abnormality is identified as malignant, in such case a code from the C34 category should be used

Code Exclusions

Important Exclusions

  • Malignant neoplasm of bronchus and lung (C34)
  • Solitary pulmonary nodule (R91.0)

Related ICD-10 Codes

Primary Codes
R91.1
Abnormal findings on diagnostic imaging of lung
R93.8
Other specified abnormal findings on diagnostic imaging of body structures
Ancillary Codes
Z80.0
Differential Codes
R91.8
R91.8
for nonspecific findings like ground-glass opacities without a definitive diagnosis.
R91
R91
for lung-specific findings.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Radiology

Specialty Applications

  • Unspecified abnormal findings on diagnostic imaging of lung
  • Other specified abnormal findings on diagnostic imaging of body structures

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Template 1

Patient underwent CT chest which revealed [describe findings].

Template 2

CT chest shows [describe abnormal findings] in the [specify location].

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What does an abnormal CT chest finding mean?

It refers to any unexpected or unusual finding identified in a CT scan of the chest. This could be due to a variety of conditions, including infections, tumors, or lung diseases.

When should R91.1 or R93.8 be used?

R91.1 should be used when there are abnormal findings on diagnostic imaging of the lung. R93.8 is used when there are other specified abnormal findings on diagnostic imaging of body structures.