M75.42 - Impingement syndrome of left shoulder

Clinical Definition

A pulmonary nodule (or lung nodule) is a small, rounded mass of tissue in the lung, typically less than 3 centimeters in diameter. These are often discovered incidentally during chest imaging and require documentation for appropriate monitoring and follow-up.

Documentation Requirements

• Size of nodule (exact measurements in mm or cm)

• Location (specific lobe and laterality)

• Characteristics:

  • Solid vs. ground-glass vs. part-solid

  • Margins (smooth, spiculated, irregular)

  • Calcification if present

• Comparison to prior studies (if available)

  • Stability vs. change in size

  • Rate of growth

• Clinical assessment of malignancy risk

• Follow-up plan and timing

Common Synonyms

• Coin lesion

• Lung spot

• Spot on the lung

• Round shadow

• Lung mass (Note: technically incorrect if <3cm)

Coding Conflicts

Excludes1:

• Multiple pulmonary nodules (R91.7)

• Pulmonary granuloma (J84.10)

• Pulmonary metastases (C78.00-C78.03)

Scribing.io Automation

The AI scribe automatically:

• Detects measurements when dictated in mm or cm

• Identifies anatomical terms indicating location

• Tags temporal language comparing to previous studies

• Highlights risk assessment terminology

• Flags follow-up recommendations for coding

Keywords the AI specifically listens for:

• "solitary"

• "nodule"

• "measured"

• "compared to previous"

• "stability"

• "follow-up recommended"