9 mm spiculated solid right upper lobe pulmonary nodule, suspicious for primary lung malignancy
From the report:
9 mm spiculated solid pulmonary nodule in the right upper lobe apical posterior segment. Spiculation raises suspicion for primary lung malignancy.
Hedging language:
raises suspicion for primary lung malignancy
Suggested problem: Solitary pulmonary nodule, right upper lobe, suspicious for malignancy (R91.1)
Suggested code, verify before adding.
Radiologist recommendation: Recommend dedicated contrast-enhanced chest CT with thin-section reconstruction and PET-CT for further evaluation. Pulmonary nodule clinic referral suggested.