Basal Cell Carcinoma



Check your diagnosis coding for this patient encounter.

A patient presents today to discuss the results of her skin biopsy.

Alice came in today for a follow-up visit. We performed a biopsy on her left ear last week. She had reported that she noticed a small lesion a few months ago. It recently began to grow, so she came in to get it checked. She has spent years in the sun and until recently did not wear any sun protection.

A recheck of the site was performed and the lesion looked to be of the same size as when examined in the office last week. It is not painful to the touch.

ASSESSMENT/PLAN: Basal cell carcinoma left ear — confirmed by pathology. We have discussed the treatment options and Alice wishes to have surgical excision performed. We will send her to the plastic surgeon to have this performed as soon as possible. We will see her back as necessary.

Code the Diagnosis

ICD-10-CM code:

C44.219 Basal cell carcinoma of skin of left ear and external auricular canal

Rationale: In ICD-10-CM, the codes for neoplasm of the skin are broken down by site, laterality, and type. There are separate codes for melanoma, Merkel cell carcinoma, basal cell carcinoma, squamous cell carcinoma, other, and unspecified.


Resource:

2021 ICD-10-CM code book

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Stacy Chaplain, MD, CPC, is a development editor at AAPC. She has worked in medicine for more than 20 years, with an emphasis on education, writing, and editing since 2015. Prior to AAPC, she led a compliance team as director of clinical coding quality for a multispecialty group practice. Chaplain received her Bachelor of Arts in biology from the University of Texas at Austin and her Medical Doctorate from the University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Oregon, local chapter.

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