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v1.0.0
ICD-10 Guide
ICD-10 CodesC44.41

C44.41

Billable

Basal cell carcinoma of skin of scalp and neck

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 C44.41 is a billable code used to indicate a diagnosis of basal cell carcinoma of skin of scalp and neck.

Key Diagnostic Point:

Basal cell carcinoma (BCC) is the most common form of skin cancer, primarily arising from the basal cells in the epidermis. C44.41 specifically refers to BCC located on the scalp and neck, areas frequently exposed to ultraviolet (UV) radiation from the sun. This type of cancer is characterized by slow growth and a low likelihood of metastasis, but it can cause significant local tissue destruction if left untreated. Risk factors include prolonged sun exposure, fair skin, and a history of sunburns. Surgical excision is the primary treatment, with the goal of achieving clear surgical margins to minimize recurrence. Reconstruction may be necessary depending on the size and location of the excised lesion, particularly in cosmetically sensitive areas like the face and neck. Proper coding requires documentation of the tumor's size, location, and treatment plan, including any reconstructive procedures performed post-excision.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for precise documentation of tumor location and size
  • Variability in surgical techniques and reconstruction methods
  • Differentiation from other skin cancers and lesions
  • Potential for recurrence requiring follow-up coding

Audit Risk Factors

  • Inadequate documentation of surgical margins
  • Failure to document the size and depth of the lesion
  • Lack of follow-up care documentation
  • Misclassification of the type of skin cancer

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

Detailed descriptions of the lesion, treatment plan, and follow-up care.

Common Clinical Scenarios

Diagnosis and treatment of BCC, Mohs micrographic surgery, and post-operative care.

Billing Considerations

Ensure clear documentation of margins and any reconstructive procedures performed.

Oncology

Documentation Requirements

Comprehensive treatment plans, including chemotherapy or radiation if applicable.

Common Clinical Scenarios

Management of advanced BCC cases and coordination of care with dermatology.

Billing Considerations

Document any systemic treatments and their indications.

Coding Guidelines

Inclusion Criteria

Use C44.41 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the site, size, and treatment of the carcinoma
  • Include any relevant patient history that may affect treatment decisions

Exclusion Criteria

Do NOT use C44.41 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

17311CPT Code

Excision, malignant skin lesion, face, ears, scalp, neck

Clinical Scenario

Used when excising a BCC from the scalp or neck.

Documentation Requirements

Document the size of the lesion and margins.

Specialty Considerations

Dermatologists should ensure clear documentation of the excision and any reconstruction.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of skin cancers, including BCC, improving data accuracy and treatment tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of skin cancers, including BCC, improving data accuracy and treatment tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of skin cancers, including BCC, improving data accuracy and treatment tracking.

Resources

Clinical References

  • •
    American Academy of Dermatology

Coding & Billing References

  • •
    American Academy of Dermatology

Frequently Asked Questions

What is the primary treatment for basal cell carcinoma?

The primary treatment for basal cell carcinoma is surgical excision, often using Mohs micrographic surgery for high-risk areas to ensure clear margins.