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v1.0.0
ICD-10 Guide
ICD-10 CodesC44.609

C44.609

Billable

Unspecified malignant neoplasm of skin of left upper limb, including shoulder

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

Code Description

ICD-10 C44.609 is a billable code used to indicate a diagnosis of unspecified malignant neoplasm of skin of left upper limb, including shoulder.

Key Diagnostic Point:

C44.609 refers to an unspecified malignant neoplasm of the skin located on the left upper limb, which includes the shoulder area. This code is used when a patient presents with a skin cancer diagnosis that has not been further specified, meaning the exact type of malignancy (such as melanoma, basal cell carcinoma, or squamous cell carcinoma) is not documented. Skin cancers are often associated with sun exposure, which is a significant risk factor due to the damaging effects of ultraviolet (UV) radiation on the skin. Surgical management typically involves excision of the tumor with clear margins to ensure complete removal and minimize recurrence. Reconstruction may be necessary depending on the size and location of the excised lesion, which can involve techniques such as skin grafting or flap surgery. Accurate coding is essential for appropriate treatment planning and reimbursement, and it requires careful documentation of the clinical findings, treatment provided, and any follow-up care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Lack of specificity regarding the type of skin cancer
  • Variability in surgical margins and reconstruction techniques
  • Need for detailed documentation of clinical findings
  • Potential for multiple treatment modalities

Audit Risk Factors

  • Insufficient documentation of the malignancy type
  • Inadequate details on surgical margins
  • Lack of follow-up care documentation
  • Failure to document reconstruction procedures

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

Detailed descriptions of the lesion, biopsy results, and treatment plans.

Common Clinical Scenarios

Diagnosis and treatment of skin lesions, including biopsies and excisions.

Billing Considerations

Ensure clear documentation of the type of malignancy and treatment provided.

Oncology

Documentation Requirements

Comprehensive treatment plans, including chemotherapy or radiation therapy if applicable.

Common Clinical Scenarios

Management of skin cancer patients, including staging and follow-up care.

Billing Considerations

Document any multidisciplinary approaches to treatment.

Coding Guidelines

Inclusion Criteria

Use C44.609 When
  • According to ICD
  • 10 coding guidelines, C44
  • 609 should be used when the specific type of malignant neoplasm is not documented
  • Coders should ensure that the diagnosis is supported by clinical findings and that any treatments are appropriately documented

Exclusion Criteria

Do NOT use C44.609 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11400CPT Code

Excision, malignant skin lesion, face, ears, eyelids, scalp; excised diameter excised 0.5 cm or less

Clinical Scenario

Used when excising a malignant skin lesion on the left upper limb.

Documentation Requirements

Document the size of the lesion and the margins obtained.

Specialty Considerations

Dermatologists should ensure accurate measurement and documentation of the excised lesion.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding skin cancers, but C44.609 remains a catch-all for unspecified cases, which can complicate billing and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding skin cancers, but C44.609 remains a catch-all for unspecified cases, which can complicate billing and treatment planning.

Reimbursement & Billing Impact

billing and treatment planning.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should I document to support the use of C44.609?

You should document the clinical findings, any biopsies performed, the treatment plan, and follow-up care. Ensure that the type of malignancy is clearly stated if known.