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ICD-10 Guide
ICD-10 CodesC44.612

C44.612

Billable

Basal cell carcinoma of skin of right upper limb, including shoulder

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

Code Description

ICD-10 C44.612 is a billable code used to indicate a diagnosis of basal cell carcinoma of skin of right upper limb, including shoulder.

Key Diagnostic Point:

Basal cell carcinoma (BCC) is the most common form of skin cancer, primarily arising from the basal cells in the epidermis. This malignancy is often associated with chronic sun exposure, particularly in fair-skinned individuals. The right upper limb, including the shoulder, is a common site for BCC due to its exposure to ultraviolet (UV) radiation. Clinically, BCC may present as a pearly or waxy bump, a flat, flesh-colored lesion, or a scar-like area. Diagnosis is typically confirmed through a biopsy. Treatment options include surgical excision, Mohs micrographic surgery, cryotherapy, and topical chemotherapy, depending on the size, location, and histological subtype of the tumor. Surgical margins are critical in BCC management to ensure complete removal and minimize recurrence. Reconstruction may be necessary post-excision, especially for larger lesions, to restore function and aesthetics. Regular follow-up is essential due to the potential for new lesions to develop, particularly in patients with a history of skin cancer.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for precise documentation of tumor location and size
  • Variability in treatment approaches (surgical vs. non-surgical)
  • Importance of specifying surgical margins
  • Potential for reconstruction coding

Audit Risk Factors

  • Inadequate documentation of surgical margins
  • Failure to specify the exact location of the carcinoma
  • Misclassification of the type of skin cancer
  • Lack of follow-up documentation post-treatment

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

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

Common Clinical Scenarios

Diagnosis and treatment of BCC, follow-up for skin cancer surveillance.

Billing Considerations

Ensure accurate coding of the tumor's characteristics and treatment modalities.

Oncology

Documentation Requirements

Comprehensive treatment plans, including surgical and non-surgical options.

Common Clinical Scenarios

Management of advanced BCC cases requiring multidisciplinary approaches.

Billing Considerations

Coordination with dermatology for accurate staging and treatment documentation.

Coding Guidelines

Inclusion Criteria

Use C44.612 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, treatment, and any associated conditions
  • Include specific details about the tumor's location and size, and document any surgical margins or reconstruction procedures performed

Exclusion Criteria

Do NOT use C44.612 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

17311CPT Code

Mohs micrographic surgery

Clinical Scenario

Used for excising BCC on the right upper limb with reconstruction.

Documentation Requirements

Document the size of the tumor, surgical margins, and reconstruction details.

Specialty Considerations

Dermatology and oncology specialties should coordinate documentation.

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 the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of skin cancers, including BCC, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    American Academy of Dermatology

Coding & Billing References

  • •
    American Academy of Dermatology

Frequently Asked Questions

What is the significance of specifying surgical margins in BCC coding?

Specifying surgical margins is crucial as it indicates whether the cancer has been completely excised, which impacts treatment decisions and potential recurrence.