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ICD-10 Guide
ICD-10 CodesD04.4

D04.4

Billable

Carcinoma in situ of skin of scalp and neck

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

Code Description

ICD-10 D04.4 is a billable code used to indicate a diagnosis of carcinoma in situ of skin of scalp and neck.

Key Diagnostic Point:

Carcinoma in situ (CIS) of the skin of the scalp and neck is a non-invasive form of skin cancer characterized by the presence of abnormal cells that have not yet invaded deeper tissues. This condition is often associated with sun exposure and can manifest as various skin lesions, including actinic keratosis or squamous cell carcinoma in situ. Patients may present with asymptomatic lesions that can appear as scaly patches, red spots, or non-healing sores. Early detection and treatment are crucial to prevent progression to invasive cancer. Treatment options typically include surgical excision, cryotherapy, or topical chemotherapy. Regular dermatological surveillance is recommended to monitor for changes in the lesions and to assess for new lesions, as individuals with a history of carcinoma in situ are at increased risk for developing subsequent skin cancers.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between carcinoma in situ and invasive carcinoma
  • Variability in clinical presentation of lesions
  • Need for precise documentation of lesion characteristics
  • Potential for multiple lesions requiring coding

Audit Risk Factors

  • Inadequate documentation of lesion characteristics
  • Failure to document follow-up care and surveillance
  • Misclassification of lesions as invasive
  • Inconsistent coding of multiple lesions

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

Detailed descriptions of lesions, treatment plans, and follow-up care.

Common Clinical Scenarios

Diagnosis and treatment of multiple skin lesions, monitoring for progression.

Billing Considerations

Ensure accurate documentation of lesion size, location, and characteristics.

Oncology

Documentation Requirements

Comprehensive treatment history and follow-up care documentation.

Common Clinical Scenarios

Management of patients with a history of skin cancers and surveillance protocols.

Billing Considerations

Coordination of care with dermatology for ongoing monitoring.

Coding Guidelines

Inclusion Criteria

Use D04.4 When
  • According to ICD
  • CM guidelines, D04
  • 4 should be used when documenting carcinoma in situ specifically located on the scalp and neck
  • Coders must ensure that the diagnosis is confirmed by a healthcare provider and that the documentation supports the diagnosis and treatment provided

Exclusion Criteria

Do NOT use D04.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11100CPT Code

Biopsy of skin, excisional

Clinical Scenario

Used when a biopsy is performed to confirm carcinoma in situ.

Documentation Requirements

Document the size, location, and type of biopsy performed.

Specialty Considerations

Dermatologists should ensure clear documentation of the biopsy site and findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the ability to track and manage skin cancer cases. This specificity aids in better patient management and research outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the ability to track and manage skin cancer cases. This specificity aids in better patient management and research outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of carcinoma in situ, improving the ability to track and manage skin cancer cases. This specificity aids in better patient management and research outcomes.

Resources

Clinical References

  • •
    American Academy of Dermatology

Coding & Billing References

  • •
    American Academy of Dermatology

Frequently Asked Questions

What is the difference between carcinoma in situ and invasive carcinoma?

Carcinoma in situ refers to cancer cells that are confined to the layer of cells where they originated and have not invaded surrounding tissues. Invasive carcinoma has spread beyond the original layer into deeper tissues.