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ICD-10 Guide
ICD-10 CodesC44.109

C44.109

Billable

Unspecified malignant neoplasm of skin of left eyelid, including canthus

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

Code Description

ICD-10 C44.109 is a billable code used to indicate a diagnosis of unspecified malignant neoplasm of skin of left eyelid, including canthus.

Key Diagnostic Point:

C44.109 refers to an unspecified malignant neoplasm of the skin located on the left eyelid, which includes the canthus area. This type of skin cancer can arise from various skin cells and may present as a growth, sore, or change in the skin texture. The eyelid is a delicate area, and malignancies here can be particularly concerning due to their proximity to the eye and potential impact on vision. Risk factors for developing skin cancer in this area include prolonged sun exposure, fair skin, and a history of skin cancer. Treatment often involves surgical excision to ensure clear margins, followed by reconstruction if necessary to restore the eyelid's appearance and function. The complexity of coding this condition arises from the need to accurately document the specific location, type of malignancy, and any associated treatments or complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for precise documentation of the tumor's location and type.
  • Variability in treatment approaches (surgical vs. non-surgical).
  • Potential for reconstruction procedures post-excision.
  • Differentiation from benign lesions and other skin conditions.

Audit Risk Factors

  • Inadequate documentation of the malignancy type.
  • Failure to document surgical margins.
  • Lack of clarity on the extent of the neoplasm.
  • Improper coding of associated reconstruction procedures.

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

Detailed descriptions of the lesion, including size, location, and histological type.

Common Clinical Scenarios

Diagnosis and treatment of skin cancers, including Mohs surgery.

Billing Considerations

Ensure clear documentation of margins and any reconstructive procedures performed.

Ophthalmology

Documentation Requirements

Documentation of visual function and any impact on the eye due to the neoplasm.

Common Clinical Scenarios

Management of eyelid malignancies and their effects on vision.

Billing Considerations

Coordination with dermatology for comprehensive care and accurate coding.

Coding Guidelines

Inclusion Criteria

Use C44.109 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the malignancy's location and type
  • Include any relevant patient history and treatment details

Exclusion Criteria

Do NOT use C44.109 When
  • Exclude codes for benign lesions or other skin conditions that do not meet the criteria for malignancy

Related ICD-10 Codes

Related CPT Codes

11600CPT Code

Excision, malignant skin lesion, face, ears, eyelids; excised diameter over 4.0 cm

Clinical Scenario

Used when excising a malignant neoplasm from the left eyelid.

Documentation Requirements

Document the size of the lesion and the surgical margins.

Specialty Considerations

Ensure coordination between dermatology and ophthalmology for comprehensive care.

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 those on the eyelid, which aids in better tracking and management of these conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of skin cancers, including those on the eyelid, which aids in better tracking and management of these conditions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of skin cancers, including those on the eyelid, which aids in better tracking and management of these conditions.

Resources

Clinical References

  • •
    American Academy of Dermatology

Coding & Billing References

  • •
    American Academy of Dermatology

Frequently Asked Questions

What is the significance of specifying the eyelid in the diagnosis?

Specifying the eyelid is crucial as it impacts treatment options, surgical approaches, and potential complications related to vision and eyelid function.