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ICD-10 Guide
ICD-10 CodesC44.611

C44.611

Billable

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

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

Code Description

ICD-10 C44.611 is a billable code used to indicate a diagnosis of basal cell carcinoma of skin of unspecified upper limb, including shoulder.

Key Diagnostic Point:

Basal cell carcinoma (BCC) is the most common form of skin cancer, arising from the basal cells in the epidermis. This malignancy is typically associated with prolonged sun exposure, which leads to DNA damage in skin cells. BCCs are characterized by slow growth and a low likelihood of metastasis, but they can cause significant local tissue destruction if left untreated. The unspecified upper limb designation indicates that the specific site of the carcinoma is not detailed, which can complicate treatment planning and surgical margins. Surgical excision is the primary treatment modality, and achieving clear margins is crucial to prevent recurrence. Reconstruction may be necessary depending on the size and location of the excised lesion, particularly in cosmetically sensitive areas. The prognosis for BCC is generally favorable, with a high cure rate when detected early and treated appropriately. However, patients with a history of skin cancer or significant sun exposure should be monitored regularly for new lesions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified location may lead to ambiguity in treatment planning.
  • Need for clear documentation of surgical margins.
  • Potential for reconstruction complicates coding.
  • Variability in treatment approaches based on tumor characteristics.

Audit Risk Factors

  • Inadequate documentation of surgical margins.
  • Failure to specify the exact location of the carcinoma.
  • Lack of follow-up documentation post-surgery.
  • Inconsistent coding of related procedures.

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

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

Common Clinical Scenarios

Diagnosis and treatment of BCC, Mohs micrographic surgery, and follow-up care.

Billing Considerations

Ensure clear documentation of margins and any reconstruction performed.

Oncology

Documentation Requirements

Comprehensive treatment plans, including chemotherapy or radiation if applicable.

Common Clinical Scenarios

Management of advanced BCC cases or those with recurrence.

Billing Considerations

Document any systemic therapies or clinical trials involved.

Coding Guidelines

Inclusion Criteria

Use C44.611 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, treatment, and any associated procedures
  • Include details on the surgical margins and reconstruction if applicable

Exclusion Criteria

Do NOT use C44.611 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

17311CPT Code

Mohs micrographic surgery

Clinical Scenario

Used for excision of BCC on the shoulder with reconstruction.

Documentation Requirements

Document the size of the lesion, margins, and reconstruction details.

Specialty Considerations

Dermatologists performing Mohs surgery must ensure accurate coding for each stage.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specificity in coding skin cancers, including BCC. This has improved the accuracy of data collection and reimbursement processes, but it also requires coders to be more diligent in documentation and coding practices.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specificity in coding skin cancers, including BCC. This has improved the accuracy of data collection and reimbursement processes, but it also requires coders to be more diligent in documentation and coding practices.

Reimbursement & Billing Impact

reimbursement processes, but it also requires coders to be more diligent in documentation and coding practices.

Resources

Clinical References

  • •
    American Academy of Dermatology

Coding & Billing References

  • •
    American Academy of Dermatology

Frequently Asked Questions

What is the significance of specifying the location for BCC coding?

Specifying the location is crucial for treatment planning, determining surgical margins, and ensuring accurate coding for reimbursement. It also helps in tracking the incidence of skin cancers in specific areas.