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v1.0.0
ICD-10 Guide
ICD-10 CodesC44.91

C44.91

Billable

Basal cell carcinoma of skin, unspecified

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

Code Description

ICD-10 C44.91 is a billable code used to indicate a diagnosis of basal cell carcinoma of skin, unspecified.

Key Diagnostic Point:

Basal cell carcinoma (BCC) is the most common form of skin cancer, arising from the basal cells in the epidermis. It is typically associated with prolonged sun exposure, particularly in fair-skinned individuals. BCCs are characterized by slow growth and a low likelihood of metastasis, making them less aggressive than other skin cancers. However, they can cause significant local tissue destruction if left untreated. The unspecified designation indicates that the specific location of the carcinoma on the skin is not documented, which can complicate treatment planning and coding. Surgical excision is the primary treatment modality, with margins of healthy tissue often removed to ensure complete resection. Reconstruction may be necessary depending on the size and location of the tumor, particularly in cosmetically sensitive areas such as the face. Accurate coding requires careful documentation of the tumor's characteristics, treatment approach, and any complications that arise during the management of the condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of tumor location and size
  • Need for precise surgical margin descriptions
  • Potential for reconstruction procedures to complicate coding
  • Differentiation from other skin cancers

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to document surgical margins
  • Lack of clarity on reconstruction procedures
  • Misclassification of skin cancer type

Specialty Focus

Medical Specialties

Dermatology

Documentation Requirements

Detailed descriptions of the tumor's size, location, and histological type, along with treatment plans.

Common Clinical Scenarios

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

Billing Considerations

Ensure clear documentation of margins and any reconstructive procedures performed.

Oncology

Documentation Requirements

Comprehensive treatment plans, including chemotherapy or radiation if applicable.

Common Clinical Scenarios

Management of advanced BCC cases or those requiring multidisciplinary approaches.

Billing Considerations

Documentation should reflect the oncological treatment rationale and outcomes.

Coding Guidelines

Inclusion Criteria

Use C44.91 When
  • According to ICD
  • CM guidelines, C44
  • 91 should be used when the specific site of the basal cell carcinoma is not documented
  • Coders should ensure that the diagnosis is confirmed by pathology reports and that treatment details are well
  • documented

Exclusion Criteria

Do NOT use C44.91 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

17311CPT Code

Mohs micrographic surgery

Clinical Scenario

Used for excising basal cell carcinoma with margins.

Documentation Requirements

Document the size of the lesion and margins taken.

Specialty Considerations

Dermatologists should ensure detailed operative notes.

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, improving the accuracy of data collection and reimbursement processes. C44.91 allows for the capture of unspecified cases, which can help in tracking the prevalence of basal cell carcinoma.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of skin cancers, improving the accuracy of data collection and reimbursement processes. C44.91 allows for the capture of unspecified cases, which can help in tracking the prevalence of basal cell carcinoma.

Reimbursement & Billing Impact

reimbursement processes. C44.91 allows for the capture of unspecified cases, which can help in tracking the prevalence of basal cell carcinoma.

Resources

Clinical References

  • •
    American Academy of Dermatology

Coding & Billing References

  • •
    American Academy of Dermatology

Frequently Asked Questions

What is the significance of the 'unspecified' designation in C44.91?

The 'unspecified' designation indicates that the exact location of the basal cell carcinoma is not documented, which can affect treatment planning and coding accuracy.