ICD-10 Code C44.111 | Basal cell carcinoma skin/ unsp eyelid, including canthus Symptoms, Diagnosis, Billing

Basal cell carcinoma (BCC) is the most common form of skin cancer, primarily caused by prolonged exposure to ultraviolet (UV) radiation. It typically presents as a pearly or waxy bump on sun-exposed areas, including the eyelid and canthus. Accurate coding with ICD-10 Code C44.111 is essential for proper diagnosis, documentation, and billing, ensuring appropriate treatment and facilitating public health reporting.

What is ICD-10 Code C44.111 for Basal cell carcinoma skin/ unsp eyelid, including canthus?

ICD-10 Code C44.111 specifically identifies basal cell carcinoma of the skin located on the unspecified eyelid, including the canthus. This code is used when documenting cases of BCC that may not have a specified location or subtype. It is crucial for accurate clinical documentation and billing, particularly in dermatology and oncology settings.

ICD-10 Code C44.111 – Clinical Definition and Explanation of Basal cell carcinoma skin/ unsp eyelid, including canthus

Basal cell carcinoma of the skin, particularly on the eyelid and canthus, arises from the basal cells in the epidermis. It is primarily linked to UV exposure and can lead to significant morbidity if left untreated. Early detection and treatment are vital to prevent local invasion and complications.

Key Clinical Features:

• Typically presents as a pearly or waxy lesion on the eyelid.
• May exhibit telangiectasia or ulceration.
• Commonly occurs in fair-skinned individuals with a history of sun exposure.
• Slow-growing and rarely metastasizes, but can cause local tissue destruction.

ICD-10 Code C44.111 for Basal cell carcinoma skin/ unsp eyelid, including canthus – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code C44.111 is utilized to document the diagnosis of basal cell carcinoma affecting the eyelid. It plays a critical role in capturing patient symptoms, assessment findings, and treatment plans, ensuring comprehensive care in both acute and chronic settings.

What Does ICD-10 Code C44.111 for Basal cell carcinoma skin/ unsp eyelid, including canthus Mean in SOAP Notes?

ICD-10 Code C44.111 connects subjective patient reports and objective clinical findings to a formal diagnosis of basal cell carcinoma. This code is essential for maintaining continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code C44.111 – Basal cell carcinoma skin/ unsp eyelid, including canthus

Management of basal cell carcinoma on the eyelid requires prompt intervention to prevent complications. Treatment options vary based on the tumor's characteristics and location.

Antibiotic Therapy:

Supportive Care:

• Regular follow-up appointments to monitor for recurrence.
• Education on sun protection and skin care.
• Wound care instructions post-surgery.

Infection Control:

How to Document Symptoms of Basal cell carcinoma skin/ unsp eyelid, including canthus (ICD-10 C44.111) in SOAP Notes

Subjective:

• Patient reports a new growth on the eyelid that has been present for several months.
• Describes the lesion as painless but occasionally itchy.
• No history of trauma or previous skin cancers noted.

Objective:

• Physical examination reveals a 0.5 cm pearly nodule on the right lower eyelid.
• No lymphadenopathy detected.
• Dermatoscopic examination shows telangiectasia and central ulceration.

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SOAP Note Guidelines for Diagnosing Basal cell carcinoma skin/ unsp eyelid, including canthus (ICD-10 Code C44.111)

Assessment:

• Diagnosis: Basal cell carcinoma of the skin, unspecified eyelid (C44.111).
• Severity: Low risk for metastasis but potential for local invasion.
• Contributing factors: History of sun exposure.

Plan:

• Refer to dermatology for excisional biopsy.
• Educate patient on sun protection measures.
• Schedule follow-up in 2 weeks to discuss biopsy results.

Treatment & Plan Section for ICD-10 Code C44.111 – Basal cell carcinoma skin/ unsp eyelid, including canthus

• Surgical excision is the primary treatment for localized basal cell carcinoma.
• Consider Mohs micrographic surgery for cosmetically sensitive areas.
• Topical chemotherapy may be an option for superficial lesions.
• Regular skin examinations are recommended to monitor for new lesions.

Using ICD-10 Code C44.111 for Basal cell carcinoma skin/ unsp eyelid, including canthus in Billing & SOAP Note Compliance

• Ensure accurate documentation of the lesion's characteristics in Subjective (S) and Objective (O) sections.
• Use C44.111 for billing when the diagnosis is confirmed by biopsy.
• Include treatment plans that align with clinical guidelines to support justified billing.
• Document any patient education provided regarding skin care and sun protection.

Related ICD-10 Codes Often Used with Basal cell carcinoma skin/ unsp eyelid, including canthus

• C44.112 – Basal cell carcinoma skin, right eyelid, including canthus
• C44.119 – Basal cell carcinoma skin, left eyelid, including canthus
• C43.9 – Malignant melanoma of skin, unspecified

ICD-10 Code C44.111 in Medical Billing and Insurance for Basal cell carcinoma skin/ unsp eyelid, including canthus

ICD-10 Code C44.111 is critical in medical billing, particularly in dermatology and oncology settings, ensuring accurate claims for treatment of basal cell carcinoma.

Billing Notes:

• Document the diagnosis clearly in the medical record to support the claim.
• Use C44.111 in outpatient and inpatient settings as appropriate.
• Ensure that all relevant clinical findings are included in the chart.

Common CPT Pairings: