ICD-10 Code C44.612 | Basal cell carcinoma skin/ right upper limb, inc shoulder Symptoms, Diagnosis, Billing

Basal cell carcinoma (BCC) is a common skin cancer originating from basal cells in the epidermis. It is primarily caused by prolonged exposure to ultraviolet (UV) radiation from the sun or tanning beds. Clinically significant due to its potential for local invasion and destruction of surrounding tissues, BCC rarely metastasizes. The ICD-10 Code C44.612 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and resource allocation.

What is ICD-10 Code C44.612 for Basal cell carcinoma skin/ right upper limb, inc shoulder?

ICD-10 Code C44.612 specifically denotes basal cell carcinoma located on the skin of the right upper limb, including the shoulder. This code is used when documenting cases of BCC that are localized to this anatomical area, aiding in the identification of the condition for treatment planning and billing purposes. It is essential for healthcare providers to use this code accurately to reflect the diagnosis in clinical documentation and billing.

ICD-10 Code C44.612 – Clinical Definition and Explanation of Basal cell carcinoma skin/ right upper limb, inc shoulder

Basal cell carcinoma is primarily caused by cumulative sun exposure, leading to mutations in the DNA of skin cells. It typically presents as a pearly or waxy bump, often with visible blood vessels. Early detection and treatment are crucial to prevent local tissue damage and complications.

Key Clinical Features:

• Pearly or waxy nodules with a translucent appearance.
• Possible ulceration or crusting on the surface.
• Bleeding or oozing lesions that do not heal.
• Typically slow-growing, with a low risk of metastasis.

ICD-10 Code C44.612 for Basal cell carcinoma skin/ right upper limb, inc shoulder – SOAP Notes & Clinical Use

ICD-10 Code C44.612 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It plays a critical role in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate billing.

What Does ICD-10 Code C44.612 for Basal cell carcinoma skin/ right upper limb, inc shoulder Mean in SOAP Notes?

In SOAP notes, ICD-10 Code C44.612 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of basal cell carcinoma. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code C44.612 – Basal cell carcinoma skin/ right upper limb, inc shoulder

Prompt treatment of basal cell carcinoma is essential to prevent local invasion and complications. Surgical excision is the primary treatment modality.

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/ right upper limb, inc shoulder (ICD-10 C44.612) in SOAP Notes

Subjective:

• Patient reports a new growth on the right shoulder that has been present for several months.
• Describes the lesion as itchy and occasionally bleeding.
• No history of similar lesions or skin cancer.
• Denies any pain associated with the lesion.

Objective:

• Physical examination reveals a 1.5 cm pearly nodule on the right shoulder.
• Lesion has telangiectasia and is slightly ulcerated.
• No lymphadenopathy noted in the axillary region.
• Skin examination shows no other suspicious lesions.

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SOAP Note Guidelines for Diagnosing Basal cell carcinoma skin/ right upper limb, inc shoulder (ICD-10 Code C44.612)

Assessment:

• Diagnosis: Basal cell carcinoma, right upper limb, including shoulder, localized.
• ICD-10 Code: C44.612.
• Contributing factors: Prolonged sun exposure.
• Severity: Low risk of metastasis but requires surgical intervention.

Plan:

• Refer to dermatology for surgical excision of the lesion.
• Educate the patient on sun protection measures.
• Schedule follow-up in 6 months to monitor for recurrence.
• Document findings and treatment in the patient's EHR.

Treatment & Plan Section for ICD-10 Code C44.612 – Basal cell carcinoma skin/ right upper limb, inc shoulder

• Surgical excision is the first-line treatment for basal cell carcinoma.
• Consider Mohs micrographic surgery for larger or recurrent lesions.
• Topical chemotherapy may be an option for superficial BCC.
• Regular skin examinations and patient education on skin care are essential.

Using ICD-10 Code C44.612 for Basal cell carcinoma skin/ right upper limb, inc shoulder in Billing & SOAP Note Compliance

• Ensure accurate documentation of the lesion's characteristics under Subjective (S) and Objective (O).
• Use C44.612 to reflect the specific location and type of basal cell carcinoma.
• Align treatment plans with clinical guidelines to support justified billing.
• Include relevant CPT codes for surgical procedures performed.

Related ICD-10 Codes Often Used with Basal cell carcinoma skin/ right upper limb, inc shoulder

• C44.611 – Basal cell carcinoma skin/ left upper limb, inc shoulder
• C44.619 – Basal cell carcinoma skin/ unspecified upper limb
• C43.9 – Melanoma skin/ unspecified

ICD-10 Code C44.612 in Medical Billing and Insurance for Basal cell carcinoma skin/ right upper limb, inc shoulder

ICD-10 Code C44.612 is crucial for accurate billing in hospital, ER, or outpatient settings, ensuring proper reimbursement for services rendered.

Billing Notes:

• Document the specific location and characteristics of the lesion to support the use of C44.612.
• Ensure that all relevant clinical findings are included in the patient's chart.
• Use this code in conjunction with procedure codes for surgical interventions.
• Review payer guidelines for any specific documentation requirements.

Common CPT Pairings: