ICD-10 Code D04.111 | Ca in situ skin of right upper eyelid, including canthus Symptoms, Diagnosis, Billing

Ca in situ skin of the right upper eyelid, including the canthus, is a localized form of skin cancer characterized by abnormal cell growth confined to the epidermis. This condition is often caused by prolonged sun exposure or other carcinogenic factors. Accurate coding with ICD-10 Code D04.111 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively track and manage this condition.

What is ICD-10 Code D04.111 for Ca in situ skin of right upper eyelid, including canthus?

ICD-10 Code D04.111 represents a diagnosis of carcinoma in situ of the skin located specifically on the right upper eyelid, including the canthus. This code is used when documenting cases of localized skin cancer that have not invaded deeper tissues. It is crucial for accurate clinical documentation and billing, particularly in dermatology and oncology settings.

ICD-10 Code D04.111 – Clinical Definition and Explanation of Ca in situ skin of right upper eyelid, including canthus

Ca in situ skin of the right upper eyelid, including canthus, is a non-invasive skin cancer that requires prompt medical attention to prevent progression. The condition is primarily caused by UV radiation exposure, leading to cellular mutations. Early detection and treatment are vital to prevent invasive cancer development.

Key Clinical Features:

• Presence of a persistent, non-healing lesion on the eyelid.
• Possible changes in skin color or texture in the affected area.
• May present as a scaly patch or a raised bump.
• Typically asymptomatic but can cause cosmetic concerns.

ICD-10 Code D04.111 for Ca in situ skin of right upper eyelid, including canthus – SOAP Notes & Clinical Use

ICD-10 Code D04.111 is utilized in SOAP notes to document the diagnosis of carcinoma in situ of the right upper 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 D04.111 for Ca in situ skin of right upper eyelid, including canthus Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D04.111 connects subjective patient reports and objective clinical findings to a formal diagnosis of skin cancer. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code D04.111 – Ca in situ skin of right upper eyelid, including canthus

Management of Ca in situ skin of the right upper eyelid requires careful consideration due to its location and potential impact on vision and appearance.

Antibiotic Therapy:

• Not applicable for non-infectious conditions.

Supportive Care:

• Regular monitoring of the lesion for changes.
• Referral to a dermatologist for specialized treatment.
• Education on sun protection and skin care.

Infection Control:

• No specific infection control measures required for non-infectious conditions.

How to Document Symptoms of Ca in situ skin of right upper eyelid, including canthus (ICD-10 D04.111) in SOAP Notes

Subjective:

• Patient reports a persistent lesion on the right upper eyelid.
• No pain or discomfort associated with the lesion.
• History of sun exposure and skin changes noted.
• Patient expresses concern about cosmetic appearance.

Objective:

• Visual examination reveals a scaly, non-healing patch on the right upper eyelid.
• No signs of inflammation or infection.
• Dermatoscopic evaluation shows atypical keratinocytes.
• No lymphadenopathy observed.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Ca in situ skin of right upper eyelid, including canthus (ICD-10 Code D04.111)

Assessment:

• Diagnosis: Ca in situ skin of right upper eyelid, including canthus, classified as non-invasive.
• ICD-10 Code: D04.111.
• Contributing factors: History of UV exposure.
• No evidence of metastasis or invasive disease.

Plan:

• Refer to dermatology for excisional biopsy.
• Educate patient on sun protection measures.
• Schedule follow-up appointment in 4-6 weeks to monitor healing.
• Document findings and treatment plan in EHR.

Treatment & Plan Section for ICD-10 Code D04.111 – Ca in situ skin of right upper eyelid, including canthus

• Consider surgical excision as the primary treatment option.
• Monitor for any changes in the lesion post-treatment.
• Educate on the importance of regular skin checks.
• Advise on lifestyle modifications to reduce UV exposure.

Using ICD-10 Code D04.111 for Ca in situ skin of right upper eyelid, including canthus in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in appropriate clinical settings, including dermatology and oncology.
• Align treatment plans with clinical guidelines to support billing.
• Include relevant CPT codes for procedures performed.

Related ICD-10 Codes Often Used with Ca in situ skin of right upper eyelid, including canthus

• D04.112 – Ca in situ skin of left upper eyelid, including canthus
• C44.519 – Other malignant neoplasm of skin, unspecified
• C43.9 – Malignant melanoma of skin, unspecified
• D03.9 – Melanoma in situ, unspecified

ICD-10 Code D04.111 in Medical Billing and Insurance for Ca in situ skin of right upper eyelid, including canthus

ICD-10 Code D04.111 is critical for accurate billing in hospital, ER, or outpatient settings, particularly for skin cancer management.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use the code in conjunction with appropriate CPT codes for procedures.
• Ensure compliance with payer-specific guidelines for skin cancer coding.
• Review documentation for completeness before submission.

Common CPT Pairings: