ICD-10 Code D04.112 | Ca in situ skin of right lower eyelid, including canthus Symptoms, Diagnosis, Billing

Ca in situ skin of the right lower eyelid, including canthus, is a localized malignant neoplasm characterized by abnormal growth of skin cells confined to the epidermis. This condition is clinically significant as it can progress to invasive cancer if left untreated. Accurate coding with ICD-10 Code D04.112 facilitates precise diagnosis, documentation, medical billing, and public health reporting, ensuring appropriate management and resource allocation.

What is ICD-10 Code D04.112 for Ca in situ skin of right lower eyelid, including canthus?

ICD-10 Code D04.112 represents a diagnosis of carcinoma in situ of the skin located specifically on the right lower eyelid, including the canthus. This code is used when documenting cases of non-invasive skin cancer that has not yet penetrated deeper layers. It is essential for accurate clinical documentation and billing, particularly in dermatology and oncology settings.

ICD-10 Code D04.112 – Clinical Definition and Explanation of Ca in situ skin of right lower eyelid, including canthus

Ca in situ skin of the right lower eyelid, including canthus, is primarily caused by prolonged sun exposure, genetic predisposition, or exposure to carcinogenic substances. This condition requires medical attention to prevent progression to invasive cancer.

Key Clinical Features:

• Localized skin lesion with irregular borders and varying pigmentation.
• May present as a scaly patch, ulcer, or raised bump.
• Typically asymptomatic but can cause cosmetic concerns.
• Higher incidence in fair-skinned individuals and those with a history of sunburn.

ICD-10 Code D04.112 for Ca in situ skin of right lower eyelid, including canthus – SOAP Notes & Clinical Use

ICD-10 Code D04.112 is utilized in SOAP notes to document the diagnosis of carcinoma in situ of the right lower eyelid. It plays a crucial role in capturing patient symptoms, assessment findings, and treatment plans, relevant in both acute and chronic care settings.

What Does ICD-10 Code D04.112 for Ca in situ skin of right lower eyelid, including canthus Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D04.112 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of skin cancer. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D04.112 – Ca in situ skin of right lower eyelid, including canthus

The treatment of Ca in situ skin of the right lower eyelid requires prompt intervention to prevent progression. Surgical excision is the primary treatment modality.

Antibiotic Therapy:

• Not applicable as this condition is not infectious.

Supportive Care:

• Regular follow-up appointments to monitor for changes.
• Patient education on sun protection and skin care.
• Psychosocial support for cosmetic concerns.

Infection Control:

• No specific infection control measures required.

How to Document Symptoms of Ca in situ skin of right lower eyelid, including canthus (ICD-10 D04.112) in SOAP Notes

Subjective:

• Patient reports a new lesion on the right lower eyelid.
• Lesion has changed in appearance over the past few months.
• No associated pain or discomfort noted.
• Patient has a history of sun exposure.

Objective:

• Physical examination reveals a 0.5 cm scaly patch on the right lower eyelid.
• Lesion has irregular borders and is slightly erythematous.
• No lymphadenopathy observed.
• Dermatoscopic examination shows atypical keratinocytes.

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 lower eyelid, including canthus (ICD-10 Code D04.112)

Assessment:

• Diagnosis: Ca in situ skin of right lower eyelid, including canthus, classified as non-invasive.
• ICD-10 Code: D04.112.
• Contributing factors include significant sun exposure.
• No evidence of metastasis or invasive disease.

Plan:

• Surgical excision of the lesion with margins.
• Educate patient on sun protection measures.
• Schedule follow-up in 6 weeks to assess healing.
• Consider referral to dermatology for further management.

Treatment & Plan Section for ICD-10 Code D04.112 – Ca in situ skin of right lower eyelid, including canthus

• Surgical excision is the first-line treatment.
• Patient education on sun safety and skin monitoring.
• Regular follow-up appointments to monitor for recurrence.
• Consideration of Mohs micrographic surgery for cosmetically sensitive areas.

Using ICD-10 Code D04.112 for Ca in situ skin of right lower eyelid, including canthus in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use D04.112 in appropriate clinical settings for skin cancer management.
• Align treatment plans with clinical guidelines to support billing.
• Document any relevant CPT codes that correspond with the treatment provided.

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

• D04.111 – Ca in situ skin of left lower eyelid, including canthus
• C44.119 – Other malignant neoplasm of skin, unspecified
• C43.9 – Malignant melanoma of skin, unspecified
• D03.9 – Melanoma in situ, unspecified

ICD-10 Code D04.112 in Medical Billing and Insurance for Ca in situ skin of right lower eyelid, including canthus

ICD-10 Code D04.112 is critical in medical billing, particularly in dermatology and oncology settings.

Billing Notes:

• Document all clinical findings clearly to support the diagnosis.
• Use D04.112 in outpatient and inpatient settings as appropriate.
• Ensure that the treatment plan aligns with the documented diagnosis for billing accuracy.

Common CPT Pairings: