Skin Cancer Documentation Guide
Malignant neoplasms of the skin including basal cell, squamous cell, and in-situ carcinomas.
ICD-10 Codes: C44.01, C44.11, C44.21, C44.31, C44.41, C44.51, C44.61, C44.71, C44.81, C44.91, D04.0, D04.1, D04.2, D04.3, D04.4, D04.5, D04.6, D04.7, D04.8, D04.9
Common Symptoms
- Non-healing lesion
- Changing mole or spot
- Pearly or waxy bump
- Ulceration
- Bleeding or crusting
Key Documentation Elements
- Histologic type (BCC, SCC, SCC in situ)
- Anatomic site and size of lesion
- Biopsy pathology with margins and depth
- Treatment modality (excision, Mohs, radiation, topical)
- Surveillance plan and sun protection counseling
Documentation Challenges
- Documenting precise anatomic site and laterality
- Recording Breslow depth and Clark level for staging
- Capturing surgical margin assessment and re-excision decisions
- Tracking surveillance schedule and prior skin cancer history
Billing Considerations
- Site-specific malignancy codes (C44.x) vs in-situ (D04.x)
- Mohs surgery staged excision coding
- Biopsy and pathology separate billing from treatment
Frequently Asked Questions
How is skin cancer coded by site in ICD-10?
Skin cancer uses site-specific C44.x codes (C44.01 lip, C44.31 face, C44.51 trunk, etc.) for invasive and D04.x for in-situ. Scribeable maps your documented lesion location to the precise anatomic site code.
How does Scribeable support skin cancer treatment documentation?
Scribeable captures lesion description, biopsy results, surgical margins, treatment modality, and surveillance plans from your encounter, creating structured oncologic dermatology documentation.