A patient presents today to discuss the results of her skin biopsy.
Alice came in today for a follow-up visit. We performed a biopsy on her left ear last week. She had reported that she noticed a small lesion a few months ago. It recently began to grow so she came in to get it checked. She has spent years in the sun and until recently did not wear any sun protection.
A recheck of the site was performed and the lesion looked to be of the same size as when examined in the office last week. It is not painful to the touch.
ASSESSMENT/PLAN: Basal cell carcinoma left ear – confirmed by pathology. We have discussed the treatment options and Alice wishes to have surgical excision performed. We will send her to the dermatologist to have this performed as soon as possible. We will see her back as necessary.
C44.219 Basal cell carcinoma of skin of left ear and external auricular canal
Rationale: In ICD-10-CM, the codes for neoplasm of the skin are broken down by site, laterality, and type. There are separate codes for melanoma, Merkel cell carcinoma, basal cell carcinoma, squamous cell carcinoma, other, and unspecified.