Wiki Recent BCC, needs derm followup

[tag60]

Here is the provider's note:

HPI: Pt had BCC excised on chest last year and SCC on right arm; needs derm f/u with multiple forearm abnormal areas.
Exam: Skin: Multiple areas of erythematous scaling lesions on both forearms.
A/P: Basal cell carcinoma of skin, 173.81. Refer to dermatology.

My question is whether I code 173.81 or 709.9? The prior BCC was removed, but could it have recurred in a different area and thus I still code as if a current condition? Or is that prior instance of BCC considered fully treated and now a history of BCC (V10.83)? (Or does provider need to state "history of" for me to use that code?)

I hope my question is making sense. How would you code this encounter?

Thanks in advance!

 

[mitchellde]

If the excision was performed last year with no further treatment then the provider obviously felt the excision was definitive treatment. I would consider the previous BCC to be history and the current lesions to be 709.9