ICD-10 Coding for History of Basal Cell Carcinoma(Z85.828, Z85.82)
Complete ICD-10-CM coding and documentation guide for History of Basal Cell Carcinoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Basal Cell Carcinoma
Z85.82-Z85.828Primary Range
Personal history of malignant neoplasm of skin
This range includes codes for documenting a personal history of skin cancer, specifically basal cell carcinoma.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z85.828 | Personal history of other malignant neoplasm of skin | Use when the patient has completed treatment for basal cell carcinoma and there is no evidence of disease. |
|
| Z85.82 | Personal history of malignant neoplasm of skin | Use when the history of skin cancer is documented but the specific site is not mentioned. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: When to use Z85.828
Essential facts and insights about History of Basal Cell Carcinoma
Primary ICD-10-CM Codes for history of basal cell carcinoma
Decision Criteria
clinical Criteria
- Patient has completed all treatment and shows no evidence of disease.
documentation Criteria
- Provider notes must specify 'no evidence of disease' and treatment completion.
Applicable To
- History of basal cell carcinoma of specific sites
Excludes
- Active basal cell carcinoma (C44.XXX)
Clinical Validation Requirements
- Pathology report confirming excision with clear margins
- Provider documentation stating 'no evidence of disease'
Code-Specific Risks
- Incorrectly using this code for active cancer cases
Coding Notes
- Ensure documentation clearly states the site and confirms no active disease.
Z85.82 - Personal history of malignant neoplasm of skin
Use when the history of skin cancer is documented but the specific site is not mentioned.
Applicable To
- History of skin cancer, site unspecified
Excludes
- Active skin cancer (C44.XXX)
Clinical Validation Requirements
- General documentation of past skin cancer without specific site
Coding Notes
Ensure documentation supports the use of a non-specific site history code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Basal Cell Carcinoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.828.
Impact
Clinical: May lead to inappropriate follow-up care., Regulatory: Potential audit risk due to non-specific coding., Financial: Claims may be denied for lack of specificity.
Mitigation Strategy
Ensure documentation includes specific site details., Use templates to guide comprehensive documentation.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use C44.XXX for active basal cell carcinoma cases.
Impact
Audits may focus on the specificity of site documentation for history codes.
Mitigation Strategy
Ensure all documentation includes specific site and treatment details.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Basal Cell Carcinoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Basal Cell Carcinoma
Use these documentation templates to ensure complete and accurate documentation for History of Basal Cell Carcinoma. These templates include all required elements for proper coding and billing.
Post-treatment follow-up
Specialty: DermatologyRequired Elements
- Patient history of basal cell carcinoma
- Details of treatment completion
- Current status: no evidence of disease
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for History of Basal Cell Carcinoma? Ask your questions below.