Wiki Recent BCC, needs derm followup

tag60

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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!
 
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
 
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