ICD-10 Code for Routine Skin Check
Use ICD-10 code Z12.83 for a routine skin cancer screening examination in an asymptomatic patient without a history of skin lesions. 1
Primary Code Selection
Z12.83 is the appropriate code for screening purposes to detect skin cancer in patients without signs, symptoms, or history of skin malignancy. 1 This code applies specifically to asymptomatic adolescents and adults presenting for preventive screening who do not have a history of premalignant or malignant skin lesions. 1
When to Add Secondary Codes
You should add secondary diagnosis codes in specific clinical contexts to justify the screening encounter:
For patients with a personal history of skin cancer: Use Z85.82 or Z85.828 as a secondary code to support more frequent surveillance examinations. 1
For patients with a family history of melanoma: Consider adding Z80.8 as a secondary diagnosis code. 1
For patients with atypical moles or dysplastic nevus syndrome: Document the findings that support the need for examination, which may warrant different coding based on what is discovered. 1
Critical Documentation Requirements
Document any risk factors that justify the screening examination to support the use of Z12.83, including: 1
- Fair skin
- Age >65 years
- History of significant sun exposure
- Family history of skin cancer
- Multiple moles (>50 moles)
- Atypical moles
Common Coding Pitfalls to Avoid
Never use symptom codes when the encounter is purely for screening purposes without symptoms—stick with Z12.83 for screening. 1 This is a frequent error that can lead to claim denials or incorrect documentation of the clinical encounter.
If you discover findings during the screening examination, document and code them separately in addition to the screening code Z12.83. 1 The screening code should still be listed to indicate the original purpose of the visit, with additional codes for any lesions identified.