What ICD‑10‑CM code should be used for the assessment of a scar?

ICD-10-CM Code for Assessment of Scar

For the assessment of a scar, use ICD-10-CM code L90.5 (Scar conditions and fibrosis of skin).

Primary Coding Recommendation

• L90.5 is the appropriate ICD-10-CM code for documenting scar assessment, evaluation, or follow-up visits where the scar itself is the focus of clinical attention.

Additional Coding Considerations

When coding for scar assessment, consider the following context-specific details:

Location-Specific Coding

• If the scar is from a previous cesarean section and being evaluated in the context of pregnancy or gynecologic care, additional codes may be relevant depending on clinical context.
• Document the anatomic location in your clinical notes, as this provides important context even though L90.5 does not require anatomic modifiers.

Assessment vs. Treatment

• L90.5 is appropriate for:
  • Routine scar evaluation visits
  • Scar quality assessment using validated tools (such as the Patient and Observer Scar Assessment Scale) 1, 2, 3
  • Follow-up monitoring of scar maturation
  • Documentation of scar characteristics (vascularity, pigmentation, thickness, relief, pliability)

Common Clinical Pitfalls

Avoid these coding errors:

• Do not use injury codes (S-codes) for scar assessment unless documenting an acute injury
• Do not use Z-codes for aftercare of healing surgical wounds if the wound is fully healed and you are assessing the resulting scar
• Be aware that ICD-10-CM implementation has shown variability in coding consistency across different conditions, so clear documentation is essential 4

Documentation Best Practices

To support proper coding:

• Specify whether the scar is hypertrophic, keloid, atrophic, or normal
• Note any functional impairment or cosmetic concerns
• Document scar maturity (acute vs. chronic)
• Record any symptoms (pain, itching, stiffness) as these influence clinical assessment 3