Understanding melasma diagnosis, treatment, and medical coding? Find information on chloasma, hyperpigmentation, skin discoloration, facial melanosis, and related ICD-10 codes L81.1 and L81.9. Learn about clinical documentation requirements for melasma, including assessment, differential diagnosis, and treatment options like hydroquinone, chemical peels, and laser therapy. Explore resources for healthcare professionals on managing melasma in patients of all skin types.
Also known as
Chloasma
Melasma, also known as chloasma, is a common skin condition.
Disorders of pigmentation
Includes various conditions affecting skin color, like melasma.
Diseases of the skin and subcutaneous tissue
Encompasses a wide range of skin conditions including pigmentation disorders.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis Melasma?
Yes
Is Melasma associated with pregnancy?
No
Do not code Melasma. Code the presenting diagnosis.
When to use each related code
| Description |
|---|
| Symmetrical facial hyperpigmentation |
| Post-inflammatory hyperpigmentation |
| Solar lentigines (sun spots) |
Using unspecified codes (L81.9) when more specific documentation supports other types like epidermal, dermal, or mixed melasma, impacting reimbursement and data accuracy.
Failing to code drug-induced melasma (L81.1) when documentation supports it, leading to inaccurate reporting of adverse drug events and affecting pharmacovigilance.
Inconsistent or missing laterality coding for melasma affecting specific body sites, hindering accurate tracking of disease presentation and treatment outcomes.
Patient presents with a chief complaint of hyperpigmentation consistent with melasma. The patient reports symmetrical, irregular, light to dark brown macules on the face, specifically involving the forehead, cheeks, upper lip, and nose. Onset is reported as gradual, and the patient notes exacerbation with sun exposure. The patient denies pruritus, pain, or other associated symptoms. Medical history is significant for [insert relevant medical history, e.g., pregnancy, oral contraceptive use, hormone replacement therapy, thyroid disorders]. Family history is positive for hyperpigmentation. Physical examination reveals well-demarcated, hyperpigmented patches with irregular borders, consistent with the diagnosis of melasma. Wood's lamp examination accentuates the pigmentation. Differential diagnoses considered include postinflammatory hyperpigmentation, solar lentigines, and ephelides. Diagnosis of melasma is made based on clinical presentation and history. The patient was counseled on sun protection measures, including daily use of broad-spectrum sunscreen with an SPF of 30 or higher, and avoidance of excessive sun exposure. Treatment options including topical hydroquinone, tretinoin, corticosteroids, and combination therapies were discussed. The patient opted to begin treatment with [insert chosen treatment]. Patient education provided on the importance of adherence to the prescribed treatment plan, potential side effects, and the chronic nature of melasma. Follow-up appointment scheduled in [timeframe] to assess treatment response and adjust the plan as needed. ICD-10 code L81.1 assigned.