Find comprehensive information on mole diagnosis, including clinical documentation, ICD-10 codes (D22, D48.5), SNOMED CT concepts, and healthcare terminology. Learn about atypical mole diagnosis, benign nevus diagnosis, dysplastic nevus diagnosis, melanoma diagnosis, and skin cancer screening. This resource offers guidance on proper medical coding for moles and assists healthcare professionals in accurate clinical documentation for improved patient care.
Also known as
Melanocytic nevi
Benign melanocytic tumors of the skin.
Congenital melanocytic nevus
A mole present at birth, sometimes large.
Other benign skin neoplasm
Includes other benign skin growths when a more specific code is not available.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the mole congenital?
Yes
Is the mole melanocytic?
No
Is the mole atypical/dysplastic?
When to use each related code
| Description |
|---|
| Common mole (nevus) |
| Atypical mole (dysplastic nevus) |
| Actinic keratosis |
Incorrectly coding benign moles (e.g., D22.x) as malignant melanoma (C43.x) or vice-versa leads to inaccurate reporting and reimbursement.
Lack of specific site documentation for mole excisions (e.g., C44.x) impacts accurate coding and potential medical necessity reviews.
Miscoding or missing documentation for dysplastic nevi (D22.1) can affect risk stratification and appropriate follow-up.
Patient presents for evaluation of skin mole(s). History includes patient concern regarding atypical mole, dysplastic nevus, or new mole growth. Review of systems includes questions regarding itching, bleeding, pain, change in size, shape, or color of existing moles. Family history of melanoma and personal history of sun exposure, tanning bed use, and previous mole biopsies were discussed. Physical examination reveals (number) mole(s) located on (body location). Mole(s) are described as (size in millimeters), (color: e.g., brown, black, pink, tan), (shape: e.g., round, oval, irregular), (border: e.g., well-defined, irregular), (surface: e.g., smooth, rough, raised), and (texture: e.g., soft, firm). Dermoscopic examination (if performed) revealed (dermoscopic features, e.g., homogenous pattern, atypical network, blue-white veil). Assessment: Benign nevus, dysplastic nevus, suspicious mole concerning for melanoma (specify clinical diagnosis). ICD-10 code (e.g., D22, D48.5) assigned based on clinical findings. Plan: Patient education provided on skin self-examination and sun protection. Photography and dermatoscopic monitoring recommended. Biopsy for histopathological evaluation recommended for suspicious lesions. Excisional biopsy vs. shave biopsy discussed with the patient and decision made based on clinical suspicion and lesion characteristics. Patient agrees with the plan. Follow-up scheduled in (timeframe) for biopsy results and further management as needed. Differential diagnoses considered include: melanoma, seborrheic keratosis, atypical melanocytic nevus, basal cell carcinoma, dermatofibroma.