CPT 11200, 17110, 11440, 11420, 17000 - Removal of Benign and Malignant Skin Lesions

procedure code and description


17000-  Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion - average fee payment- $70 - $80

 17003 — ... second through 14 lesions, each (List separately in addition to code for first lesion)

 17004 — Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions

11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS

11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS

11401 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM

11402 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM

11420 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS

11421 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM

11440 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS

11441 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM

Coding Guidelines

1. Use the Procedure  code that best describes the procedure, the location and the size of the lesion. If there are multiple lesions, multiple codes from 11300 through 11446 or 17106 through 17111 may be used, but National Correct Coding Initiative guidelines apply for all submitted codes.

For excision of benign lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 14000-14300, 15000- 15261, and 15570-15770.

Procedure  code 11200 should be reported with one unit of service. Procedure  code 11201 should be reported with units equal to one for each additional group of 10 lesions.

Procedure  code 17000 should be reported with one unit of service for destruction of the first lesion; Procedure  code 17003 should be reported with the units equal to the number of additional lesions from 2 through 14; 17004 should be reported with one unit of service, representing 15 or more lesions and should not be used with 17000 or 17003.

Procedure  code 17110 should be reported with one unit of service for removal of benign lesions other than skin tags or cutaneous vascular lesions, up to 14 lesions. Procedure  code 17111 is also reported with one unit of service representing 15 or more lesions.

Procedure  codes 11400-11446 should be used when the excision is a full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.


The NCCI edits with column one CPT codes 17000 and 17004 (Destruction of benign or premalignant lesions) each with column two CPT code 11100 (Biopsy of single skin lesion) are often bypassed by utilizing modifier 59. Use of modifier 59 with the column two CPT code 11100 of these NCCI edits is only appropriate if the two procedures of a code pair edit are performed on separate lesions or at separate patient encounters. Refer to the CPT Manual instructions preceding CPT code 11100 for additional clarification about the CPT codes 11100-11101.


Removal by Shave Technique

According to the American Medical Association Current Procedural Terminology® (AMA CPT), shaving “is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full thickness dermal excision. This includes local anesthesia, chemical or electrocauterization of the wound, and does
not require suture closure.”

Removal of lesions by shave technique is not considered an “excision,” requires a more superficial “removal” and does not involve the full thickness of the dermis, which could result in portions of the lesion remaining in the deeper layers of the dermis. This is a therapeutic procedure, intended to remove a lesion or the problematic portion of the lesion. Removed tissue is typically submitted for pathologic examination. The obtaining of this tissue sample is not a separate biopsy procedure and cannot be reported as such.

Such service is appropriately reported using CPT Codes 11300 - 11313 Shaving of epidermal or dermal lesions.

Each shaved lesion treated is reported separately and code selection is based on lesion size and anatomic location.



However, if the defect following an excision goes “through the entire thickness of the dermis,” it is considered an excision even though the defect may not be closed. Sometimes dermatologists use a deeper tangential removal known as “saucerization” that may go through the dermis into fat. This may be done in the case of suspected melanomas to assure that the complete depth of the lesion is available for pathology.


Such lesions are intentionally left open pending histopathology examination, anticipating that a more definitive excision procedure will be required. Such saucerization procedures are appropriately coded as excisions with the 11400 or 11600 series, depending on whether the lesion was pathologically determined to be benign or malignant. Because such procedures go “through the dermis,” they exceed the definition of shave removal procedures that would be coded in the 11300 series. 

Coverage Indications, Limitations, and/or Medical Necessity

Benign skin lesions are common in the elderly and are sometimes removed at the patient’s request. Removal of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic and, as such, are not covered by the Medicare program (statutory exclusion). This policy describes the medical conditions for which skin lesion removal using one of the services listed in the CPT section (shaving, removal and destruction) would be medically necessary and would, therefore, not be excluded.
Medicare would consider the removal of any malignant lesion to be medically necessary.
There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts and viral warts is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic if one or more of the following conditions is present and clearly documented in the medical record:

  • The lesion has one or more of the following characteristics:
    • Bleeding.
    • Persistent or intense itching.
    • Pain.
  • The lesion has physical evidence of inflammation (purulence, oozing, edema, erythema, etc.).
  • The lesion obstructs an orifice or clinically restricts vision.
  • There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesional appearance, such as increased rate of growth and/or color changes.
  • The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.
  • Wart destruction will be covered if it falls under one of the conditions of the first five bullets above. In addition, because warts are a viral infection of the skin, wart destruction will be covered when any one of the following clinical circumstances is present:
    • Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding.
    • Warts of recent origin in immunosuppressed patients.
  • Lesions in sensitive anatomic locations that are non-problematic do not qualify for removal coverage on the basis of location alone.
  • The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.
  • The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.
  • Office visits will be covered when the diagnosis of a benign skin lesion(s) is made, even if the removal of a particular lesion(s) is not medically indicated and is, therefore, not done.


This policy applies to the following: seborrheic keratoses, skin tags, milia, molluscum contagiosum, sebaceous (epidermoid) cysts, moles (nevi), acquired hyperkeratosis (keratoderma) and viral warts (excluding condyloma acuminatum). The treatment of actinic keratosis is covered by NCD 250.4. This policy does not address routine foot care or the treatment of other skin lesions, e.g., ulcers, abscess, malignancies, dermatoses or psoriasis.

Benign skin lesions are common in the elderly and are frequently removed at the patient’s request to improve appearance. Removal of benign skin lesions that do not pose a threat to health or function is considered cosmetic and as such is not covered by the Medicare program. Cosmesis is statutorily non-covered and no payment may be made for such lesion removal.

Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or more of the following conditions is present and clearly documented in the medical record:

A. The lesion has one or more of the following characteristics:
1. bleeding 
2. intense itching 
3. pain 

B. The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema.

C. The lesion obstructs an orifice or clinically restricts vision.

D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction.

E. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy.

F. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.

G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction will be covered when the following clinical circumstance is present: 

Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding

Evidence of spread from one body area to another, particularly in immunocompromised/immunosuppressed patients.


Note:
1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually cosmetic. When using these CPT codes the clinical records should clearly document the medical necessity of such treatment and why the procedure is not cosmetic. 

2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g., corns and calluses). Coverage for these three codes is described in the Medicare Internet Only Manual.

If the beneficiary wishes one or more benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service(s) rendered.

Regarding other Malignancy: 
If a diagnosis of malignancy has already been established for a specific lesion, a shave biopsy would not be medically reasonable and necessary. 

When a diagnosis of malignancy has not yet been established at the time the biopsy procedure was performed, the correct diagnosis code to list on the claim would most likely be D49.2, (Neoplasm of unspecified behavior, bone soft tissue, and skin).


Compliance with the provisions in this policy may be subject to monitoring by post payment data analysis and subsequent medical review.

Limitations:

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

CPT/HCPCS Codes
11200 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS
11201 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS
11301 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM
11302 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM
11303 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM
11305 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS
11306 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM
11307 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM
11308 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM
11310 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS
11311 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM
11312 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM
11313 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM
11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS
11401 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM
11402 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM
11403 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM
11404 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM
11406 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM
11420 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS
11421 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM
11422 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM
11423 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM
11424 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM
11426 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM
11440 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS
11441 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM
11442 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM
11443 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM
11444 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM
11446 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM
17110 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS
17111 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS

ICD-10 Codes that Support Medical Necessity

 These are the  only  covered diagnosis codes for CPT codes 11200, 11201, 11300, 11301- 11313, 11400-11406, 11420-11426, 11440-11446, 17000, 17003, 17004, 17110 and 17111:
(Additionally, diagnosis L57.0 may be used for CPT Codes 17000, 17003 and 17004 as listed in the JE A/B MAC Actinic Keratosis LCD.)

List I.
These ICD-10-CM codes identify the lesion being treated and will, by themselves, allowed payment

A63.0
Anogenital (venereal) warts
B07.0
Plantar wart
B07.8
Other viral warts
B07.9
Viral wart, unspecified
B08.1
Molluscum contagiosum
D48.5
Neoplasm of uncertain behavior of skin
D49.2
Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.5
Neoplasm of unspecified behavior of other genitourinary organs
H02.821
Cysts of right upper eyelid
H02.822
Cysts of right lower eyelid
H02.824
Cysts of left upper eyelid
H02.825
Cysts of left lower eyelid
H61.001
Unspecified perichondritis of right external ear
H61.002
Unspecified perichondritis of left external ear
H61.003
Unspecified perichondritis of external ear, bilateral
H61.009
Unspecified perichondritis of external ear, unspecified ear
H61.011
Acute perichondritis of right external ear
H61.012
Acute perichondritis of left external ear
H61.013
Acute perichondritis of external ear, bilateral
H61.021
Chronic perichondritis of right external ear
H61.022
Chronic perichondritis of left external ear
H61.023
Chronic perichondritis of external ear, bilateral
H61.031
Chondritis of right external ear
H61.032
Chondritis of left external ear
H61.033
Chondritis of external ear, bilateral
L11.0*
Acquired keratosis follicularis
L28.0
Lichen simplex chronicus
L28.1
Prurigo nodularis
L56.5
Disseminated superficial actinic porokeratosis (DSAP)
L57.0
Actinic keratosis
L72.3
Sebaceous cyst
L82.0
Inflamed seborrheic keratosis
L85.0*
Acquired ichthyosis
L85.1*
Acquired keratosis [keratoderma] palmaris et plantaris
L85.2*
Keratosis punctata (palmaris et plantaris)
L85.8
Other specified epidermal thickening
L86*
Keratoderma in diseases classified elsewhere
L87.0*
Keratosis follicularis et parafollicularis in cutem penetrans

L87.2*
Elastosis perforans serpiginosa
L91.0*
Hypertrophic scar
L92.8
Other granulomatous disorders of the skin and subcutaneous tissue
L98.0
Pyogenic granuloma


Medical Indications

There may be instances in which the removal of non-malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record:
The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or

The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or

The lesion obstructs an orifice; or

The lesion clinically restricts vision; or

There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the lesion appearance; or

A prior biopsy suggests or is indicative of lesion malignancy; or

The lesion is in an anatomical region subject to recurrent trauma, and there is documentation of such trauma.

Wart removals will be covered under the guidelines listed above. In addition, wart destruction will be covered when any one of the following clinical circumstances is present:
Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding.

Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients.

Lesions are condyloma acuminata or molluscum contagiosum.

Cervical dysplasia or pregnancy is associated with genital warts.

An E&M service to determine a diagnosis of benign skin lesion(s) may be allowed (paid), even in the event the subsequent lesion(s) removal is determined to be cosmetic.

Repair (Closure) With Excision of Benign Lesions
Payment for the excision of benign lesions of skin includes payment for simple repairs. Separate payment may be made for medically necessary layered closures, adjacent tissue transfers, flaps and grafts.

Limitations: 

Medicare will not pay for a separate E & M service on the same day as a dermatologic service unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient’s medical record and a modifier 25 should be used.

Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient’s medical record.

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.

The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesion excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. 

Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Each benign lesion excised should be reported separately. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the narrowest margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.

References to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. 

1 comment:

Anonymous said...

I work for primary care physician. He wants to remove a skin lesion on a nursing home patient. Is cpt 11442 billable in pos 32 ? pt is Medicare primary.

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