Removal of Benign and Malignant Skin Lesions CPT 11300 - 17111

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.

Limitations:

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). 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.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 21X, 71X, 83X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all Note: TrailBlazer has identified the Bill Type and RevenueCodes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

Revenue codes have not been identified for these procedures, as they can be performed in a number of revenue centers within a hospital, such as emergency room (450), operating room (360), or clinic (510). Providers should report these HCPCS codes under the revenue center where they were performed.

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
11300©	Shave skin lesion
11301©	Shave skin lesion
11302©	Shave skin lesion
11303©	Shave skin lesion
11305©	Shave skin lesion
11306©	Shave skin lesion
11307©	Shave skin lesion
11308©	Shave skin lesion
11310©	Shave skin lesion
11311©	Shave skin lesion
11312©	Shave skin lesion
11313©	Shave skin lesion
11400©	Exc tr-ext b9+marg 0.5 < cm
11401©	Exc tr-ext b9+marg 0.6-1 cm
11402©	Exc tr-ext b9+marg 1.1-2 cm
11403©	Exc tr-ext b9+marg 2.1-3 cm
11404©	Exc tr-ext b9+marg 3.1-4 cm
11406©	Exc tr-ext b9+marg > 4.0 cm
11420©	Exc h-f-nk-sp b9+marg 0.5 <
11421©	Exc h-f-nk-sp b9+marg 0.6-1
11422©	Exc h-f-nk-sp b9+marg 1.1-2
11423©	Exc h-f-nk-sp b9+marg 2.1-3
11424©	Exc h-f-nk-sp b9+marg 3.1-4
11426©	Exc h-f-nk-sp b9+marg > 4 cm
11440©	Exc face-mm b9+marg 0.5 < cm
11441©	Exc face-mm b9+marg 0.6-1 cm
11442©	Exc face-mm b9+marg 1.1-2 cm
11443©	Exc face-mm b9+marg 2.1-3 cm
11444©	Exc face-mm b9+marg 3.1-4 cm
11446©	Exc face-mm b9+marg > 4 cm
17000©	Destruct premalg lesion
17003©	Destruct premalg les, 2-14
17004©	Destroy premlg lesions 15+
17110©	Destruct b9 lesion, 1-14
17111©	Destruct lesion, 15 or more

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 17000, 17003, 17004, 17110 and 17111:

Covered for:

078.0	Molluscum contagiosum
078.10–078.12	Viral warts
078.19	Other specified viral warts
171.0	Malignant neoplasm of connective and other soft tissue of head face and neck
173.0–173.9	Other malignant neoplasm of skin
215.0	Other benign neoplasm of connective and other soft tissue of head face and neck
215.2–215.8	Other benign neoplasm of connective and other soft tissue
216.0–216.8	Benign neoplasm of skin
232.0–232.7	Carcinoma in situ of skin
238.2	Neoplasm of uncertain behavior of skin
448.1	Nevus non-neoplastic
528.5	Diseases of lips
686.1	Pyogenic granuloma of skin and subcutaneous tissue
686.8	Other specified local infections of skin and subcutaneous tissue
690.10–690.12	Seborrheic dermatitis
690.18	Other seborrheic dermatitis
690.8	Other erythematosquamous dermatosis
691.8	Other atopic dermatitis and related conditions
692.70	Unspecified dermatitis due to sun
692.75	Disseminated superficial actinic porokeratosis (dsap)
695.89	Other specified erythematous conditions
701.0	Circumscribed scleroderma
701.2	Acquired acanthosis nigricans
702.0	Actinic keratosis
702.11	Inflamed seborrheic keratosis
706.2	Sebaceous cyst
707.10–707.15	Ulcer of lower limb, except decubitis
707.19	Ulcer of other part of lower limb
707.8–707.9	Chronic ulcer of skin
919.7	Superficial foreign body (splinter) of other multiple and unspecified sites without major open wound infected
V10.82	Personal history of malignant melanoma of skin
V10.83	Personal history of other malignant neoplasm of skin

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

• All services billed to Medicare must have the appropriate medical record documentation supporting the medical necessity of the service. It is not necessary to submit documentation with claims. However, Medicare may request documentation for further clarification of medical necessity at a later time.
• When using diagnosis code 702.11, inflamed seborrheic keratosis, the medical records should reference a patient’s complaint or a physician’s physical findings.
• In most situations, Medicare will not pay for a separate E/M service on the same day dermatologic surgery is performed unless significant and separately identifiable medical services were rendered and clearly documented in the patient’s medical record. Check the Medicare Physician Fee Schedule Database (MPFSDB) for the codes where the global policy would be applied. Use modifier 25 appended to the appropriate visit code to indicate that the patient’s condition required a significant, separately identifiable visit service in addition to the procedure that was performed.

Appendices

N/A

Utilization Guidelines

N/A