CPT 11300, 17000, 11400, 11420, 11440 - 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.


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.

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.
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.

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-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


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.


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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