Procedure code 11400, 11401, 11402 and 11406 - Excision benign lesion

Procedure code and description

11400-  Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less   - average fee payment - $130 - $140

11401 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm

11402- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm

11403 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm

11404 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm

11406 xcision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm


Coding Information

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.


Claims for removal of benign skin lesions performed merely for cosmetic reasons may not necessarily need to be submitted to Medicare unless the patient requests that a formal Medicare denial is issued. If a claim is filed, ICD-9 CM code V50.1 (Other plastic surgery for unacceptable cosmetic appearance) should be used in conjunction with the appropriate procedure code



If a dermatologist performs an excision (11400) with benign lesion destruction (17110), both codes are reportable and a modifier will be necessary to “bypass” the edit. 11400 is mutually exclusive to the 17110 which documentation of both procedures will support reporting both codes with the appropriate modifier. According to CMS, there must be a NCCI procedure to procedure (PTP) edits, which in this case there is, to require a modifier. Otherwise it is not needed.

Col 1 Col 2 Effect Date Allowance

17000 11900 19980401 1

17000 11901 19980401 1

17110 11400 19990101 1


Documentations Requirements

The medical record must be made available to Medicare upon request.

The HCPCS/procedure code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.

When requesting a written redetermination (formerly appeal), please send all relevant documentation with the request.

Benign skin lesion removals for reasons other than those given under the Indications andLimitations of Coverage and or Medical Necessity Section above are considered to be cosmetic and will not be covered. These noncovered reasons include, but are not limited to, emotional distress, “makeup trapping” and non-problematic lesions in any anatomic location.


Medical documentation must clearly and unequivocally document the medical necessity for lesion removal(s) if Medicare is billed for the service.

A medical record statement of “irritated skin lesion” is insufficient justification for lesion removal when solely used to reference a patient’s complaint or a physician’s physical findings. Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient to justify lesional removal without medical documentation of the patient’s symptoms and physical findings.

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. Append modifier 25 to the appropriate visit code to indicate the patient’s condition required a significant, separately identifiable visit service unrelated to the procedure that was performed.

Office visits will be covered when the diagnosis of a benign skin lesion(s) is made even if the removal of a particular lesion or lesion(s) is not medically indicated and is therefore not done.

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 (procedure 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. This means the medical record for a benign lesion excision (procedure 11400-11446) must show why an excisional removal was the 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.

How should CPT or HCPCS codes such as 11400 (excision of benign lesion) be billed when they are performed on both sides of the body and are not CMS bilateral eligible?

A: An excision of a lesion is not truly bilateral. It should be billed with units, rather than the bilateral modifier.

Indications and Limitations of Coverage and/or Medical Necessity 

Abstract:

Benign skin lesions are common in the elderly and are frequently removed at the patient's request to improve appearance. Removals 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. These cosmetic reasons include, but are not limited to, emotional distress, "makeup trapping," and non-problematic lesions in any anatomic location. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone.

Benign skin lesions to which the accompanying lesion removal policy applies are the following: seborrheic keratoses, sebaceous (epidermoid) cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts.

Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient characteristics.

Indications:

There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia 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 are presented and clearly documented in the medical record:

Bleeding;
Intense itching;
Pain;
Change in physical appearance (reddening or pigmentary change);
Recent enlargement;
Increase in the number of lesions;
Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.;
Lesion obstructs an orifice;
Lesion clinically restricts eye function. For example:
Lesion restricts eyelid function;
lesion causes misdirection of eyelashes or eyelid;
lesion restricts lacrimal puncta and interferes with tear flow;
lesion touches globe;
Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance;
A prior biopsy suggests or is indicative of lesion malignancy;
The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has, in fact, occurred;
Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of rupture of epidermal inclusion (sebaceous) cyst.
Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are 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 or warts of recent origin in an immunocompromised patients;
Lesions are condyloma acuminata or molluscum contagiosum;
Cervical dysplasia or pregnancy is associated with genital warts.
Limitations:

Medicare will not pay for a separate E & M service on the same day as a minor surgical procedure 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 (CPT 11400-11446) 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 most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.

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