CPT 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


Coverage Indications, Limitations, and/or Medical Necessity

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.


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.


ICD-10 CODE DESCRIPTION

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
D49.511 Neoplasm of unspecified behavior of right kidney
D49.512 Neoplasm of unspecified behavior of left kidney
D49.519 Neoplasm of unspecified behavior of unspecified kidney
D49.59 Neoplasm of unspecified behavior of other genitourinary organ
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)
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
L92.8 Other granulomatous disorders of the skin and subcutaneous tissue
L98.0 Pyogenic granuloma

ICD-10 CODE DESCRIPTION
D10.0 Benign neoplasm of lip
D18.01 Hemangioma of skin and subcutaneous tissue
D22.0 Melanocytic nevi of lip
D22.11 Melanocytic nevi of right eyelid, including canthus
D22.12 Melanocytic nevi of left eyelid, including canthus
D22.21 Melanocytic nevi of right ear and external auricular canal
D22.22 Melanocytic nevi of left ear and external auricular canal
D22.39 Melanocytic nevi of other parts of face
D22.4 Melanocytic nevi of scalp and neck
D22.5 Melanocytic nevi of trunk
D22.61 Melanocytic nevi of right upper limb, including shoulder
D22.62 Melanocytic nevi of left upper limb, including shoulder
D22.71 Melanocytic nevi of right lower limb, including hip
D22.72 Melanocytic nevi of left lower limb, including hip
D22.9 Melanocytic nevi, unspecified
D23.0 Other benign neoplasm of skin of lip
D23.11 Other benign neoplasm of skin of right eyelid, including canthus
D23.12 Other benign neoplasm of skin of left eyelid, including canthus
D23.21 Other benign neoplasm of skin of right ear and external auricular canal
D23.22 Other benign neoplasm of skin of left ear and external auricular canal
D23.39 Other benign neoplasm of skin of other parts of face
D23.4 Other benign neoplasm of skin of scalp and neck
D23.5 Other benign neoplasm of skin of trunk
D23.61 Other benign neoplasm of skin of right upper limb, including shoulder
D23.62 Other benign neoplasm of skin of left upper limb, including shoulder
D23.70 Other benign neoplasm of skin of unspecified lower limb, including hip
D23.71 Other benign neoplasm of skin of right lower limb, including hip
D23.72 Other benign neoplasm of skin of left lower limb, including hip
D23.9 Other benign neoplasm of skin, unspecified
D28.0 Benign neoplasm of vulva
D29.0 Benign neoplasm of penis
D29.4 Benign neoplasm of scrotum
D86.3 Sarcoidosis of skin
D86.89 Sarcoidosis of other sites
D86.9 Sarcoidosis, unspecified
I78.1 Nevus, non-neoplastic
K64.4 Residual hemorrhoidal skin tags
L12.30 Acquired epidermolysis bullosa, unspecified
L12.31 Epidermolysis bullosa due to drug
L12.8 Other pemphigoid
L72.0 Epidermal cyst
L72.11 Pilar cyst
L72.12 Trichodermal cyst
L72.2 Steatocystoma multiplex
L72.3 Sebaceous cyst
L72.8 Other follicular cysts of the skin and subcutaneous tissue
L82.1 Other seborrheic keratosis
L85.9 Epidermal thickening, unspecified
L87.9 Transepidermal elimination disorder, unspecified
L90.5 Scar conditions and fibrosis of skin
L90.9 Atrophic disorder of skin, unspecified
L91.0 Hypertrophic scar
L91.8 Other hypertrophic disorders of the skin
L91.9 Hypertrophic disorder of the skin, unspecified
L94.9 Localized connective tissue disorder, unspecified
Q17.0 Accessory auricle
Q81.0 Epidermolysis bullosa simplex
Q81.1 Epidermolysis bullosa letalis
Q81.2 Epidermolysis bullosa dystrophica
Q81.8 Other epidermolysis bullosa
Q81.9 Epidermolysis bullosa, unspecified
Q82.8 Other specified congenital malformations of skin
B78.1 Cutaneous strongyloidiasis
D48.5 Neoplasm of uncertain behavior of skin
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
E83.2 Disorders of zinc metabolism
K12.2 Cellulitis and abscess of mouth
L02.01 Cutaneous abscess of face
L02.11 Cutaneous abscess of neck
L02.211 Cutaneous abscess of abdominal wall
L02.212 Cutaneous abscess of back [any part, except buttock]
L02.213 Cutaneous abscess of chest wall
L02.214 Cutaneous abscess of groin
L02.215 Cutaneous abscess of perineum
L02.216 Cutaneous abscess of umbilicus
L02.31 Cutaneous abscess of buttock
L02.411 Cutaneous abscess of right axilla
L02.412 Cutaneous abscess of left axilla
L02.413 Cutaneous abscess of right upper limb
L02.414 Cutaneous abscess of left upper limb
L02.415 Cutaneous abscess of right lower limb
L02.416 Cutaneous abscess of left lower limb
L02.511 Cutaneous abscess of right hand
L02.512 Cutaneous abscess of left hand
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L02.811 Cutaneous abscess of head [any part, except face]
L02.818 Cutaneous abscess of other sites
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.121 Acute lymphangitis of right axilla
L03.122 Acute lymphangitis of left axilla
L03.123 Acute lymphangitis of right upper limb
L03.124 Acute lymphangitis of left upper limb
L03.125 Acute lymphangitis of right lower limb
L03.126 Acute lymphangitis of left lower limb
L03.211 Cellulitis of face
L03.212 Acute lymphangitis of face
L03.221 Cellulitis of neck
L03.222 Acute lymphangitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.321 Acute lymphangitis of abdominal wall
L03.322 Acute lymphangitis of back [any part except buttock]
L03.323 Acute lymphangitis of chest wall
L03.324 Acute lymphangitis of groin
L03.325 Acute lymphangitis of perineum
L03.326 Acute lymphangitis of umbilicus
L03.327 Acute lymphangitis of buttock
L03.811 Cellulitis of head [any part, except face]
L03.818 Cellulitis of other sites
L03.891 Acute lymphangitis of head [any part, except face]
L03.898 Acute lymphangitis of other sites
L08.82 Omphalitis not of newborn
L08.89 Other specified local infections of the skin and subcutaneous tissue
L08.9 Local infection of the skin and subcutaneous tissue, unspecified
L26 Exfoliative dermatitis
L29.9 Pruritus, unspecified
L30.4 Erythema intertrigo
L53.8 Other specified erythematous conditions
L53.9 Erythematous condition, unspecified
L54 Erythema in diseases classified elsewhere
L92.0 Granuloma annulare
L95.1 Erythema elevatum diutinum
L98.2 Febrile neutrophilic dermatosis [Sweet]
L98.3 Eosinophilic cellulitis [Wells]
R20.0 Anesthesia of skin
R20.1 Hypoesthesia of skin
R20.2 Paresthesia of skin
R20.3 Hyperesthesia
R20.8 Other disturbances of skin sensation
R58 Hemorrhage, not elsewhere classified

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