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LCD Reference Article Billing and Coding Article

Billing and Coding: Removal of Benign Skin Lesions

A54602

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Source Article ID
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Article ID
A54602
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Removal of Benign Skin Lesions
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2024
Revision Ending Date
N/A
Retirement Date
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Article Text

Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery (CMS publication 100-02; Medicare Benefit Policy Manual, Chapter 16, Section 20). including complications resulting from non-covered services (CMS publication IOM 100-02, Chapter 16, Section 180). This coding article provides documentation requirements and coding instructions for non-cosmetic removal of benign skin lesions.

The following are examples of benign skin lesions:

    • sebaceous (epidermoid) cysts

 

    • skin tags

 

    • milia ( keratin-filled cysts)

 

    • nevi (moles)

 

    • acquired hyperkeratosis (keratoderma)

 

    • papillomas

 

    • hemangiomas

 

  • viral warts



Removal of benign skin lesions is not considered cosmetic when symptoms or signs which warrant medical intervention are present, including but not limited to:

    • Bleeding

 

    • Intense itching

 

  • Pain

 

    • Change in physical appearance, for example, but not limited to:

 

      • reddening

 

      • pigmentary change

 

      • 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, but not limited to:

 

      • 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

 

    • Wart removals is not considered cosmetic when guidelines above are met or if 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



      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.



Coding Guidelines

      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.



      CPT 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.



      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.



Units of service:

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



      CPT code 17000 should be reported with one unit of service for destruction of the first lesion; CPT 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.



      CPT 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. CPT code 17111 is also reported with one unit of service representing 15 or more lesions.



Billing for cosmetic surgery:

      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 CPT code.



GY Modifier

      The definition of the GY modifier is - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

 

      The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit



Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

      An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.



For claims submitted to the Part B MAC:

      All services/procedures performed on the same day for the same beneficiary by physician/provider should be billed on the same claim.



      Modifier –24 should be used when unrelated evaluation and management services, by the same physician, are reported during a postoperative global period.



      Modifier – 25 should be used when separately identifiable evaluation and management services that are above and beyond the pre- and post-operative work of the procedure, by the same physician are performed on the same day as a covered minor surgical service is performed.



      Evaluation and management services provided on the day, or the day before a minor surgical procedure, for the purpose of making the decision to perform the procedure, are not payable. The modifier – 57 cannot be used since the decision to perform the minor surgical procedure is considered a routine preoperative service and a visit or consultation should not be billed. (Modifier 57 is only applicable for major procedures that have a 90-day global period.)



For claims submitted to the Part A MAC:

Hospital Inpatient Claims:

      • The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
      • The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
      • For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)

Hospital Outpatient Claims:

      • The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
      • The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.



Documentation Requirements

      Medical records maintained by the physician must clearly document the medical necessity for the lesion removal(s).

 

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Coding Information

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

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Group 1 Paragraph

Claims for removal of benign skin lesions performed merely for cosmetic reasons should be submitted with ICD-10-CM code Z41.1

 Group 1 Codes
Code Description
Z41.1 Encounter for cosmetic surgery
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ICD-10-PCS Codes

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
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Coding Table Information

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2024 R5

Due to the annual CPT/HCPCS code updates, either the short and/or long code description was changed for CPT codes 11200 and 11201. Please Note: Depending on which descriptor was used, there may not be any changes to the code display in this document.
05/07/2020 R4

Updated to indicate the article is not an LCD Reference Article
05/07/2020 R3

This article was converted to the new Billing and Coding Article format.
01/01/2018 R2

Descriptor for CPT code 11403 has been revised.
10/01/2015 R1 The following language relating to places of service has been removed, effective for services rendered on or after 10/01/2015:

CPT codes covered under this policy are paid under Part B when rendered in the following places of service: office (11), urgent care facility (20), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32), independent clinic (49), inpatient psychiatric facility (51) and intermediate care facility/mentally retarded (54).

CPT codes 11200, 11201, 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, and 11313 are also payable when rendered in place of service home (12) and temporary lodging (16).

CPT codes 17000, 17003, 17004, 17110 and 17111 are also payable in the following places of service: home (12), assisted living (13), group home (14), temporary lodging (16), and custodial care facility (33).
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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Updated On Effective Dates Status
12/21/2023 01/01/2024 - N/A Currently in Effect You are here
11/20/2023 05/07/2020 - 12/31/2023 Superseded View
05/01/2020 05/07/2020 - N/A Superseded View
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