Billing and Coding: Removal of Benign Skin Lesions (A54602) (2024)

General Information

Article Guidance

Article Text

• 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 circ*mstances 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.

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.

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.)

• 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).