Billing and Coding: Removal of Benign Skin Lesions

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).