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

CMS National Coverage PolicyN/AArticle TextMedicare 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) cystsskin tagsmilia ( keratin-filled cysts)nevi (moles)acquired hyperkeratosis (keratoderma)papillomashemangiomasviral wartsRemoval of benign skin lesions is not considered cosmetic when symptoms or signs which warrant medical intervention are present, including but not limited to:BleedingIntense itchingPainChange in physical appearance, for example, but not limited to:reddeningpigmentary changeenlargementincrease in the number of lesionsPhysical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.Lesion obstructs an orificeLesion clinically restricts eye function, for example, but not limited to:Lesion restricts eyelid functionlesion causes misdirection of eyelashes or eyelidlesion 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 appearanceWart 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 sheddingWarts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patientsLesions are condyloma acuminata or molluscum contagiosumCervical dysplasia or pregnancy is associated with genital wartsMedicare 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 patients 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 patients medical record.Coding GuidelinesFor 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 ModifierThe 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 benefitAdvance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn 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 patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould 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 RequirementsMedical records maintained by the physician must clearly document the medical necessity for the lesion removal(s).