Article - Billing and Coding: Excision of Malignant Skin Lesions (A57660)

CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33818 Excision of Malignant Skin Lesions provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesWhen a lesion is excised that is a neoplasm of uncertain morphology (e.g., melanoma vs. dyplastic nevi), choose the correct CPT code based on the manner in which the lesion is excised rather than the final pathological diagnosis. The CPT code should reflect the knowledge, skill, time and effort that the provider invests in the excision of the lesion.For example, an ambiguous, but low-suspicion lesion might be excised with minimal surrounding, grossly normal skin/soft tissue margins, as for a benign lesion. This would be most appropriately reported using the excision of benign lesion codes 11400-11446. An ambiguous, but moderate to high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion. This type of excision would be most appropriately reported using the excision of malignant lesion including margins codes 11600- 11646.Notice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record/ progress note should indicate the removal of a malignant or an ambiguous, but moderate to high suspicion lesion with a corresponding pathology report.The size and location of the lesion should be documented in the operative report.Utilization Guidelines:In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33818, Excision of Malignant Skin Lesions may be monitored and addressed through post payment data analysis and subsequent medical review audits.