Local Coverage Article: Billing and Coding: Removal of Benign Skin Lesions (A57482) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information CONTRACTOR NAME CONTRACT CONTRACT JURISDICTION STATE(S) TYPE NUMBER Wisconsin Physicians Service Insurance MAC - Part A 05101 - MAC A J - 05 Iowa Corporation Wisconsin Physicians Service Insurance MAC - Part B 05102 - MAC B J - 05 Iowa Corporation Wisconsin Physicians Service Insurance MAC - Part A 05201 - MAC A J - 05 Kansas Corporation Wisconsin Physicians Service Insurance MAC - Part B 05202 - MAC B J - 05 Kansas Corporation Wisconsin Physicians Service Insurance MAC - Part A 05301 - MAC A J - 05 Missouri - Entire Corporation State Wisconsin Physicians Service Insurance MAC - Part B 05302 - MAC B J - 05 Missouri - Entire Corporation State Wisconsin Physicians Service Insurance MAC - Part A 05401 - MAC A J - 05 Nebraska Corporation Wisconsin Physicians Service Insurance MAC - Part B 05402 - MAC B J - 05 Nebraska Corporation Wisconsin Physicians Service Insurance MAC - Part A 05901 - MAC A J - 05 Alabama Corporation Alaska Arizona Arkansas California - Entire State Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Created on 11/15/2019. 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Page 2 of 14 Article Information General Information Article ID Original Effective Date A57482 10/31/2019 Article Title Revision Effective Date Billing and Coding: Removal of Benign Skin Lesions N/A Article Type Revision Ending Date Billing and Coding N/A AMA CPT / ADA CDT / AHA NUBC Copyright Retirement Date Statement N/A CPT codes, descriptions and other data only are copyright 2018 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Current Dental Terminology © 2018 American Dental Association. All rights reserved. Copyright © 2019, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. 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Page 3 of 14 CMS National Coverage Policy CMS Pub.100-02 Medicare Benefit Policy Manual, Chapter 16 - General Exclusions From Coverage, Section §120 - Cosmetic Surgery CMS Pub. 100-03 Medicare National Coverage Determinations Manual-Chapter 1, Coverage Determinations, Part 4, Section 250.4 - Treatment of Actinic Keratosis CMS Pub.100-04 Medicare Claims Processing Manual, Ch. 23 Fee Schedule Administration and Coding Requirements, Section 10.1-10.1.7 – Reporting ICD Diagnosis and Procedure Codes Title XVIII of the Social Security Act, section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary. CMS Transmittal No, 857, effective date October 3, 2018 Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019. Article Guidance Article Text: The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L35498 Removal of Benign Skin Lesions. Coding Information 1. Use the CPT code that best describes the procedure, the location and the size of the lesion. If there are multiple lesions treated, multiple codes may be reported but you must follow National Correct Coding Initiative guidelines. CPT code 11200 should be reported with one unit of service. CPT code 11201 should be reported with 1 unit for each additional group of 10 lesions. 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 should be reported with one unit of service for removal of benign lesions other than skin tags or cutaneous vascular lesions, representing 15 or more. 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. 2. The provider should use the appropriate CPT code and the diagnosis code should match the CPT code. If a provider bills a benign skin lesion CPT code, it is not correct to use a malignant diagnosis code. 3. If a beneficiary wishes to have one or more benign asymptomatic lesions removed that pose no threat to health or function, and for cosmetic purposes: a. The physician should explain to the patient, in advance, that Medicare will not cover cosmetic cutaneous surgery and that the beneficiary will be liable for the cost of the service. Charges should be clearly stated. A claim for cosmetic services does not need to be submitted to the Medicare Contractor, unless the patient requests that the claim be submitted on his/her behalf. b. When the patient requests the claim for cosmetic services be submitted on his/her behalf, the services should be reported with modifier GY (items or services statutorily excluded or does not meet the definition of any Medicare benefit) and diagnosis code Z41.1. Created on 11/15/2019. Page 4 of 14 4. Evaluation and management services provided on the day, or the day before a dermatological 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 dermatological 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.) Please refer to Modifier-57 Fact Sheet on WPS GHA website. 5. An E&M service reported on the same day as a dermatological surgery is subject to the Medicare global surgery rules and will only be payable if a significant and separately identifiable medical service is rendered and clearly documented in the patient's medical record. A modifier-25 should be appended to the appropriate visit code to indicate the patient's condition required a significant, separately identifiable visit service in addition to the procedure that was performed. Please refer to Modifier-25 Fact Sheet on WPS GHA website. Removal of benign lesions is elective surgery and generally pre-scheduled. It is inappropriate to report an E&M service with a -25 modifier on the same date of service as these surgeries for the usual pre/post-operative care associated with these surgeries. 6. When billing the destruction of multiple other benign lesions use CPT 17110 or 17111 with a “1” in the unit box. CPT 17110 and CPT 17111 may not be reported together. 7. Medicare will not pay for a separate E/M service on the same day dermatologic surgery is performed unless significant and separately identifiable medical services were rendered and clearly documented in the patient’s medical record. Append modifier 25 to the appropriate visit code to indicate the patient’s condition required a significant, separately identifiable visit service unrelated to the procedure that was performed. Providers should bill the appropriate CPT code and match the diagnosis code to the procedure code. Coding Information CPT/HCPCS Codes Group 1 Paragraph: CPT codes 11300-11313 may also be covered for the removal of cancerous skin lesions which are not addressed in this LCD Group 1 Codes: CODE DESCRIPTION 11200 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS 11201 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS 11301 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS;