Removal of Benign Skin Lesions (L30330)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30330 LCD Title Removal of Benign Skin Lesions Contractor's Determination Number DERM-008 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 08/16/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 05/01/2012 Revision Ending Date |
CMS National Coverage Policy
CMS Pub.100-2 Ch.16 §120
Title XVIII of the Social Security Act, section 1862(a)(1)(A).
Title XVIII of the Social Security Act, section 1833(e).
Title XVIII of the Social Security Act, section 1862(a)(7)
Title XVIII of the Social Security Act, section 1862(a)(1)(A).
Title XVIII of the Social Security Act, section 1833(e).
Title XVIII of the Social Security Act, section 1862(a)(7)
Indications and Limitations of Coverage and/or Medical Necessity
This
policy addresses the Medicare coverage for the removal of benign skin
lesions, such as seborrheic keratoses, sebaceous (epidermoid) cysts,
skin tags. Benign skin lesions are common in the elderly and are
frequently removed at the patient's request to improve appearance.
Removal of certain benign skin lesions that does not pose a threat to
health or function, are considered cosmetic and as such are not covered
by the Medicare program.
A. Medical Indications
There may be instances in which the removal of non-malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record:
1. The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or
2. The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or
3. The lesion obstructs an orifice; or
4. The lesion clinically restricts vision; or
5. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the lesion appearance; or
6. A prior biopsy suggests or is indicative of lesion malignancy
7. The lesion is in an anatomical region subject to recurrent trauma, and there is documentation of such trauma.
8. Wart removals will be covered under the guidelines listed above. In addition, wart destruction will be covered when any one of the following clinical circumstances is 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.
a. Lesions are condyloma acuminata or molluscum contagiosum;
b. Cervical dysplasia or pregnancy is associated with genital warts.
An E&M service to determine a diagnosis of benign skin lesion(s) may be allowed (paid), even in the event the subsequent lesion(s) removal is determined to be cosmetic.
B. Repair (Closure) With Excision of Benign Lesions
Payment for the excision of benign lesions of skin includes payment for simple repairs. Separate payment may be made for medically necessary layered closures, adjacent tissue transfers, flaps and grafts.
Limitations:
Medicare will not pay for a separate E & M service on the same day as a dermatologic service 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.
If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.
The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesion excision (CPT 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.
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 narrowest margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for removal of benign skin lesion services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
A. Medical Indications
There may be instances in which the removal of non-malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record:
1. The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or
2. The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or
3. The lesion obstructs an orifice; or
4. The lesion clinically restricts vision; or
5. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the lesion appearance; or
6. A prior biopsy suggests or is indicative of lesion malignancy
7. The lesion is in an anatomical region subject to recurrent trauma, and there is documentation of such trauma.
8. Wart removals will be covered under the guidelines listed above. In addition, wart destruction will be covered when any one of the following clinical circumstances is 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.
a. Lesions are condyloma acuminata or molluscum contagiosum;
b. Cervical dysplasia or pregnancy is associated with genital warts.
An E&M service to determine a diagnosis of benign skin lesion(s) may be allowed (paid), even in the event the subsequent lesion(s) removal is determined to be cosmetic.
B. Repair (Closure) With Excision of Benign Lesions
Payment for the excision of benign lesions of skin includes payment for simple repairs. Separate payment may be made for medically necessary layered closures, adjacent tissue transfers, flaps and grafts.
Limitations:
Medicare will not pay for a separate E & M service on the same day as a dermatologic service 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.
If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.
The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesion excision (CPT 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.
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 narrowest margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for removal of benign skin lesion services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 083x | Ambulatory Surgery Center |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 031X | Laboratory Pathology - General Classification |
| 0360 | Operating Room Services - General Classification |
| 036X | Operating Room Services - General Classification |
| 0361 | Operating Room Services - Minor Surgery |
| 0369 | Operating Room Services - Other OR Services |
| 0456 | Emergency Room - Urgent Care |
| 0490 | Ambulatory Surgical Care - General Classification |
| 049X | Ambulatory Surgical Care - General Classification |
| 0499 | Ambulatory Surgical Care - Other Ambulatory Surgical |
| 0510 | Clinic - General Classification |
| 051X | Clinic - General Classification |
| 071X | Recovery Room - General Classification |
| 073X | EKG/ECG (Electrocardiogram) - General Classification |
| 076X | Specialty Services - General Classification |
| 077X | Preventive Care Services - General Classification |
National Coverage Determination 250.4 outlines coverage for the treatment of actinic keratosis(AK)ICD-9 702.0.
| 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; LESION DIAMETER 0.6 TO 1.0 CM |
| 11302 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM |
| 11303 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM |
| 11305 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS |
| 11306 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM |
| 11307 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM |
| 11308 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM |
| 11310 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS |
| 11311 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM |
| 11312 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM |
| 11313 | SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM |
| 11400 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS |
| 11401 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM |
| 11402 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM |
| 11403 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM |
| 11404 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM |
| 11406 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM |
| 11420 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS |
| 11421 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM |
| 11422 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM |
| 11423 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM |
| 11424 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM |
| 11426 | EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM |
| 11440 | EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS |
| 11441 | EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM |
| 11442 | EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM |
| 11443 | EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM |
| 11444 | EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM |
| 11446 | EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM |
| 17110 | DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS |
| 17111 | DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS |
ICD-9 Codes that Support Medical Necessity
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 078.0 | MOLLUSCUM CONTAGIOSUM |
| 078.10 | VIRAL WARTS UNSPECIFIED |
| 078.11 | CONDYLOMA ACUMINATUM |
| 078.12 | PLANTAR WART |
| 078.19 | OTHER SPECIFIED VIRAL WARTS |
| 210.0 | BENIGN NEOPLASM OF LIP |
| 210.4 | BENIGN NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF MOUTH |
| 214.0 | LIPOMA OF SKIN AND SUBCUTANEOUS TISSUE OF FACE |
| 214.1 | LIPOMA OF OTHER SKIN AND SUBCUTANEOUS TISSUE |
| 216.0 | BENIGN NEOPLASM OF SKIN OF LIP |
| 216.1 | BENIGN NEOPLASM OF EYELID INCLUDING CANTHUS |
| 216.2 | BENIGN NEOPLASM OF EAR AND EXTERNAL AUDITORY CANAL |
| 216.3 | BENIGN NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE |
| 216.4 | BENIGN NEOPLASM OF SCALP AND SKIN OF NECK |
| 216.5 | BENIGN NEOPLASM OF SKIN OF TRUNK EXCEPT SCROTUM |
| 216.6 | BENIGN NEOPLASM OF SKIN OF UPPER LIMB INCLUDING SHOULDER |
| 216.7 | BENIGN NEOPLASM OF SKIN OF LOWER LIMB INCLUDING HIP |
| 216.8 | BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF SKIN |
| 216.9 | BENIGN NEOPLASM OF SKIN SITE UNSPECIFIED |
| 221.1 | BENIGN NEOPLASM OF VAGINA |
| 221.2 | BENIGN NEOPLASM OF VULVA |
| 222.1 | BENIGN NEOPLASM OF PENIS |
| 222.4 | BENIGN NEOPLASM OF SCROTUM |
| 228.01 | HEMANGIOMA OF SKIN AND SUBCUTANEOUS TISSUE |
| 235.1 | NEOPLASM OF UNCERTAIN BEHAVIOR OF LIP ORAL CAVITY AND PHARYNX |
| 236.6 | NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED MALE GENITAL ORGANS |
| 237.71 | NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE |
| 237.73 | SCHWANNOMATOSIS |
| 237.79 | OTHER NEUROFIBROMATOSIS |
| 238.2 | NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN |
| 238.9 | NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED |
| 239.2 | NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN |
| 239.89 | NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES |
| 274.81 | GOUTY TOPHI OF EAR |
| 274.82 | GOUTY TOPHI OF OTHER SITES EXCEPT EAR |
| 279.00 | HYPOGAMMAGLOBULINEMIA UNSPECIFIED |
| 373.2 | CHALAZION |
| 374.51 | XANTHELASMA OF EYELID |
| 374.84 | CYSTS OF EYELIDS |
| 455.9 | RESIDUAL HEMORRHOIDAL SKIN TAGS |
| 528.4 | CYSTS OF ORAL SOFT TISSUES |
| 528.6 | LEUKOPLAKIA OF ORAL MUCOSA INCLUDING TONGUE |
| 528.8 | ORAL SUBMUCOSAL FIBROSIS INCLUDING OF TONGUE |
| 616.2 | CYST OF BARTHOLIN'S GLAND |
| 624.01 | VULVAR INTRAEPITHELIAL NEOPLASIA I [VIN I] |
| 624.02 | VULVAR INTRAEPITHELIA LNEOPLASIA II [VIN II] |
| 624.6 | POLYP OF LABIA AND VULVA |
| 682.0 | CELLULITIS AND ABSCESS OF FACE |
| 682.2 | CELLULITIS AND ABSCESS OF TRUNK |
| 682.4 | CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB |
| 682.5 | CELLULITIS AND ABSCESS OF BUTTOCK |
| 682.6 | CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT |
| 682.7 | CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES |
| 682.8 | CELLULITIS AND ABSCESS OF OTHER SPECIFIED SITES |
| 682.9 | CELLULITIS AND ABSCESS OF UNSPECIFIED SITES |
| 686.1 | PYOGENIC GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE |
| 701.1 | KERATODERMA ACQUIRED |
| 701.4 | KELOID SCAR |
| 701.5 | OTHER ABNORMAL GRANULATION TISSUE |
| 701.8 | OTHER SPECIFIED HYPERTROPHIC AND ATROPHIC CONDITIONS OF SKIN |
| 701.9 | UNSPECIFIED HYPERTROPHIC AND ATROPHIC CONDITIONS OF SKIN |
| 702.11 | INFLAMED SEBORRHEIC KERATOSIS |
| 702.19 | OTHER SEBORRHEIC KERATOSIS |
| 702.8 | OTHER SPECIFIED DERMATOSES |
| 706.2 | SEBACEOUS CYST |
| 708.9 | UNSPECIFIED URTICARIA |
| 709.3 | DEGENERATIVE SKIN DISORDERS |
| 709.4 | FOREIGN BODY GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE |
| 709.9 | UNSPECIFIED DISORDER OF SKIN AND SUBCUTANEOUS TISSUE |
| 727.40 | SYNOVIAL CYST UNSPECIFIED |
| 744.47 | PREAURICULAR CYST |
| 757.32 | VASCULAR HAMARTOMAS |
| 757.33 | CONGENITAL PIGMENTARY ANOMALIES OF SKIN |
| 757.39 | OTHER SPECIFIED CONGENITAL ANOMALIES OF SKIN |
| 782.2 | LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP |
| V58.44 | AFTERCARE FOLLOWING ORGAN TRANSPLANT |
Diagnoses that Support Medical Necessity
All codes listed above under "Covered ICD-9-CM Codes that Support Medical Necessity".
ICD-9 Codes that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that support Medical Necessity".
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medical Necessity".
General Information
1. Physicians'
Services must be submitted with an ICD-9 code to support medical
necessity and must be coded to the greatest level of accuracy and
highest level of digit completeness. This means the precise ICD-9 code
that fully explain the narrative description of the diagnosis contained
in the medical records, including the 4th or 5th digit
sub-classification for that diagnosis category. In the absence of
signs, symptoms, illness or injury a screening ICD-9 code (V50.1) should
be reported, and payment will be denied. (Ref. CP Pub.100-04 Ch. 23
§§10.1-10.1.7)
2. Medical records maintained by the physician must clearly document the medical necessity for lesion(s) removal if Medicare is billed for the service. The relevant history and physical finding conforming to the criteria stated in the "Indication and Limitations of Coverage and/or Medical Necessity" section above must be made available to the Carrier on request.
3. Surgical Procedures Lesions and Closures:
Operative note(s) for surgical procedures performed in the office location may be contained in the patient's medical record for the date of service or as a separate report maintained within the patients chart. The operative note for the procedure performed must be of significant detail to support the surgical procedure billed. The surgical technique used should be described. Surgical procedures should include the lesion size(s) location(s) and number. Layered closures should include the length recorded in centimeters. Add together the length of multiple closures from all anatomical sites grouped together in the same code descriptor. (See the American Medical Associations Physicians' Current Procedural Terminology, CPT subsection instruction for Removal of Skin Tags, Shaving of Epidermal or Dermal Lesions, Excisions - Benign Lesions, Repairs (Closures) and Destruction.)
4. The decision to submit a specimen for pathological interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that the pathology description and tissue diagnosis will be part of the medical record if a specimen is submitted to pathology.
5. A medical record statement of "irritated skin lesion" is insufficient justification for lesion removal when solely used to reference a patient's complaint or a physician's physical findings. Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient to justify lesional removal without medical documentation of the patient's symptoms and physical findings
6. 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.
7. Providers should bill the appropriate CPT code and match the ICD-9 code to the procedure code.
The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision (CPT 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. This means the medical record for a benign lesion excision (CPT 11400-11446) must show why an excisional removal was the procedure of choice.
The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.
2. Medical records maintained by the physician must clearly document the medical necessity for lesion(s) removal if Medicare is billed for the service. The relevant history and physical finding conforming to the criteria stated in the "Indication and Limitations of Coverage and/or Medical Necessity" section above must be made available to the Carrier on request.
3. Surgical Procedures Lesions and Closures:
Operative note(s) for surgical procedures performed in the office location may be contained in the patient's medical record for the date of service or as a separate report maintained within the patients chart. The operative note for the procedure performed must be of significant detail to support the surgical procedure billed. The surgical technique used should be described. Surgical procedures should include the lesion size(s) location(s) and number. Layered closures should include the length recorded in centimeters. Add together the length of multiple closures from all anatomical sites grouped together in the same code descriptor. (See the American Medical Associations Physicians' Current Procedural Terminology, CPT subsection instruction for Removal of Skin Tags, Shaving of Epidermal or Dermal Lesions, Excisions - Benign Lesions, Repairs (Closures) and Destruction.)
4. The decision to submit a specimen for pathological interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that the pathology description and tissue diagnosis will be part of the medical record if a specimen is submitted to pathology.
5. A medical record statement of "irritated skin lesion" is insufficient justification for lesion removal when solely used to reference a patient's complaint or a physician's physical findings. Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient to justify lesional removal without medical documentation of the patient's symptoms and physical findings
6. 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.
7. Providers should bill the appropriate CPT code and match the ICD-9 code to the procedure code.
The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision (CPT 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. This means the medical record for a benign lesion excision (CPT 11400-11446) must show why an excisional removal was the procedure of choice.
The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.
Appendices
Utilization Guidelines
Sources of Information and Basis for Decision
Alterations in the
Skin, Chapter 47. Eczema, Psoriasis, Cutaneous Infections, Acne, and
Other Common Skin Disorders.
Guttman C, Routine Destruction of Aks Called Unnecessary, Dermatology Times, April 2000.
Epstein E, The Merck Manual of Diagnosis and Therapy, Section 10- Dermatologic Disorders, Chapter 115, Viral Skin Infections Topics, Ch 125, Benign Tumors Topics.
Euvrard S, Lanitakis J, Decullier E, et al, Subusequent skin cancers in Kidney and heart transplant receipients after the first squamouns cell carcinoma, Tranplantation, 2006 Apr 27;81(8):1093-100.
Ferri Fred F, Ferris Clinical Advisor, Instant Diagnosis and Treatment.
HARRISON'S ONLINE Part 2.Cardinal Manifestations and Presentation of Diseases, Section 9.
Ho V, McLean Di. General in Dermatology tumors epithelial, 4th Ed., McGraw Hill, Inc., pp 855-872.
Krusinski Paul A, and Flowers Franklin P, Common Viral Infections of the Skin, Best Practice of Medicine, March 2000.
Marcil I, Stern RS, Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis. Arch Dermatol, 2000, Dec;136(12):1524-30.
Stone MS, Lynch PJ. Viral warts in Principles and Practices of Dermatology, Churchhill Livingstone, 1990, pp 119-127.
White Gary M, Cox Neil H, Diseases of the Skin, Section I Diseases and Disorders.
Guttman C, Routine Destruction of Aks Called Unnecessary, Dermatology Times, April 2000.
Epstein E, The Merck Manual of Diagnosis and Therapy, Section 10- Dermatologic Disorders, Chapter 115, Viral Skin Infections Topics, Ch 125, Benign Tumors Topics.
Euvrard S, Lanitakis J, Decullier E, et al, Subusequent skin cancers in Kidney and heart transplant receipients after the first squamouns cell carcinoma, Tranplantation, 2006 Apr 27;81(8):1093-100.
Ferri Fred F, Ferris Clinical Advisor, Instant Diagnosis and Treatment.
HARRISON'S ONLINE Part 2.Cardinal Manifestations and Presentation of Diseases, Section 9.
Ho V, McLean Di. General in Dermatology tumors epithelial, 4th Ed., McGraw Hill, Inc., pp 855-872.
Krusinski Paul A, and Flowers Franklin P, Common Viral Infections of the Skin, Best Practice of Medicine, March 2000.
Marcil I, Stern RS, Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis. Arch Dermatol, 2000, Dec;136(12):1524-30.
Stone MS, Lynch PJ. Viral warts in Principles and Practices of Dermatology, Churchhill Livingstone, 1990, pp 119-127.
White Gary M, Cox Neil H, Diseases of the Skin, Section I Diseases and Disorders.
Advisory Committee Meeting Notes
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2008
J-5 MAC (IA,KS,MO, NE) 02/12/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2008
J-5 MAC (IA,KS,MO, NE) 02/12/2009
Start Date of Comment Period
02/12/2009
End Date of Comment Period
03/30/2009
Start Date of Notice Period
10/01/2010
Revision History Number
X
Revision History Explanation
06/19/2009: Added ICD-9 codes 238.2
238.9
07/01/2009, one, replaced all previous LCDs, including DERM-008 and DERM-508, with current one that was taken to the CAC;
8/10/2009 - The description for Revenue code 0760 was changed
8/10/2009 - The description for Revenue code 0761 was changed
8/10/2009 - The description for Revenue code 0762 was changed
8/10/2009 - The description for Revenue code 0769 was changed
10/01/2009, ICD-9 2010 coding update (two); 07/01/2009, one, replaced all previous LCDs, including DERM-008 and DERM-508, with current one that was taken to the CAC
03/01/2010, removed reference to DERM-001
04/19/2010-In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
06/01/2010, three, removed reference to DERM-009
8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 83 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0310 was changed
8/1/2010 - The description for Revenue code 0311 was changed
8/1/2010 - The description for Revenue code 0312 was changed
8/1/2010 - The description for Revenue code 0314 was changed
8/1/2010 - The description for Revenue code 0319 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0456 was changed
8/1/2010 - The description for Revenue code 0490 was changed
8/1/2010 - The description for Revenue code 0499 was changed
8/1/2010 - The description for Revenue code 0510 was changed
8/1/2010 - The description for Revenue code 0511 was changed
8/1/2010 - The description for Revenue code 0512 was changed
8/1/2010 - The description for Revenue code 0513 was changed
8/1/2010 - The description for Revenue code 0514 was changed
8/1/2010 - The description for Revenue code 0515 was changed
8/1/2010 - The description for Revenue code 0516 was changed
8/1/2010 - The description for Revenue code 0517 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0760 was changed
8/1/2010 - The description for Revenue code 0761 was changed
8/1/2010 - The description for Revenue code 0762 was changed
8/1/2010 - The description for Revenue code 0769 was changed
10/01/2010, four, ICD-9 2011 update added ICD-9 Codes 237.73 and 737.79
10/01/2010, four, ICD-9 2011 update added ICD-9 Codes 237.73 and 237.79
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
12/01/2010, five added ICD-9 078.0
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
17110 descriptor was changed in Group 1
17111 descriptor was changed in Group 1
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
12/01/2011, six, annual reviewed LCD, no updates;
05/01/2012; seven, added ICD-9 codes 078.11, 235.1. 236.6, 239.2, 686.1, 701.1 , 701.4, 709.3 , 709.4,757.32 , 757.33 ,757.39.
238.9
07/01/2009, one, replaced all previous LCDs, including DERM-008 and DERM-508, with current one that was taken to the CAC;
8/10/2009 - The description for Revenue code 0760 was changed
8/10/2009 - The description for Revenue code 0761 was changed
8/10/2009 - The description for Revenue code 0762 was changed
8/10/2009 - The description for Revenue code 0769 was changed
10/01/2009, ICD-9 2010 coding update (two); 07/01/2009, one, replaced all previous LCDs, including DERM-008 and DERM-508, with current one that was taken to the CAC
03/01/2010, removed reference to DERM-001
04/19/2010-In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
06/01/2010, three, removed reference to DERM-009
8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 83 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0310 was changed
8/1/2010 - The description for Revenue code 0311 was changed
8/1/2010 - The description for Revenue code 0312 was changed
8/1/2010 - The description for Revenue code 0314 was changed
8/1/2010 - The description for Revenue code 0319 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0456 was changed
8/1/2010 - The description for Revenue code 0490 was changed
8/1/2010 - The description for Revenue code 0499 was changed
8/1/2010 - The description for Revenue code 0510 was changed
8/1/2010 - The description for Revenue code 0511 was changed
8/1/2010 - The description for Revenue code 0512 was changed
8/1/2010 - The description for Revenue code 0513 was changed
8/1/2010 - The description for Revenue code 0514 was changed
8/1/2010 - The description for Revenue code 0515 was changed
8/1/2010 - The description for Revenue code 0516 was changed
8/1/2010 - The description for Revenue code 0517 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0760 was changed
8/1/2010 - The description for Revenue code 0761 was changed
8/1/2010 - The description for Revenue code 0762 was changed
8/1/2010 - The description for Revenue code 0769 was changed
10/01/2010, four, ICD-9 2011 update added ICD-9 Codes 237.73 and 737.79
10/01/2010, four, ICD-9 2011 update added ICD-9 Codes 237.73 and 237.79
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
12/01/2010, five added ICD-9 078.0
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
17110 descriptor was changed in Group 1
17111 descriptor was changed in Group 1
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
12/01/2011, six, annual reviewed LCD, no updates;
05/01/2012; seven, added ICD-9 codes 078.11, 235.1. 236.6, 239.2, 686.1, 701.1 , 701.4, 709.3 , 709.4,757.32 , 757.33 ,757.39.
Reason for Change
ICD9 Addition/Deletion
Related Documents
This LCD has no Related Documents.
LCD Attachments
Billing & Coding Guidelines 05/01/12 (PDF - 24 KB)
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Page Last Updated: Thursday, 03-May-2012 12:32:27 CDT
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