Download Skin Lesion Removal Codes and ICD-10 Codes for Benign and Premalignant Lesions and more Exercises Logic in PDF only on Docsity!
Benign Skin Lesion Removal
Policy Number: PG Last Review: 09/11/ GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. SCOPE X Professional _ Facility DESCRIPTION Benign skin lesions are common in the elderly and are frequently removed at the patient's request to improve appearance. Removals of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic. These cosmetic reasons include, but are not limited to, emotional distress, "makeup trapping," and non- problematic lesions in any anatomic location. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage based on location alone. Destruction of benign skin lesions such as seborrheic keratosis, sebaceous (epidermoid) cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts may be medically appropriate based on lesion or patient characteristics. POLICY Cosmetic procedures are non-covered. Benign skin lesion removal does not require prior authorization but must follow criteria below. Removal of skin tags (11200 & 11201) is non-covered for HMO, PPO, & Individual Marketplace. The ICD-10 diagnosis codes that are covered for these procedures are listed below in the CODING/BILLING INFORMATION section. COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Paramount will consider removal of benign seborrheic keratoses, sebaceous cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts as medically necessary, and not cosmetic, if one or more of the following conditions are presented and clearly documented in the medical record: Bleeding Intense itching Pain Change in physical appearance (reddening or pigmentary change) Recent 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: a. Lesion restricts eyelid function ADVANTAGE | ELITE | HMO INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO
b. lesion causes misdirection of eyelashes or eyelid c. lesion restricts lacrimal puncta and interferes with tear flow d. lesion touches globe Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance A prior biopsy suggests or is indicative of lesion malignancy The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has, in fact, occurred Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of rupture of epidermal inclusion (sebaceous) cyst Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are present: a. Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding b. Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patients c. Lesions are condyloma acuminata or molluscum contagiosum d. Cervical dysplasia or pregnancy is associated with genital warts Paramount will not pay for a separate evaluation and management (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. Paramount 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. 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 reimbursement consideration, documentation must clearly indicate the medical necessity for performing the procedure and include: The removal is due to bleeding, pain, recent changes in color, enlargement, or exposure to frequent irritation ("irritated skin lesion" does not justify reimbursement) Performed for a medical indication, such as malignancy or abnormal changes requiring pathology consultation and evaluation Pathological submission is independent from the decision to remove the lesion, and alone does not support reimbursement of the lesion If this is reviewed, a provider must always support the reporting of service with a clear and concise procedure documentation stating how many skin tags were removed, their location, how the patient tolerated the procedure, and other pertinent information to support the medical necessity based on clinical examination and findings. Failure to follow documentation guidelines supports the procedure as not billable. Paramount does not cover benign skin lesion treatment or removal when performed solely for the purpose of altering appearance or self-esteem, or to treat psychological symptomatology or psychosocial complaints related to one’s appearance because it is considered cosmetic and not medically necessary.
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 17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion 17003 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) 17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions (^17110) Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions 17111 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions ICD-10 CODES: The codes listed below identify the lesion being treated and will, by themselves, be considered for payment: A63.0 Anogenital (venereal) warts B08.1 Molluscum contagiosum D37.01 Neoplasm of uncertain behavior of lip D37.02 Neoplasm of uncertain behavior of tongue D37.04 Neoplasm of uncertain behavior of the minor salivary glands D37.05 Neoplasm of uncertain behavior of pharynx D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity D39.8 Neoplasm of uncertain behavior of other specified female genital organs
D39.9 Neoplasm of uncertain behavior of female genital organ, unspecified D40.8 Neoplasm of uncertain behavior of other specified male genital organs D40.9 Neoplasm of uncertain behavior of male genital organ, unspecified D48.5 Neoplasm of uncertain behavior of skin D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin H02.821 Cysts of right upper eyelid H02.822 Cysts of right lower eyelid H02.824 Cysts of left upper eyelid H02.825 Cysts of left lower eyelid L28.1 Prurigo nodularis L57.0 Actinic keratosis L70.0 Acne vulgaris L82.0 Inflamed seborrheic keratosis L92.8 (^) Other granulomatous disorders of the skin and subcutaneous tissue L98.0 Pyogenic granuloma ICD-10 CODES: For the conditions below, a Primary ICD- 10 - CM code AND a Secondary ICD- 10 - CM code that represents a complication are required. Primary Diagnoses: B07.0 Plantar wart B07.8 Other viral warts B07.9 (^) Viral wart, unspecified D10.0 Benign neoplasm of lip D10.30 Benign neoplasm of unspecified part of mouth D10.39 (^) Benign neoplasm of other parts of mouth D17.0 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck D17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk D17.21 - D17. Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm - Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg D17.39 Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites D18.01 Hemangioma of skin and subcutaneous tissue D22.0 Melanocytic nevi of lip D22.11 Melanocytic nevi of right eyelid, including canthus D22.12 Melanocytic nevi of left eyelid, including canthus D22.21 Melanocytic nevi of right ear and external auricular canal D22.22 Melanocytic nevi of left ear and external auricular canal D22.30 Melanocytic nevi of unspecified part of face D22.39 Melanocytic nevi of other parts of face D22.4 Melanocytic nevi of scalp and neck D22.5 Melanocytic nevi of trunk D22.61 Melanocytic nevi of right upper limb, including shoulder D22.62 (^) Melanocytic nevi of left upper limb, including shoulder D22.71 Melanocytic nevi of right lower limb, including hip D22.72 Melanocytic nevi of left lower limb, including hip D22.9 (^) Melanocytic nevi, unspecified D23.0 Other benign neoplasm of skin of lip D23.11 Other benign neoplasm of skin of right eyelid, including canthus D23.12 Other benign neoplasm of skin of left eyelid, including canthus D23.21 Other benign neoplasm of skin of right ear and external auricular canal D23.22 Other benign neoplasm of skin of left ear and external auricular canal D23.30 (^) Other benign neoplasm of skin of unspecified part of face D23.39 Other benign neoplasm of skin of other parts of face D23.4 Other benign neoplasm of skin of scalp and neck D23.5 Other benign neoplasm of skin of trunk
L98.5 Mucinosis of the skin L98.6 Other infiltrative disorders of the skin and subcutaneous tissue L99 Other disorders of skin and subcutaneous tissue in diseases classified elsewhere M10.9 Gout, unspecified M71.30 Other bursal cyst, unspecified site N75.0 Cyst of Bartholin's gland N75.8 Other diseases of Bartholin's gland N84.3 Polyp of vulva N90.0 Mild vulvar dysplasia N90.1 Moderate vulvar dysplasia Q17.0 Accessory auricle Q18.1 Preauricular sinus and cyst Q81.0 - Q81. Epidermolysis bullosa simplex - Epidermolysis bullosa dystrophica Q81.8 Other epidermolysis bullosa Q82.1 - Q82. Xeroderma pigmentosum - Incontinentia pigmenti Q82.5 Congenital non-neoplastic nevus Q82.8 Other specified congenital malformations of skin Q85.01 (^) Neurofibromatosis, type 1 ICD-10 CODES: For the conditions below, a Primary ICD- 10 - CM code AND a Secondary ICD- 10 - CM code that represents a complication are required. Secondary Diagnoses: B78.1 (^) Cutaneous strongyloidiasis D48.5 Neoplasm of uncertain behavior of skin D80.0 - D80.8 Hereditary hypogammaglobulinemia - Other immunodeficiencies with predominantly antibody defects D81.0 - D81.2 Severe combined immunodeficiency [SCID] with reticular dysgenesis - Severe combined immunodeficiency [SCID] with low or normal B-cell numbers D81.4 Nezelof's syndrome D81.6 Major histocompatibility complex class I deficiency D81.7 Major histocompatibility complex class II deficiency D81.89 Other combined immunodeficiencies D82.0 Wiskott-Aldrich syndrome D82.1 Di George's syndrome D83.0 - D83.2 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function - Common variable immunodeficiency with autoantibodies to B- or T-cells D83.8 (^) Other common variable immunodeficiencies D84.8 Other specified immunodeficiencies D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified E83.2 Disorders of zinc metabolism H02.89 Other specified disorders of eyelid H10.401 - H10. Unspecified chronic conjunctivitis, right eye - Unspecified chronic conjunctivitis, bilateral H10.421 - H10. Simple chronic conjunctivitis, right eye - Simple chronic conjunctivitis, bilateral H10.431 - H10. Chronic follicular conjunctivitis, right eye - Chronic follicular conjunctivitis, bilateral H10.9 Unspecified conjunctivitis H53.40 Unspecified visual field defects H53.451 - H53. Other localized visual field defect, right eye - Other localized visual field defect, bilateral
H53.71 Glare sensitivity H53.72 Impaired contrast sensitivity H53.8 Other visual disturbances H53.9 Unspecified visual disturbance H54.61 Unqualified visual loss, right eye, normal vision left eye H54.62 Unqualified visual loss, left eye, normal vision right eye K12.2 Cellulitis and abscess of mouth L02.01 Cutaneous abscess of face L02.11 Cutaneous abscess of neck L02.211 - L02. Cutaneous abscess of abdominal wall - Cutaneous abscess of umbilicus L02.31 Cutaneous abscess of buttock L02.411 - L02. Cutaneous abscess of right axilla - Cutaneous abscess of left lower limb L02.511 Cutaneous abscess of right hand L02.512 Cutaneous abscess of left hand L02.611 Cutaneous abscess of right foot L02.612 Cutaneous abscess of left foot L02.811 Cutaneous abscess of head [any part, except face] L02.818 (^) Cutaneous abscess of other sites L03.111 - L03. Cellulitis of right axilla - Cellulitis of left lower limb L03.121 - L03. Acute lymphangitis of right axilla - Acute lymphangitis of left lower limb L03.211 Cellulitis of face L03.212 Acute lymphangitis of face L03.221 Cellulitis of neck L03.222 Acute lymphangitis of neck L03.311 - L03. Cellulitis of abdominal wall - Cellulitis of buttock L03.321 - L03. Acute lymphangitis of abdominal wall - Acute lymphangitis of buttock L03.811 Cellulitis of head [any part, except face] L03.818 Cellulitis of other sites L03.891 Acute lymphangitis of head [any part, except face] L03.898 Acute lymphangitis of other sites L08.82 (^) Omphalitis not of newborn L08.89 Other specified local infections of the skin and subcutaneous tissue L08.9 Local infection of the skin and subcutaneous tissue, unspecified L26 Exfoliative dermatitis L29.9 Pruritus, unspecified L30.0 Nummular dermatitis L30.2 (^) Cutaneous autosensitization L30.4 Erythema intertrigo L30.8 Other specified dermatitis L50.9 Urticaria, unspecified L53.8 Other specified erythematous conditions L54 Erythema in diseases classified elsewhere L92.0 Granuloma annulare L95.1 Erythema elevatum diutinum L98.2 Febrile neutrophilic dermatosis [Sweet] L98.3 Eosinophilic cellulitis [Wells]
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.
