Does 11426 require prior authorization?

No, 11426 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 11426?

Medicare facility rate: $244.83. Non-facility rate: $340.02. Work RVU: 3.99.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.99

Facility

$244.83

Non-Facility

$340.02

Physician medical records must clearly document medical necessity for each lesion removal.
Measure and document the greatest clinical diameter of the lesion plus the most narrow margin required for complete excision prior to excision; use this measurement to determine CPT code selection.
Report each benign lesion excised separately and document units of service per CPT-specific rules (11200/11201, 17000/17003/17004, 17110/17111).
When a separate, significant E&M is billed the service must be fully and clearly documented in the patient record and appropriate modifier 25 must be appended.

Removal of a benign skin lesion is covered when the lesion is symptomatic (bleeding, intense itching, or pain).
Removal is covered when there is a change in physical appearance such as new reddening, pigmentary change, enlargement, or increase in number of lesions prompting medical intervention.
Removal is covered when there is physical evidence of inflammation or infection (purulence, oozing, edema, erythema).
Removal is covered when the lesion obstructs an orifice (e.g., nasal vestibule, ear canal).
Removal is covered when the lesion clinically restricts eye function (restricts eyelid function, causes misdirection of eyelashes, restricts lacrimal puncta or interferes with tear flow, or touches the globe).
Removal is covered when clinical uncertainty exists and malignancy is a realistic consideration based on lesion appearance.

L35498 — Removal of Benign Skin Lesions

J05

A57482 — Billing and Coding: Removal of Benign Skin Lesions

J05

A54602 — Billing and Coding: Removal of Benign Skin Lesions

J06

A57113 — Billing and Coding: Removal of Benign Skin Lesions

J12

L34938

Ask Verity about documentation requirements, denial risks, or coverage in your state.