Does 11604 require prior authorization?

No, 11604 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 11604?

Medicare facility rate: $181.03. Non-facility rate: $310.96. Work RVU: 3.09.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.09

Facility

$181.03

Non-Facility

$310.96

Legible medical records must reference the patient's complaint or the physician's physical findings when billing with diagnosis L82.0.
Documentation must support a significant, separately identifiable E/M service when modifier 25 is appended (separate E/M note tied to the visit and not just the procedure).
Verify applicable procedure and global policy coding via the Medicare Physician Fee Schedule Database (MPFSDB) to determine where the global surgical policy applies.
Maintain complete, legible medical records with patient identification on every page and the legible signature of the treating physician or non-physician practitioner.

Removal of benign or malignant skin lesions is addressed per the Local Coverage Determination L33445 and related billing/coding guidance.
Diagnosis code L82.0 (inflamed seborrheic keratosis) may be used when the medical record documents the patient's complaint or the physician's physical findings for the lesion.
Excision of malignant or clinically ambiguous lesions with moderate-to-high suspicion that require moderate-to-wide grossly normal skin/soft-tissue margins should be coded using excision of malignant lesion including margins codes 11600-11646.
Excision of benign or low-clinical-suspicion lesions that are removed with minimal surrounding grossly normal skin/soft-tissue margins should be coded using excision of benign lesion codes 11400-11446.
Services are covered only when they meet all indications and limitations in LCD L33818, applicable CMS payment policy manuals, any CMS national coverage determinations, and Medicare payment rules.
Removal of any malignant skin lesion is considered medically necessary and covered.

A56346 — Billing and Coding: Removal of Benign and Malignant Skin Lesions

A57660 — Billing and Coding: Excision of Malignant Skin Lesions

L33445 — Removal of Benign and Malignant Skin Lesions

L33818 — Excision of Malignant Skin Lesions

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