11643
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.33
Facility
$193.39
Non-Facility
$315.97
Documentation Required
- Maintain complete, legible medical records with patient identification on every page and the legible signature of the treating physician or non-physician practitioner.
- Medical records must support the selected ICD-10-CM diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- The progress/operative note should document removal of a malignant lesion or an ambiguous but moderate-to-high-suspicion lesion and the record should include the corresponding pathology report.
- The size and anatomical location of the lesion must be documented in the operative report.
Key Coverage Criteria
- 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.
- Complete surgical excision of a malignant skin lesion, including an appropriate margin of surrounding tissue to eradicate microscopic tumor cells, is the treatment of choice and considered medically necessary.
- Excision of a skin lesion including margins is medically necessary when a pathology (histopathology) report verifies the lesion is malignant.
2 Active Policies
A57660 — Billing and Coding: Excision of Malignant Skin Lesions
L33818 — Excision of Malignant Skin Lesions
Related Codes
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