17111
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.95
Facility
$73.82
Non-Facility
$129.93
Documentation Required
- 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.
Key Coverage Criteria
- 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.
20 Active Policies
A57482 — Billing and Coding: Removal of Benign Skin Lesions
J05
L35498 — 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
Related Codes
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