54055
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.22
Facility
$86.84
Non-Facility
$139.28
Documentation Required
- Maintain all documentation in the patient’s medical record and make it available to the contractor upon request.
- Ensure every page of the record is legible and includes appropriate patient identification information, such as complete name and dates of service.
- Include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
Key Coverage Criteria
- Report histopathologic examination separately when performed using CPT codes 88304-88305.
- Select the CPT code for lesion removal by measuring the greatest clinical diameter of the apparent lesion plus the margin required for complete excision, with measurement made prior to excision.
- When shave removal is performed solely to obtain a pathologic diagnosis, report tangential (shave) biopsy CPT codes 11102-11103 instead of shave removal codes.
- Follow the reasonable and necessary requirements in LCD L34938 for coverage determinations of benign skin lesion removal.
- Removal of benign skin lesions (e.g., seborrheic keratoses, epidermoid cysts, nevi, hyperkeratosis, molluscum contagiosum, milia, viral warts, benign neoplasms, hemangiomas, lipomas, pyogenic granulomas) is medically necessary when one or more specified clinical conditions below are present and documented.
- Lesion that is symptomatic or has undergone a change in appearance or displays evidence of inflammation or infection supports medical necessity for removal.
2 Active Policies
A57113 — Billing and Coding: Removal of Benign Skin Lesions
J12
L34938 — Removal of Benign Skin Lesions
J12
Related Codes
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