D21.11 — Benign neoplasm of connective and other soft tissue of right upper limb, including shoulder
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
Key Coverage Criteria
- 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.
- Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
- True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
- If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
- Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
12 Active Policies
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
A56787 — Billing and Coding: Nonvascular Extremity Ultrasound
J06
L36850 — Peripheral Nerve Blocks
J06
L33619 — Nonvascular Extremity Ultrasound
J06
A56346 — Billing and Coding: Removal of Benign and Malignant Skin Lesions
Related Codes
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