D28.1 — Benign neoplasm of vagina
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
- If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.
- Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.
Key Coverage Criteria
- 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.
- Excision of a benign skin lesion is covered when there is clinical suspicion of malignancy (e.g., ICD-10-CM D48.5) documented in the medical record.
- Removal is covered to address disturbance of skin sensation when documented (ICD-10-CM R20.0-R20.3, R20.8).
14 Active Policies
A57482 — Billing and Coding: Removal of Benign Skin Lesions
J05
L35498 — Removal of Benign Skin Lesions
J05
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
L36850 — Peripheral Nerve Blocks
J06
L34938 — Removal of Benign Skin Lesions
Related Codes
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