L11.1 — Transient acantholytic dermatosis [Grover]
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record must include the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.
- The office visit record or operative report must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
- Claims must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and the reason(s) for the service.
- For excisions, document the greatest clinical diameter of the lesion plus the margin required (measurement made prior to excision) and the rationale for choosing excision if not cosmetic.
Key Coverage Criteria
- 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).
- Removal is covered when documented objective changes (e.g., increase in size) support a diagnosis warranting excision.
- Removal of a benign lesion is covered when the treating physician documents medical necessity for removal (physician judgment that lesion merits removal).
- Destruction of actinic keratoses is covered without restrictions based on lesion or patient characteristics.
- Removal of benign skin lesions (seborrheic keratoses, sebaceous/epidermoid cysts, skin tags, nevi/moles, acquired hyperkeratosis/keratoderma, molluscum contagiosum, milia, viral warts) is considered medically necessary when one or more documented clinical criteria below are present.
2 Active Policies
A57044 — Billing and Coding: Removal of Benign Skin Lesions
L34200 — Removal of Benign Skin Lesions
Related Codes
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