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Back to Local Coverage Determinations (LCDs) for Palmetto GBA (01192, MAC - Part B)
Local Coverage Determination (LCD) for Skin
Lesion (Non-Melanoma) Removal (L28300)
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Contractor Information
Contractor Name
Palmetto GBA
Contractor Number
01192
Contractor Type
MAC - Part B
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LCD Information
Document Information
LCD ID Number
L28300
LCD Title
Skin Lesion (Non-Melanoma) Removal
Primary Geographic
Jurisdiction
California - Southern
Oversight Region
Region X
Contractor's Determination Number
J1B-08-0072-L
AMA CPT/ADA CDT Copyright Statement
CPT only copyright 2002-2012 American
Medical Association. All Rights Reserved.
CPT is a registered trademark of the American
Medical Association. Applicable FARS/DFARS
Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or
related components are not assigned by the
AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not
directly or indirectly practice medicine or
Original Determination
Effective Date
For services performed on or
after 09/02/2008
Original Determination
Ending Date
Revision Effective Date
For services performed on or
after 01/15/2012
dispense medical services. The AMA assumes
no liability for data contained or not contained
herein. The Code on Dental Procedures and
Nomenclature (Code) is published in Current
Dental Terminology (CDT). Copyright ©
American Dental Association. All rights
reserved. CDT and CDT-2010 are trademarks
of the American Dental Association.
Revision Ending Date
CMS National Coverage Policy
Title XVIII of the Social Security Act, §1862(a)(1)(A). Allows coverage and payment for
only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act, §1833(e). Prohibits Medicare payment for any claim,
which lacks the necessary information to process the claim.
CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual,
Chapter 1, Part 4, §250.4.
Indications and Limitations of Coverage and/or Medical Necessity
This policy applies to the following: seborrheic keratoses, skin tags, milia, molluscum
contagiosum, sebaceous (epidermoid) cysts, moles (nevi), acquired hyperkeratosis
(keratoderma) and viral warts (excluding condyloma acuminatum). The treatment of actinic
keratosis is covered in another policy. This policy does not address routine foot care or the
treatment of other skin lesions, e.g., ulcers, abscess, malignancies, dermatoses or
psoriasis.
Benign skin lesions are common in the elderly and are frequently removed at the patient’s
request to improve appearance. Removal of benign skin lesions that do not pose a threat
to health or function is considered cosmetic and as such is not covered by the Medicare
program.
Medicare will consider the removal of benign skin lesions as medically necessary, and not
cosmetic, if one or more of the following conditions is present and clearly documented in
the medical record:
A. The lesion has one or more of the following characteristics:
1. bleeding
2. intense itching
3. pain
B. The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema,
erythema, etc.
C. The lesion obstructs an orifice or clinically restricts vision.
D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic
consideration based on lesional appearance (e.g. non-response to conventional treatment,
or change in appearance). However, if the diagnosis is uncertain, either biopsy or
removal may be more prudent than destruction.
E. A prior biopsy suggests or is indicative of lesion malignancy.
F. The lesion is in an anatomical region subject to recurrent physical trauma and there is
documentation that such trauma has in fact occurred.
G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction
will be covered when the following clinical circumstance is present:
● Periocular warts associated with chronic recurrent conjunctivitis thought secondary to
lesional virus shedding
Note:
1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually
cosmetic. Their coverage will be addressed in a separate policy.
2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g.,
corns and calluses). Coverage for these three codes is described in separate policies.
If the beneficiary wishes one or more benign asymptomatic lesions removed for cosmetic
purposes, the beneficiary becomes liable for the service rendered.
Removal of benign skin lesions that do not pose a threat to health or function are
considered cosmetic and as such are not covered by the Medicare program.
Regarding Melanoma:
While it is recognized that some diagnoses resulting from a shave biopsy will at times be
melanoma, the diagnosis at the time the procedure was performed would most likely be
238.2, (Neoplasm of uncertain behavior of other and unspecified sites and tissues, skin)
and this would be the appropriate code. Since proper coding requires the highest level of
diagnosis known at the time the procedure was performed, melanoma would not be a
reasonable diagnosis, since if the lesion were known to be a melanoma, a shave biopsy
would not be medically reasonable and necessary.
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Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically
used to report this service. Absence of a Bill Type does not guarantee that the policy
does not apply to that Bill Type. Complete absence of all Bill Types indicates that
coverage is not influenced by Bill Type and the policy should be assumed to apply
equally to all claims.
999x
Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue
Codes typically used to report this service. In most instances Revenue Codes are purely
advisory; unless specified in the policy services reported under other Revenue Codes
are equally subject to this coverage determination. Complete absence of all Revenue
Codes indicates that coverage is not influenced by Revenue Code and the policy should
be assumed to apply equally to all Revenue Codes.
99999
Not Applicable
CPT/HCPCS Codes
11200
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA;
UP TO AND INCLUDING 15 LESIONS
11201
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA;
EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
11300
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK,
ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS
11301
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK,
ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM
11302
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK,
ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM
11303
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK,
ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM
11305
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS
11306
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM
11307
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM
11308
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM
11310
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS,
EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR
LESS
11311
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS,
EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0
CM
11312
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS,
EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0
CM
11313
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS,
EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0
CM
11400
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED
DIAMETER 0.5 CM OR LESS
11401
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED
DIAMETER 0.6 TO 1.0 CM
11402
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED
DIAMETER 1.1 TO 2.0 CM
11403
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED
DIAMETER 2.1 TO 3.0 CM
11404
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED
DIAMETER 3.1 TO 4.0 CM
11406
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED
DIAMETER OVER 4.0 CM
11420
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA;
EXCISED DIAMETER 0.5 CM OR LESS
11421
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA;
EXCISED DIAMETER 0.6 TO 1.0 CM
11422
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA;
EXCISED DIAMETER 1.1 TO 2.0 CM
11423
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA;
EXCISED DIAMETER 2.1 TO 3.0 CM
11424
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA;
EXCISED DIAMETER 3.1 TO 4.0 CM
11426
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA;
EXCISED DIAMETER OVER 4.0 CM
11440
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS
11441
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM
11442
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM
11443
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM
11444
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM
11446
EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG
(UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; EXCISED DIAMETER OVER 4.0 CM
17000
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS
(EG, ACTINIC KERATOSES); FIRST LESION
17003
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS
(EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST
SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)
17004
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS
(EG, ACTINIC KERATOSES), 15 OR MORE LESIONS
17110
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER
THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP
TO 14 LESIONS
17111
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER
THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15
OR MORE LESIONS
ICD-9 Codes that Support Medical Necessity
These are the only covered diagnosis codes for CPT codes 11200, 11201, 11300, 11301
-11313, 11400-11406, 11420-11426, 11440-11446, 17000, 17003, 17004, 17110 and
17111:
(Additionally, diagnosis 702.0 may be used for CPT Codes 17000, 17003 and 17004 as
listed in the J1 A/B MAC Actinic Keratosis LCD.)
List I. These ICD-9-CM codes identify the lesion being treated and will, by
themselves, allow payment:
078.0
MOLLUSCUM CONTAGIOSUM
078.10
VIRAL WARTS UNSPECIFIED
078.12
PLANTAR WART
078.19
OTHER SPECIFIED VIRAL WARTS
238.2
NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
374.84
CYSTS OF EYELIDS
380.00
PERICHONDRITIS OF PINNA UNSPECIFIED
380.01
ACUTE PERICHONDRITIS OF PINNA
380.02
CHRONIC PERICHONDRITIS OF PINNA
380.03
CHONDRITIS OF PINNA
686.1
PYOGENIC GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE
698.3
LICHENIFICATION AND LICHEN SIMPLEX CHRONICUS
701.1*
KERATODERMA ACQUIRED
701.4*
KELOID SCAR
702.0
ACTINIC KERATOSIS
702.11
INFLAMED SEBORRHEIC KERATOSIS
* 701.1 – Use for symptomatic, painful and/or inflamed lesions only
* 701.4 - Refer to Documentation Requirements Section for qualifying criteria
List II. These ICD-9-CM codes identify those conditions for which payment is
allowed only if the conditions have complications, these being listed in List III
below.
Note: Diagnoses from List II must be accompanied by one of the diagnoses from
List III for payment to be allowed. List III gives justification (reasonable and
necessary) for allowing payment.
135
SARCOIDOSIS
216.0
BENIGN NEOPLASM OF SKIN OF LIP
216.1
BENIGN NEOPLASM OF EYELID INCLUDING CANTHUS
216.2
BENIGN NEOPLASM OF EAR AND EXTERNAL AUDITORY CANAL
216.3
BENIGN NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
216.4
BENIGN NEOPLASM OF SCALP AND SKIN OF NECK
216.5
BENIGN NEOPLASM OF SKIN OF TRUNK EXCEPT SCROTUM
216.6
BENIGN NEOPLASM OF SKIN OF UPPER LIMB INCLUDING SHOULDER
216.7
BENIGN NEOPLASM OF SKIN OF LOWER LIMB INCLUDING HIP
216.8
BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF SKIN
216.9
BENIGN NEOPLASM OF SKIN SITE UNSPECIFIED
221.2
BENIGN NEOPLASM OF VULVA
222.1
BENIGN NEOPLASM OF PENIS
222.4
BENIGN NEOPLASM OF SCROTUM
448.1
NEVUS NON-NEOPLASTIC
455.9
RESIDUAL HEMORRHOIDAL SKIN TAGS
701.9
UNSPECIFIED HYPERTROPHIC AND ATROPHIC CONDITIONS OF SKIN
702.19
OTHER SEBORRHEIC KERATOSIS
706.2
SEBACEOUS CYST
744.1
ACCESSORY AURICLE
757.39
OTHER SPECIFIED CONGENITAL ANOMALIES OF SKIN
List III. These ICD-9-CM codes identify the complicating pathology that justifies
Medicare payment (reasonable and necessary):
Note: Diagnoses from List II must be accompanied by one of the diagnoses from
List III for payment to be allowed. List III gives justification (reasonable and
necessary) for allowing payment.
238.2
NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
369.8
UNQUALIFIED VISUAL LOSS ONE EYE
372.13
VERNAL CONJUNCTIVITIS
459.0
HEMORRHAGE UNSPECIFIED
682.0
CELLULITIS AND ABSCESS OF FACE
682.1
CELLULITIS AND ABSCESS OF NECK
682.2
CELLULITIS AND ABSCESS OF TRUNK
682.3
CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM
682.4
CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB
682.5
CELLULITIS AND ABSCESS OF BUTTOCK
682.6
CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT
682.7
CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES
682.8
CELLULITIS AND ABSCESS OF OTHER SPECIFIED SITES
682.9
CELLULITIS AND ABSCESS OF UNSPECIFIED SITES
686.8
OTHER SPECIFIED LOCAL INFECTIONS OF SKIN AND SUBCUTANEOUS
TISSUE
695.89
OTHER SPECIFIED ERYTHEMATOUS CONDITIONS
695.9
UNSPECIFIED ERYTHEMATOUS CONDITION
698.9
UNSPECIFIED PRURITIC DISORDER
782.0
DISTURBANCE OF SKIN SENSATION
959.8
OTHER AND UNSPECIFIED INJURY TO OTHER SPECIFIED SITES INCLUDING
MULTIPLE
List IV. The following ICD-9-CM codes are the only malignant diagnoses that are
appropriate and their use is limited to CPT codes 11300-11313:
173.00
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP
173.01
BASAL CELL CARCINOMA OF SKIN OF LIP
173.02
SQUAMOUS CELL CARCINOMA OF SKIN OF LIP
173.09
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP
173.10
UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING
CANTHUS
173.11
BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS
173.12
SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS
173.19
OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING
CANTHUS
173.20
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND
EXTERNAL AUDITORY CANAL
173.21
BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL
AUDITORY CANAL
173.22
SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL
AUDITORY CANAL
173.29
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND
EXTERNAL AUDITORY CANAL
173.30
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND
UNSPECIFIED PARTS OF FACE
173.31
BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED
PARTS OF FACE
173.32
SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND
UNSPECIFIED PARTS OF FACE
173.39
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER
AND UNSPECIFIED PARTS OF FACE
173.40
UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF
NECK
173.41
BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK
173.42
SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK
173.49
OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF
NECK
173.50
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT
SCROTUM
173.51
BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM
173.52
SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT
SCROTUM
173.59
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK,
EXCEPT SCROTUM
173.60
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB,
INCLUDING SHOULDER
173.61
BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING
SHOULDER
173.62
SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB,
INCLUDING SHOULDER
173.69
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER
LIMB, INCLUDING SHOULDER
173.70
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB,
INCLUDING HIP
173.71
BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP
173.72
SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB,
INCLUDING HIP
173.79
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER
LIMB, INCLUDING HIP
173.80
UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
OF SKIN
173.81
BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN
173.82
SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF
SKIN
173.89
OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED
SITES OF SKIN
173.90
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED
173.91
BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED
173.92
SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED
173.99
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE
UNSPECIFIED
184.0
MALIGNANT NEOPLASM OF VAGINA
184.1
MALIGNANT NEOPLASM OF LABIA MAJORA
184.2
MALIGNANT NEOPLASM OF LABIA MINORA
184.3
MALIGNANT NEOPLASM OF CLITORIS
184.4
MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE
184.8
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE
GENITAL ORGANS
184.9
MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE
UNSPECIFIED
187.1
MALIGNANT NEOPLASM OF PREPUCE
187.2
MALIGNANT NEOPLASM OF GLANS PENIS
187.3
MALIGNANT NEOPLASM OF BODY OF PENIS
187.4
MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED
187.7
MALIGNANT NEOPLASM OF SCROTUM
187.8
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF MALE
GENITAL ORGANS
187.9
MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE
UNSPECIFIED
209.31 - 209.36
MERKEL CELL CARCINOMA OF THE FACE - MERKEL CELL
CARCINOMA OF OTHER SITES
232.0
CARCINOMA IN SITU OF SKIN OF LIP
232.1
CARCINOMA IN SITU OF EYELID INCLUDING CANTHUS
232.2
CARCINOMA IN SITU OF SKIN OF EAR AND EXTERNAL AUDITORY
CANAL
232.3
CARCINOMA IN SITU OF SKIN OF OTHER AND UNSPECIFIED PARTS
OF FACE
232.4
CARCINOMA IN SITU OF SCALP AND SKIN OF NECK
232.5
CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM
232.6
CARCINOMA IN SITU OF SKIN OF UPPER LIMB INCLUDING
SHOULDER
232.7
CARCINOMA IN SITU OF SKIN OF LOWER LIMB INCLUDING HIP
232.8
CARCINOMA IN SITU OF OTHER SPECIFIED SITES OF SKIN
232.9
CARCINOMA IN SITU OF SKIN SITE UNSPECIFIED
Diagnoses that Support Medical Necessity
All codes listed above under “Covered ICD-9-CM Codes That Support Medical Necessity”.
ICD-9 Codes that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes That Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes That Support Medical
Necessity".
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General Information
Documentations Requirements
The medical record must be made available to Medicare upon request.
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This
policy does not take precedence over CCI edits. Please refer to the CCI for correct coding
guidelines and specific applicable code combinations prior to billing Medicare.
When, the documentation does not meet the criteria for the service rendered or the
documentation does not establish the medical necessity for the services, such services
will be denied as not reasonable and necessary.
When requesting a written redetermination (formerly appeal), please send all relevant
documentation with the request.
Benign skin lesion removals for reasons other than those given under the Indications and
Limitations of Coverage and or Medical Necessity Section above are considered to be
cosmetic and will not be covered. These noncovered reasons include, but are not limited
to, emotional distress, “makeup trapping” and non-problematic lesions in any anatomic
location.
Medical documentation must clearly and unequivocally document the medical necessity
for lesion removal(s) if Medicare is billed for the service.
A medical record statement of “irritated skin lesion” is insufficient justification for lesion
removal when solely used to reference a patient’s complaint or a physician’s physical
findings. Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient
to justify lesional removal without medical documentation of the patient’s symptoms and
physical findings.
Medicare will not pay for a separate E/M service on the same day dermatologic surgery is
performed unless significant and separately identifiable medical services were rendered
and clearly documented in the patient’s medical record. Append modifier 25 to the
appropriate visit code to indicate the patient’s condition required a significant, separately
identifiable visit service unrelated to the procedure that was performed.
Office visits will be covered when the diagnosis of a benign skin lesion(s) is made even if
the removal of a particular lesion or lesion(s) is not medically indicated and is therefore
not done.
Lesions in sensitive anatomic locations that are non-problematic do not qualify for
removal coverage on the basis of location alone.
The type of removal is at the discretion of the treating physician and the appropriateness
of the technique used will not be a factor in deciding if a lesion merits removal. However,
a benign lesional excision (CPT 11400-11446) must have medical record documentation
as to why an excisional removal, other than for cosmetic purposes, was the surgical
procedure of choice. This means the medical record for a benign lesion excision (CPT
11400-11446) must show why an excisional removal was the procedure of choice.
The decision to submit a specimen for pathologic interpretation will be independent of the
decision to remove or not remove the lesion. It is assumed, however, that a tissue
diagnosis will be part of the medical record when an ultimately benign lesion is removed
based on physician uncertainty as to the final clinical diagnosis.
Appendices
Utilization Guidelines
Sources of Information and Basis for Decision
National Model Policy developed by CMD Workgroup
Iowa Local Medical Review Policy
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical
Director. Although the final decision rests with the contractor, this policy was developed in
cooperation with advisory groups, which include representatives from the affected
provider community.
Contractor Advisory Committee meeting dates:
California -
Hawaii Nevada Start Date of Comment Period
End Date of Comment Period
Start Date of Notice Period
06/16/2008
Revision History Number
Revision #7
Revision History Explanation
Revision#7 effective for dates of service on or after 01/15/2012
Revision made: Under ICD-9-Codes that Support Medical Necessity added 702.0 to
Group 1, as this diagnosis code is also located in the Actinic Keratosis LCD and as well
as some of the CPT Codes in this LCD are also in the Actinic Keratosis LCD. Under
section titled 'Sources of Information and Basis for Decision' removed "Other carriers'
policies", as this is a non-specific statement it does not tell which carriers policies were
used or the title of the policies used to develop the LCD.
Revision #6 effective for dates of service on or after 10/01/2011
Revisions made: Under ICD-9 Codes that Support Medical Necessity deleted 173.0-173.9
and added 173.00-173.99. This LCD is being revised due to the annual FY 2012 ICD-9CM code update.
Revision #5, effective for dates of service on or after 10/01/2009
Revisions made: Under "ICD-9 Codes that Support Medical Necessity," the following ICD9 codes were added to support the medical necessity for CPT codes 11300, 11301,
11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313: 209.31, 209.3,
209.33, 209.34, 209.35 and 209.36. This revision is per CMS Manual System, Publication
100-04, Medicare Claims Process Manual, Chapter 23, §10.2; Annual Update of the
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM),
CR 6520, Transmittal 1770, dated July 10, 2009.
Revision #4, 02/26/2009
This LCD is being revised to implement the streamlining of the Part B LCDs per the
published article “Palmetto Team to Streamline Part B LCDs in Jurisdiction 1 (J1).” This
article can be viewed at www.PalmettoGBA.com by searching for the above article name.
This revision will become effective on 02/26/2009. The title of the LCD was changed to
only Skin Lesion (Non-Melanoma) Removal. The previous LCD name change by the
previous contractor is no longer applicable to this contractor's title name for this LCD.
Revision #3 effective for dates of service on or after 01/09/2009
Revisions made: Under "CMS National Coverage Policy" removed unnecessary wording
(section). "CPT/HCPCS Codes" descriptor of CPT code 11201 was revised. The effective
date for the CPT code descriptor revision is 01/01/2009.
Revision #2, 10/01/2008
This LCD is being revised due to the annual FY2009 ICD-9-CM code update. Under "ICD9 Codes that Support Medical Necessity" section added 078.12 for the following CPT
codes 11200, 11201, 11300, 11301-11313, 11400-11406, 11420-11426, 11440-11446,
17000, 17003, 17004, 17110 and 17111. In the “Documentation Requirements” section of
LCD a duplicate SSA citation was removed. This revision will become effective
10/01/2008.
Revision #1, 09/02/2008
This LCD is being revised to add Bill Type 999X because the automated system
transcription process was incomplete.
11/09/2008 - The description for CPT/HCPCS code 11201 was changed in group 1
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the
long description was changed. Depending on which description is used in this LCD, there
may not be any change in how the code displays in the document:
17003 descriptor was changed in Group 1
17110 descriptor was changed in Group 1
17111 descriptor was changed in Group 1
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the
long description was changed. Depending on which description is used in this LCD, there
may not be any change in how the code displays in the document:
17004 descriptor was changed in Group 1
Reason for Change
Maintenance (annual review with new changes, formatting, etc.)
Typographical Correction
Related Documents
This LCD has no Related Documents.
LCD Attachments
There are no attachments for this LCD.
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All Versions
Updated on 09/21/2012 with effective dates 01/15/2012 - N/A
Updated on 01/05/2012 with effective dates 01/15/2012 - N/A
Updated on 12/16/2011 with effective dates 10/01/2011 - 01/14/2012
Updated on 11/21/2011 with effective dates 10/01/2011 - N/A
Updated on 09/14/2011 with effective dates 10/01/2011 - N/A
Updated on 12/22/2010 with effective dates 10/01/2009 - 09/30/2011
Updated on 11/21/2010 with effective dates 10/01/2009 - N/A
Updated on 12/23/2009 with effective dates 10/01/2009 - N/A
Updated on 08/21/2009 with effective dates 10/01/2009 - N/A
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