Local Coverage Determination (LCD) for Skin Lesion (Non-Melanoma) Removal (L28300)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Local Coverage Determination (LCD) for Skin Lesion (Non-Melanoma) Removal (L28300)"

Transcription

1 Search Home Medicare Medicaid CHIP About CMS Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education People with Medicare & Medicaid Questions Careers Newsroom Contact CMS Acronyms Help Print Back to Local Coverage Determinations (LCDs) for Palmetto GBA (01192, MAC - Part B) Local Coverage Determination (LCD) for Skin Lesion (Non-Melanoma) Removal (L28300) Select the Print Record, Add to Basket or Record buttons to print the record, to add it to your basket or to the record. Section Navigation Select Section Go Contractor Information Contractor Name Palmetto GBA Contractor Number Contractor Type MAC - Part B Back to Top LCD Information Document Information LCD ID Number L28300 LCD Title Skin Lesion (Non-Melanoma) Removal Contractor's Determination Number J1B L AMA CPT/ADA CDT Copyright Statement CPT only copyright 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 Primary Geographic Jurisdiction California - Southern Oversight Region Region X 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

2 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 , Medicare National Coverage Determinations Manual, Chapter 1, Part 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.

3 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, and describe treatment of lesions that are usually cosmetic. Their coverage will be addressed in a separate policy. 2) CPT codes 11055, and 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. Back to Top 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.

4 99999 Not Applicable CPT/HCPCS Codes REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS 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) SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS

5 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM 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 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 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

6 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 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 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 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION 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) DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS 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 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, , , , , 17000, 17003, 17004, and 17111: (Additionally, diagnosis may be used for CPT Codes 17000, and 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: MOLLUSCUM CONTAGIOSUM VIRAL WARTS UNSPECIFIED PLANTAR WART OTHER SPECIFIED VIRAL WARTS

7 238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN CYSTS OF EYELIDS PERICHONDRITIS OF PINNA UNSPECIFIED ACUTE PERICHONDRITIS OF PINNA CHRONIC PERICHONDRITIS OF PINNA CHONDRITIS OF PINNA PYOGENIC GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE LICHENIFICATION AND LICHEN SIMPLEX CHRONICUS 701.1* KERATODERMA ACQUIRED 701.4* KELOID SCAR ACTINIC KERATOSIS INFLAMED SEBORRHEIC KERATOSIS * Use for symptomatic, painful and/or inflamed lesions only * 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 BENIGN NEOPLASM OF SKIN OF LIP BENIGN NEOPLASM OF EYELID INCLUDING CANTHUS BENIGN NEOPLASM OF EAR AND EXTERNAL AUDITORY CANAL BENIGN NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE BENIGN NEOPLASM OF SCALP AND SKIN OF NECK BENIGN NEOPLASM OF SKIN OF TRUNK EXCEPT SCROTUM BENIGN NEOPLASM OF SKIN OF UPPER LIMB INCLUDING SHOULDER BENIGN NEOPLASM OF SKIN OF LOWER LIMB INCLUDING HIP

8 216.8 BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF SKIN BENIGN NEOPLASM OF SKIN SITE UNSPECIFIED BENIGN NEOPLASM OF VULVA BENIGN NEOPLASM OF PENIS BENIGN NEOPLASM OF SCROTUM NEVUS NON-NEOPLASTIC RESIDUAL HEMORRHOIDAL SKIN TAGS UNSPECIFIED HYPERTROPHIC AND ATROPHIC CONDITIONS OF SKIN OTHER SEBORRHEIC KERATOSIS SEBACEOUS CYST ACCESSORY AURICLE 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 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN UNQUALIFIED VISUAL LOSS ONE EYE VERNAL CONJUNCTIVITIS HEMORRHAGE UNSPECIFIED CELLULITIS AND ABSCESS OF FACE CELLULITIS AND ABSCESS OF NECK CELLULITIS AND ABSCESS OF TRUNK CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB CELLULITIS AND ABSCESS OF BUTTOCK CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT

9 682.7 CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES CELLULITIS AND ABSCESS OF OTHER SPECIFIED SITES CELLULITIS AND ABSCESS OF UNSPECIFIED SITES OTHER SPECIFIED LOCAL INFECTIONS OF SKIN AND SUBCUTANEOUS TISSUE OTHER SPECIFIED ERYTHEMATOUS CONDITIONS UNSPECIFIED ERYTHEMATOUS CONDITION UNSPECIFIED PRURITIC DISORDER DISTURBANCE OF SKIN SENSATION 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 : UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP BASAL CELL CARCINOMA OF SKIN OF LIP SQUAMOUS CELL CARCINOMA OF SKIN OF LIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

10 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP

11 UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED MALIGNANT NEOPLASM OF VAGINA MALIGNANT NEOPLASM OF LABIA MAJORA MALIGNANT NEOPLASM OF LABIA MINORA MALIGNANT NEOPLASM OF CLITORIS MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE GENITAL ORGANS MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED MALIGNANT NEOPLASM OF PREPUCE MALIGNANT NEOPLASM OF GLANS PENIS MALIGNANT NEOPLASM OF BODY OF PENIS MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED MALIGNANT NEOPLASM OF SCROTUM MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED MERKEL CELL CARCINOMA OF THE FACE - MERKEL CELL CARCINOMA OF OTHER SITES

12 232.0 CARCINOMA IN SITU OF SKIN OF LIP CARCINOMA IN SITU OF EYELID INCLUDING CANTHUS CARCINOMA IN SITU OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL CARCINOMA IN SITU OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE CARCINOMA IN SITU OF SCALP AND SKIN OF NECK CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM CARCINOMA IN SITU OF SKIN OF UPPER LIMB INCLUDING SHOULDER CARCINOMA IN SITU OF SKIN OF LOWER LIMB INCLUDING HIP CARCINOMA IN SITU OF OTHER SPECIFIED SITES OF SKIN 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". Back to Top 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

13 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 , 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 ) 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 ) 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 -

14 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 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 and added This LCD is being revised due to the annual FY 2012 ICD-9- CM 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 ICD- 9 codes were added to support the medical necessity for CPT codes 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313: , 209.3, , , and This revision is per CMS Manual System, Publication , 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, 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 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 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 "ICD- 9 Codes that Support Medical Necessity" section added for the following CPT codes 11200, 11201, 11300, , , , , 17000, 17003, 17004, and 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

15 transcription process was incomplete. 11/09/ The description for CPT/HCPCS code was changed in group 1 11/21/ 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: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 1 08/27/ This policy was updated by the ICD Annual Update. 11/21/ 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: 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. Back to Top All Versions Updated on 09/21/2012 with effective dates 01/15/ N/A Updated on 01/05/2012 with effective dates 01/15/ N/A Updated on 12/16/2011 with effective dates 10/01/ /14/2012 Updated on 11/21/2011 with effective dates 10/01/ N/A Updated on 09/14/2011 with effective dates 10/01/ N/A Updated on 12/22/2010 with effective dates 10/01/ /30/2011 Updated on 11/21/2010 with effective dates 10/01/ N/A Updated on 12/23/2009 with effective dates 10/01/ N/A Updated on 08/21/2009 with effective dates 10/01/ N/A Some older versions have been archived. Please visit the MCD Archive Site them. to retrieve Read the LCD Disclaimer Back to Top Department of Health & Human Services Medicare.gov USA.gov Web Policies & Important Links Privacy Policy Freedom of Information Act No Fear Act Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD 21244

16 64

Removal of Benign and Malignant Skin Lesions (DRAFT POLICY)

Removal of Benign and Malignant Skin Lesions (DRAFT POLICY) Removal of Benign and Malignant Skin Lesions (DRAFT POLICY) Search LCDs/LMRPs Effective: 3/1/2008 Status: Draft Final Revision Date: 12/3/2007 LCD Title Removal of Benign and Malignant Skin Lesions - 4S-140AB

More information

Coding Skin Procedures in the Office Setting. Disclaimer

Coding Skin Procedures in the Office Setting. Disclaimer Coding Skin Procedures in the Office Setting Written and Presented by Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC All Rights Reserved AAPC 1 Disclaimer The information you are receiving today is based

More information

Local Coverage Determination (LCD) for Trigger Point Injections (L28310)

Local Coverage Determination (LCD) for Trigger Point Injections (L28310) Page 1 of 8 Search Home Medicare Medicaid CHIP About CMS Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education People with Medicare & Medicaid Questions Careers Newsroom Contact

More information

Contractor Number 11302. Oversight Region Region IV

Contractor Number 11302. Oversight Region Region IV Local Coverage Determination (LCD): Spinal Cord Stimulators for Chronic Pain (L32549) Contractor Information Contractor Name Palmetto GBA opens in new window Contractor Number 11302 Contractor Type MAC

More information

Excision of Lesions. Brenda Chidester-Palmer CPC, CPC-I, CEMC, CASCC, CCS-P. All Rights Reserved. Objectives

Excision of Lesions. Brenda Chidester-Palmer CPC, CPC-I, CEMC, CASCC, CCS-P. All Rights Reserved. Objectives Excision of Lesions Surgical Approach Brenda Chidester-Palmer CPC, CPC-I, CEMC, CASCC, CCS-P 1 Objectives In this session we will discuss Lesion categories Removal versus biopsy Different lesion removal

More information

Local Coverage Determination (LCD) for Surgery: Trigger Point Injections (L30066)

Local Coverage Determination (LCD) for Surgery: Trigger Point Injections (L30066) Local Coverage Determination (LCD) for Surgery: Trigger Point Injections (L30066) Contractor Information Contractor Name Cahaba Government Benefit Administrators, LLC LCD Information Document Information

More information

Local Coverage Article: Venipuncture Necessitating Physician s Skill for Specimen Collection Supplemental Instructions Article (A50852)

Local Coverage Article: Venipuncture Necessitating Physician s Skill for Specimen Collection Supplemental Instructions Article (A50852) Local Coverage Article: Venipuncture Necessitating Physician s Skill for Specimen Collection Supplemental Instructions Article (A50852) Contractor Information Contractor Name CGS Administrators, LLC Article

More information

Oklahoma Facts CPT. Definitions. Mohs Micrographic Surgery. What Does That Mean? Billing and Coding for Mohs Surgery

Oklahoma Facts CPT. Definitions. Mohs Micrographic Surgery. What Does That Mean? Billing and Coding for Mohs Surgery Billing and Coding for Mohs Surgery Cindy L. Wilson Dermatology Associates of Tulsa Oklahoma Facts Per square mile, Oklahoma has more tornadoes than any other place in the world. The highest wind speed

More information

DERMATOLOGY. For specific procedures, please refer to the Procedure Codes Table beginning on page 5.

DERMATOLOGY. For specific procedures, please refer to the Procedure Codes Table beginning on page 5. DERMATOLOGY Policy NHP reimburses participating providers for the provision of medically necessary dermatology services, including the diagnosis and treatment of skin disorders and disease. Prerequisites

More information

Appropriate use of skin cancer item numbers a guide for primary care skin cancer doctors

Appropriate use of skin cancer item numbers a guide for primary care skin cancer doctors Appropriate use of skin cancer item numbers a guide for primary care skin cancer doctors Disclaimer: This document reflects the personal views of the authors based on their own experience and is not the

More information

LCD L30256 - C-Reactive Protein High Sensitivity Testing (hscrp)

LCD L30256 - C-Reactive Protein High Sensitivity Testing (hscrp) LCD L30256 - C-Reactive Protein High Sensitivity Testing (hscrp) Contractor Information Contractor Name: Novitas Solutions, Inc. Contractor Number(s): 12501, 12101, 12102, 12201, 12202, 12301, 12302, 12401,

More information

Coding Dermatology Procedures. Presented by: Betty A Hovey Director, ICD-10 Development and Training AAPC

Coding Dermatology Procedures. Presented by: Betty A Hovey Director, ICD-10 Development and Training AAPC Coding Dermatology Procedures Presented by: Betty A Hovey Director, ICD-10 Development and Training AAPC 1 No part of this presentation may be reproduced or transmitted in any form or by any means (graphically,

More information

Contractor Information. LCD Information. Local Coverage Determination (LCD): HbA1c (L32939) Contract Number 11202

Contractor Information. LCD Information. Local Coverage Determination (LCD): HbA1c (L32939) Contract Number 11202 Local Coverage Determination (LCD): HbA1c (L32939) Contractor Information Contractor Name Palmetto GBA opens in new window Contract Number 11202 Contract Type MAC - Part B LCD Information Document Information

More information

MEDICAL MANAGEMENT POLICY

MEDICAL MANAGEMENT POLICY TITLE: Scar Revision/Keloid PAGE: 1of 9 This Medical policy is not a guarantee of benefits or coverage, nor should it be deemed as medical advice. In the event of any conflict concerning benefit coverage,

More information

INTRODUCTION: CPT CODES & ICD-9 CODES

INTRODUCTION: CPT CODES & ICD-9 CODES INTRODUCTION: CPT CODES & ICD-9 CODES Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.

More information

DERMABOND Portfolio 2012 LACERATION REPAIR REIMBURSEMENT GUIDE

DERMABOND Portfolio 2012 LACERATION REPAIR REIMBURSEMENT GUIDE 2012 LACERATION REPAIR REIMBURSEMENT GUIDE ETHICON, INC. IS PLEASED TO PROVIDE THIS LACERATION REPAIR REIMBURSEMENT GUIDE AS A RESOURCE FOR HEALTHCARE PROVIDERS. This guide is intended for informational

More information

Modifiers 25 and 59. Modifier 25

Modifiers 25 and 59. Modifier 25 Modifiers 25 and 59 This article discusses the appropriate use of modifier 25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure

More information

Local Coverage Determination (LCD): Surgical Treatment of Nails (L33833)

Local Coverage Determination (LCD): Surgical Treatment of Nails (L33833) Local Coverage Determination (LCD): Surgical Treatment of Nails (L33833) Contractor Information Contractor Name First Coast Service Options, Inc. LCD Information Document Information LCD ID L33833 Original

More information

Local Coverage Article: Cardiovascular Stress Testing (A53123)

Local Coverage Article: Cardiovascular Stress Testing (A53123) Local Coverage Article: Cardiovascular Stress Testing (A53123) Contractor Information Contractor Name Novitas Solutions, Inc. Article Information General Information Article ID A53123 Original ICD-9 Article

More information

Local Coverage Determination (LCD): Non- Emergency Ground Ambulance Services (L33383)

Local Coverage Determination (LCD): Non- Emergency Ground Ambulance Services (L33383) Local Coverage Determination (LCD): Non- Emergency Ground Ambulance Services (L33383) Contractor Information Contractor Name First Coast Service Options, Inc. LCD Information Document Information LCD ID

More information

Physicians as Assistants at Surgery: 2013 Study Participating Organizations:

Physicians as Assistants at Surgery: 2013 Study Participating Organizations: Physicians as Assistants at Surgery: 2013 Study Participating Organizations: American College of Surgeons American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of

More information

MODIFIER 59 ARTICLE. The CPT Manual defines modifier 59 as follows:

MODIFIER 59 ARTICLE. The CPT Manual defines modifier 59 as follows: MODIFIER 59 ARTICLE The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when two Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural

More information

Local Coverage Article: Kyprolis (Carfilzomib) Coding and Billing Guidelines and Indications (A53779)

Local Coverage Article: Kyprolis (Carfilzomib) Coding and Billing Guidelines and Indications (A53779) Local Coverage Article: Kyprolis (Carfilzomib) Coding and Billing Guidelines and Indications (A53779) Contractor Information Contractor Name Palmetto GBA Article Information General Information Article

More information

Deborah Rondeau. NY Part B

Deborah Rondeau. NY Part B Page 1 of 8 Deborah Rondeau From: Saved by Windows Internet Explorer 7 Sent: Saturday, August 23, 2008 7:22 PM Subject: NGS Article for Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and

More information

Disclaimer CODING 101 BOOT CAMP CODING SEMINAR FOR NEW PHYSICIANS

Disclaimer CODING 101 BOOT CAMP CODING SEMINAR FOR NEW PHYSICIANS CODING 101 BOOT CAMP CODING SEMINAR FOR NEW PHYSICIANS AND STAFF Chicago Dermatological Society January 26, 2013 Presented by Joy Newby, LPN, CPC, PCS Newby Consulting, Inc. 5725 Park Plaza Court Indianapolis,

More information

Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L29328)

Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L29328) Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L29328) Contractor Information Contractor Name First Coast Service Options, Inc. LCD Information Document Information LCD ID L29328

More information

An individual is considered an incident case only once per lifetime.

An individual is considered an incident case only once per lifetime. 1 DERM 4 MALIGNANT MELANOMA; SKIN Includes Invasive Malignant Melanoma Only; Does Not Include Secondary Melanoma; For Malignant Melanoma In-Situ, See Corresponding Case Definition Background This case

More information

Umass Medical School Division of Dermatology

Umass Medical School Division of Dermatology Basal Cell and Squamous Cell Carcinoma Dori Goldberg, MD Umass Medical School Division of Dermatology Basal and squamous cell carcinoma Definition The most common types of skin cancer Excluding melanoma,

More information

Medical Necessity Guidelines: Reconstructive and Cosmetic Surgery

Medical Necessity Guidelines: Reconstructive and Cosmetic Surgery Medical Necessity Guidelines: Reconstructive and Cosmetic Surgery Effective: October 1, 2015 Clinical Documentation and Prior Authorization Required Coverage Guideline, No Prior Authorization Applies to:

More information

Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal Column Stimulation) (L34705)

Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal Column Stimulation) (L34705) Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal Column Stimulation) (L34705) Contractor Information Contractor Name Novitas Solutions, Inc. LCD Information Document Information LCD

More information

Local Coverage Determination (LCD): Vitamin B 12 Injection (L33502)

Local Coverage Determination (LCD): Vitamin B 12 Injection (L33502) Local Coverage Determination (LCD): Vitamin B 12 Injection (L33502) Contractor Name Noridian Administrative Services, LLC LCD Information Document Information LCD ID L33502 LCD Title Vitamin B 12 Injection

More information

Dermatology & Wound Care Services

Dermatology & Wound Care Services Dermatology & Wound Care Services Presenter: Sara San Pedro CPC, CPMA, CEMC, CCP-P AHIMA Approved ICD-10 CM&PCS Trainer/Ambassador Objectives The Surgical Package and modifiers Common wound care services

More information

Global Surgery Fact Sheet

Global Surgery Fact Sheet DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Global Surgery Fact Sheet Fact Sheet Definition of a Global Surgical Package Medicare established a national definition

More information

LCD L30551 - Vitamin B12 Assays Print

LCD L30551 - Vitamin B12 Assays Print LCD L30551 - Vitamin B12 Assays Print Contractor Information Contractor Name: Highmark Medicare Services, Inc. Contractor Number(s): 12102, 12202, 12302, 12501, 12301, 12201, 12401, 12402, 12101, 12502,

More information

Modifiers Q7, Q8, and Q9

Modifiers Q7, Q8, and Q9 1-47 Modifiers Q7, Q8, and Q9 (Routine Foot Care) CPT Modifier Q7 One Class A finding Q8 Two Class B findings Q9 One Class B and two Class C findings General Information The Office of Inspector General

More information

Physicians as Assistants at Surgery: 2016 Update Participating Organizations:

Physicians as Assistants at Surgery: 2016 Update Participating Organizations: Physicians as Assistants at Surgery: 2016 Update Participating Organizations: American College of Surgeons American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of

More information

APPENDIX D. April 1, 2015 AD1 Amd 12 Draft 1. Appendix DApril 1, 2015 PREAMBLE

APPENDIX D. April 1, 2015 AD1 Amd 12 Draft 1. Appendix DApril 1, 2015 PREAMBLE Appendix DApril 1, 2015 PREAMBLE 1. Surgery to alleviate significant physical symptoms, which have not responded to a minimum of six months active treatment, or to restore or improve function to any area

More information

Local Coverage Determination (LCD) for Transportation Services: Ambulance (L30022)

Local Coverage Determination (LCD) for Transportation Services: Ambulance (L30022) Local Coverage Determination (LCD) for Transportation Services: Ambulance (L30022) Contractor Information Contractor Name Cahaba Government Benefit Administrators, LLC Back to Top LCD Information Document

More information

Clinical Indicators: Parotidectomy

Clinical Indicators: Parotidectomy Clinical Indicators: Parotidectomy Procedure CPT Days 1 Excision of parotid tumor or parotid gland; lateral lobe, without 42410 90 nerve dissection Excision of parotid tumor or parotid gland; lateral lobe,

More information

Medical Necessity Guidelines: Reconstructive and Cosmetic Surgery

Medical Necessity Guidelines: Reconstructive and Cosmetic Surgery Medical Necessity Guidelines: Reconstructive and Cosmetic Surgery Effective: April 13, 2016 Clinical Documentation and Prior Authorization Coverage Guideline, No Prior Required Authorization Applies to:

More information

MEDICAL ASSISTANCE BULLETIN

MEDICAL ASSISTANCE BULLETIN MEDICAL ASSISTANCE BULLETIN ISSUE DATE October 20, 2008 EFFECTIVE DATE November 3, 2008 NUMBER 99-08-17 SUBJECT BY Implementation of ClaimCheck Michael Nardone, Deputy Secretary Office of Medical Assistance

More information

CMS National Coverage Policy

CMS National Coverage Policy LCD ID Number L32748 LCD Title Respiratory Therapy Rehabilitation Contractor s Determination Number L32748 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association.

More information

SAMPLE. Anesthesia Services. An essential coding, billing, and reimbursement resource for anesthesiology and pain management ICD-10

SAMPLE. Anesthesia Services. An essential coding, billing, and reimbursement resource for anesthesiology and pain management ICD-10 Coding and Payment Guide www.optumcoding.com Anesthesia Services An essential coding, billing, and reimbursement resource for anesthesiology and pain management 2017 a ICD10 A full suite of resources including

More information

Re: Horizon Blue Cross Blue Shield of New Jersey Inappropriate Application of Modifier 25

Re: Horizon Blue Cross Blue Shield of New Jersey Inappropriate Application of Modifier 25 February 5, 2015 Glenn Pomerantz, MD, JD Vice President and Chief Medical Officer Horizon Blue Cross Blue Shield of New Jersey 3 Penn Plaza East Newark, NJ 07105 Re: Horizon Blue Cross Blue Shield of New

More information

Medicare Part B. Mammograms - Updated Billing Guide for Screening and Diagnostic Tests

Medicare Part B. Mammograms - Updated Billing Guide for Screening and Diagnostic Tests Mammograms - Updated Billing Guide for Screening and Diagnostic Tests This article from Medicare B News Issue 223 dated October 21, 2005 is being updated and reprinted to ensure that the Noridian Administrative

More information

Coding Challenges in Internal Medicine. Presented by: Brenda Edwards, CPC, CPMA, CPC-I, CEMC AAPCCA Board of Directors

Coding Challenges in Internal Medicine. Presented by: Brenda Edwards, CPC, CPMA, CPC-I, CEMC AAPCCA Board of Directors Coding Challenges in Internal Medicine Presented by: Brenda Edwards, CPC, CPMA, CPC-I, CEMC AAPCCA Board of Directors Topics to Discuss Medical necessity Bulletproof E/M documentation Cerumen removal Skin

More information

Medical Policy Original Effective Date: Revised Date: Page 1 of 8

Medical Policy Original Effective Date: Revised Date: Page 1 of 8 Page 1 of 8 Breast Implant Removal and/or Replacement and Capsulectomy Disclaimer Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on

More information

Claims submission simplified for emergency dental procedure codes

Claims submission simplified for emergency dental procedure codes January 2002 No. 2002-02 PHC 1844 To: Dentists HMOs and Other Managed Care Programs Claims submission simplified for emergency dental procedure codes Effective immediately, both electronic and paper claims

More information

Suppliers are to follow The Health Plan requirements for precertification, as applicable.

Suppliers are to follow The Health Plan requirements for precertification, as applicable. Eye Prostheses Adopted from the National Government Services website. For any item to be covered by The Health Plan, it must: 1. Be eligible for a defined Medicare or Health Plan benefit category 2. Be

More information

Status Active. Assistant Surgeons. This policy addresses reimbursement for assistant surgical procedures during the same operative session.

Status Active. Assistant Surgeons. This policy addresses reimbursement for assistant surgical procedures during the same operative session. Status Active Reimbursement Policy Section: Surgery/Interventional Procedure Policy Number: RP - Surgery/Interventional Procedure - 001 Assistant Surgeons Effective Date: June 1, 2015 Assistant Surgeons

More information

Integumentary System Individual Exercises

Integumentary System Individual Exercises Integumentary System Individual Exercises 1. A physician performs an incision and drainage of a subcutaneous abscess in his office for a particularly uncooperative established patient. How should this

More information

A review of Next Steps in Derm s most read articles on Legal and Billing & Coding When Starting a Practice

A review of Next Steps in Derm s most read articles on Legal and Billing & Coding When Starting a Practice IN DERM Your Virtual Mentor NEW FALL EDITION A review of Next Steps in Derm s most read articles on Legal and Billing & Coding When Starting a Practice www.nextstepsinderm.com To view these articles, as

More information

Medical Association of Billers

Medical Association of Billers Page 1 of 9 Certified Medical Billing Specialist (CMBS) Sample Examination Copyright of the. All rights reserved. No part of this sample exam may be reproduced or transmitted in any form or by any means,

More information

Local Coverage Determination (LCD): Medicine: Autonomic Function Tests (L34500)

Local Coverage Determination (LCD): Medicine: Autonomic Function Tests (L34500) Local Coverage Determination (LCD): Medicine: Autonomic Function Tests (L34500) Contractor Information Contractor Name Cahaba Government Benefit Administrators, LLC LCD Information Document Information

More information

REGION D MEDICARE GROUP 2 PRESSURE REDUCING SUPPORT SUFACE. Documentation Checklist Local Coverage Determination (LCD)

REGION D MEDICARE GROUP 2 PRESSURE REDUCING SUPPORT SUFACE. Documentation Checklist Local Coverage Determination (LCD) REGION D MEDICARE GROUP 2 PRESSURE REDUCING SUPPORT SUFACE Documentation Checklist Local Coverage Determination (LCD) Disclaimer: The ROHO Group gathered these documents from various sources as an educational

More information

Wound Care Management

Wound Care Management Rule Category: Billing ` Ref: No: 2012-BR-0007 Version Control: Version No. 3.0 Effective Date: 08 December 2012 Revision Date: August 2015 Wound Care Management Adjudication Rule Table of content Abstract

More information

CMS National Coverage Policy

CMS National Coverage Policy LCD ID Number L32764 LCD Title Pulmonary Rehabilitation (PR) Programs Contractor s Determination Number L32764 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association.

More information

Medicare C/D Medical Coverage Policy

Medicare C/D Medical Coverage Policy Varicose Vein Treatment Medicare C/D Medical Coverage Policy Origination Date: June 1, 1993 Review Date: September 16, 2015 Next Review: September, 2017 DESCRIPTION OF PROCEDURE OR SERVICE Varicose veins

More information

Local Coverage Article: Endovascular Repair of Aortic Aneurysms (A53124)

Local Coverage Article: Endovascular Repair of Aortic Aneurysms (A53124) Local Coverage Article: Endovascular Repair of Aortic Aneurysms (A53124) Contractor Information Contractor Name Novitas Solutions, Inc. Article Information General Information Article ID A53124 Original

More information

Medicare Podiatry Services: Information for Medicare Fee-For-Service Health Care Professionals

Medicare Podiatry Services: Information for Medicare Fee-For-Service Health Care Professionals R DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services FACT SHEET Medicare Podiatry Services: Information for Medicare Fee-For-Service Health Care Professionals Overview This

More information

Local Coverage Determination (LCD): MolDX: Breast Cancer Assay: Prosigna (L36125)

Local Coverage Determination (LCD): MolDX: Breast Cancer Assay: Prosigna (L36125) Local Coverage Determination (LCD): MolDX: Breast Cancer Assay: Prosigna (L36125) Contractor Information Contractor Name Palmetto GBA LCD Information Document Information LCD ID L36125 Original ICD-9 LCD

More information

istent Trabecular Micro-Bypass Stent Reimbursement Guide

istent Trabecular Micro-Bypass Stent Reimbursement Guide istent Trabecular Micro-Bypass Stent Reimbursement Guide Table of Contents Overview Coding 2 3 Coding Overview Procedure Coding Device Coding Additional Coding Information Coverage Payment 8 9 Payment

More information

How to Use the Medicare Coverage Database

How to Use the Medicare Coverage Database How to Use the Medicare Coverage Database The searchable Medicare Coverage Database allows me to learn about any national and local determinations regarding coverage for specific services. http://www.cms.gov/medicare-coverage-database

More information

Askin biopsy may be performed for either. The Vanishing Biopsy: The Trend Toward Smaller Specimens THERAPEUTICS FOR THE CLINICIAN

Askin biopsy may be performed for either. The Vanishing Biopsy: The Trend Toward Smaller Specimens THERAPEUTICS FOR THE CLINICIAN THERAPEUTICS FOR THE CLINICIAN The Vanishing Biopsy: The Trend Toward Smaller Specimens Emmy M. Fernandez, MD; Thomas Helm, MD; Michael Ioffreda, MD; Klaus F. Helm, MD Dermatopathologists have noted an

More information

Billing and Coding Guidance Co-morbidities associated with morbid obesity

Billing and Coding Guidance Co-morbidities associated with morbid obesity Billing and Coding Guidance Co-morbidities associated with morbid obesity AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved.

More information

ICD-10 Code Analysis Dermotology

ICD-10 Code Analysis Dermotology Page 1 of 7 ICD-10 Code Analysis Dermotology 6.5% 5.6% 12.1% 15% 13.1% Filing Date Range: 5/1/14 to 5/1/15 17.8% 29.9% Ratio ICD-9 Codes Percentage 1:1 Exact 32 29.9% 1:3 19 17.8% 1:1 14 13.1% 1:2 13 12.1%

More information

Separate, But Not Distinct: The Appropriate Use Of Modifiers 25 And 59

Separate, But Not Distinct: The Appropriate Use Of Modifiers 25 And 59 Separate, But Not Distinct: The Appropriate Use Of Modifiers 25 And 59 Sandy Giangreco, RHIT, CCS, CPC, CPC-H, CPC-I, PCS AHIMA Approved ICD-10-CM/PCS Trainer Jenny Studdard, CPC, RCC, CPCO AHIMA Approved

More information

National Medical Policy

National Medical Policy National Medical Policy Subject: Policy Number: Benign Skin Lesion Removal NMP150 Effective Date: June 2004 Updated: August 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE

More information

Introduction to Medical Coding For Lawyers

Introduction to Medical Coding For Lawyers American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues March 20-22, 2013 Introduction to Medical Coding for Payment Lawyers Robert A. Pelaia Senior University Counsel for

More information

Coding and Payment Guide for Dental Services. A comprehensive coding, billing, and reimbursement resource for dental services

Coding and Payment Guide for Dental Services. A comprehensive coding, billing, and reimbursement resource for dental services Coding and Payment Guide for Dental Services A comprehensive coding, billing, and reimbursement resource for dental services 2014 Contents Introduction...1 Coding Systems... 1 Claim Forms... 2 Contents

More information

Anesthesia Services. UnitedHealthcare Medicare Reimbursement Policy Committee

Anesthesia Services. UnitedHealthcare Medicare Reimbursement Policy Committee Anesthesia Services Policy Number ANES08272009RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 08/27/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable

More information

Diabetes Outpatient Self-Management Training (NCD 40.1)

Diabetes Outpatient Self-Management Training (NCD 40.1) Policy Number 40.1 Approved By UnitedHealthcare Medicare Reimbursement Policy Committee Current Approval Date 02/11/2015 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare

More information

AHLA. HH. Introduction to Medical Coding for Payment Lawyers

AHLA. HH. Introduction to Medical Coding for Payment Lawyers AHLA HH. Introduction to Medical Coding for Payment Lawyers Robert A. Pelaia Senior University Counsel University of Florida Jacksonville Jacksonville, FL Institute on Medicare and Medicaid Payment Issues

More information

Correct Coding to Maximize Reimbursements: Common Urological Coding and Billing Errors. Michael A. Ferragamo, MD, FACS

Correct Coding to Maximize Reimbursements: Common Urological Coding and Billing Errors. Michael A. Ferragamo, MD, FACS Correct Coding to Maximize Reimbursements: Common Urological Coding and Billing Errors Michael A. Ferragamo, MD, FACS Coding and Reimbursement Consultant; Assistant Clinical Professor of Urology, University

More information

KYPHON. Reimbursement Guide. Physician Reimbursement. Balloon Kyphoplasty Procedure. ICD-9-CM Diagnosis Codes. CPT Codes and Payment

KYPHON. Reimbursement Guide. Physician Reimbursement. Balloon Kyphoplasty Procedure. ICD-9-CM Diagnosis Codes. CPT Codes and Payment KYPHON Balloon Kyphoplasty Procedure Reimbursement Guide ICD-9-CM Diagnosis Codes Providers should report the ICD-9-CM diagnosis code that most accurately describes the patient s condition. Please refer

More information

Medicare 101: Basics of Modifier Billing. Part B Provider Outreach and Education February 26, 2014

Medicare 101: Basics of Modifier Billing. Part B Provider Outreach and Education February 26, 2014 Medicare 101: Basics of Modifier Billing Part B Provider Outreach and Education February 26, 2014 Housekeeping Tips When you called in, did you enter your attendee code? Dial-in number: 1-800-791-2345

More information

Meditec.com Free Trial Offer Medical Coding Mini Course. Notice to user:

Meditec.com Free Trial Offer Medical Coding Mini Course. Notice to user: Meditec.com Free Trial Offer Medical Coding Mini Course Notice to user: The materials contained in this mini course are copyrighted and may not be reproduced or distributed by any means, or used for any

More information

CMS Limitations Guide Mammograms and Bone Density Radiology Services

CMS Limitations Guide Mammograms and Bone Density Radiology Services CMS Limitations Guide Mammograms and Bone Density Radiology Services Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with

More information

Medical Necessity: Can You Please Define That? Part I. Riva Lee Asbell Philadelphia, PA

Medical Necessity: Can You Please Define That? Part I. Riva Lee Asbell Philadelphia, PA Medical Necessity: Can You Please Define That? Part I Riva Lee Asbell Philadelphia, PA INTRODUCTION One of Medicare=s most elusive concepts is the term Amedical necessity@. Yet, lack thereof is the reason

More information

Medicare 101: Basics of CPT. Part B Provider Outreach and Education February 11, 2015

Medicare 101: Basics of CPT. Part B Provider Outreach and Education February 11, 2015 Medicare 101: Basics of CPT Part B Provider Outreach and Education February 11, 2015 Housekeeping Tips When you called in, did you enter your attendee code? Dial-in number: 1-800-791-2345 Attendee (participant)

More information

New Patient Visit. UnitedHealthcare Medicare Reimbursement Policy Committee

New Patient Visit. UnitedHealthcare Medicare Reimbursement Policy Committee New Patient Visit Policy Number NPV04242013RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 12/16/2015 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to

More information

Cryosurgery has been used

Cryosurgery has been used COVER ARTICLE Cryosurgery for Common Skin Conditions MARK D. ANDREWS, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina Cryosurgery is a highly effective treatment for a broad

More information

Coding and Payment Guide for Dental Services. A comprehensive coding, billing, and reimbursement resource for dental services

Coding and Payment Guide for Dental Services. A comprehensive coding, billing, and reimbursement resource for dental services Coding and Payment Guide for Dental Services A comprehensive coding, billing, and reimbursement resource for dental services 2011 Contents Introduction...1 Coding Systems... 1 Claim Forms... 2 Contents

More information

Electrosurgery is used to destroy

Electrosurgery is used to destroy PRACTICAL THERAPEUTICS Electrosurgery for the Skin BARRY L. HAINER, M.., Medical University of South Carolina, Charleston, South Carolina RICHAR B. USATINE, M.., University of California, Los Angeles,

More information

REIMBURSEMENT GUIDE. External Ocular Photography CPT 92285

REIMBURSEMENT GUIDE. External Ocular Photography CPT 92285 REIMBURSEMENT GUIDE External Ocular Photography CPT 92285 This guide is intended to provide coding and billing information valid from July 23, 2013. Reimbursement codes and billing practices change over

More information

Coding and Payment Guide for Anesthesia Services

Coding and Payment Guide for Anesthesia Services Coding and Payment Guide for Anesthesia Services An essential coding, billing, and payment resource for anesthesiology and pain management 2006 4th edition Contents Introduction...............................

More information

Coding with. Snayhil Rana

Coding with. Snayhil Rana Coding with ICD-9-CM CM Snayhil Rana ICD-9-CM CM Index Pre-Test Introduction to ICD-9-CM Coding The Three Volumes of the ICD-9-CM ICD-9-CM Coding Conventions Other ICD-9-CM Sections ICD-9-CM for Claim

More information

EYELID SKIN CANCER. Speakers Bureau Series

EYELID SKIN CANCER. Speakers Bureau Series Speakers Bureau Series EYELID SKIN CANCER By Leslie M Sims, MSPH, MD, FAAO Board Certified Ophthalmologist The Sims Center for Eyelid and Facial Aesthetics 1 Most Common Eyelid Skin Cancers: Basal Cell

More information

Central Office N/A N/A

Central Office N/A N/A LCD ID Number L32688 LCD Title Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Contractor s Determination Number L32688 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American

More information

CPT Disclaimer. Objectives. How to Avoid Common Coding Errors. Presented by: Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I

CPT Disclaimer. Objectives. How to Avoid Common Coding Errors. Presented by: Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I How to Avoid Common Coding Errors Presented by: Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I CPT Disclaimer CPT copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative

More information

istent Trabecular Micro-Bypass Stent Reimbursement Guide

istent Trabecular Micro-Bypass Stent Reimbursement Guide istent Trabecular Micro-Bypass Stent Reimbursement Guide Table of Contents Overview Coding 3 4 Coding Overview Procedure Coding Device Coding Additional Coding Information Coverage Payment 10 11 Payment

More information

National Coverage Determination. Vagus Nerve Stimulation (VNS)

National Coverage Determination. Vagus Nerve Stimulation (VNS) National Coverage Determination Vagus Nerve Stimulation (VNS) Number NEURO-004 Contractor Name Wisconsin Physicians Service Insurance Corporation AMA CPT Copyright Statement CPT codes, descriptions and

More information

Non-Pharmacologic Treatment of Rosacea

Non-Pharmacologic Treatment of Rosacea Non-Pharmacologic Treatment of Rosacea Policy Number: 2.01.71 Last Review: 5/2016 Origination: 5/2009 Next Review: 5/2017 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will not provide coverage

More information

Common Pathology Diagnoses: ICD-9 to ICD-10 Mapping

Common Pathology Diagnoses: ICD-9 to ICD-10 Mapping PERFORMANCE THAT MATTERS NUMBER OF CODES 14,000 69,000 ICD-9 DIAGNOSIS CODES ICD-10 DIAGNOSIS CODES CODE STRUCTURE ICD-9-CM CODE FORMAT ICD-10-CM CODE FORMAT X X X X X X X X X X X X CATEGORY ETIOLOGY,

More information

Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service

Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service Manual: Policy Title: Reimbursement Policy Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM027 Last Updated:

More information

Anesthesia Cross Coder. Essential links from CPT codes to ICD-9-CM and HCPCS codes

Anesthesia Cross Coder. Essential links from CPT codes to ICD-9-CM and HCPCS codes Anesthesia Cross Coder Essential links from CPT codes to ICD-9-CM and HCPCS codes Contents Introduction... i CPT Anesthesia to Procedure Crosswalk...i Format...i Icon Key...ii CPT Codes...ii Code Links...iii

More information

ICD-10 FROM A NURSE PERSPECTIVE. Learning Objectives 4/22/2015. Adoption of ICD-10 Classification of Diseases CD-10-CM Diagnostic Codes

ICD-10 FROM A NURSE PERSPECTIVE. Learning Objectives 4/22/2015. Adoption of ICD-10 Classification of Diseases CD-10-CM Diagnostic Codes ICD-10 FROM A NURSE PERSPECTIVE Learning Objectives 1. New ICD-10-CM diagnostic system for Dermatology. 2. Impact of new codes on nursing and clinical support staff. 3. Education and resources available.

More information

Procedural Coding Guidelines Utilizing CPT, HCPCS and CDT

Procedural Coding Guidelines Utilizing CPT, HCPCS and CDT saving faces changing lives Procedural Coding Guidelines Utilizing CPT, HCPCS and CDT I. INTRODUCTION This paper discusses procedure coding, using the Current Procedural Terminology (CPT), Health Care

More information

Pathology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Pathology and Top 25 codes

Pathology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Pathology and Top 25 codes Pathology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Pathology and Top 25 codes Chapter 2 Neoplasms (C00-D49) Classification improvements Code expansions Significant expansions or revisions

More information

Chapter 12 Diseases of the Skin and Subcutaneous Tissue L00-L99. Presented by Jesicca Andrews

Chapter 12 Diseases of the Skin and Subcutaneous Tissue L00-L99. Presented by Jesicca Andrews Chapter 12 Diseases of the Skin and Subcutaneous Tissue L00-L99 Presented by Jesicca Andrews 1 Skin and Subcutaneous Tissue 2 Introduction L00-L08 Infections of skin and subcutaneous tissue L10-L14 Bullous

More information