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 Email 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 Email Record buttons to print the record, to add it to your basket or to email the record. Section Navigation Select Section Go Contractor Information Contractor Name Palmetto GBA Contractor Number 01192 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-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 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
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. 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.
99999 Not Applicable CPT/HCPCS Codes 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 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
11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 (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
11443 11444 11446 17000 17003 17004 17110 17111 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, 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 173.19 173.20 173.21 173.22 173.29 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
173.30 173.31 173.32 173.39 173.40 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 173.41 BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK 173.42 SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK 173.49 173.50 OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM 173.51 BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM 173.52 173.59 173.60 173.61 173.62 173.69 173.70 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 173.71 BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP 173.72 173.79 SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP 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 173.82 173.89 SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN 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 184.8 184.9 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE GENITAL ORGANS 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 187.8 187.9 209.31-209.36 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
232.0 CARCINOMA IN SITU OF SKIN OF LIP 232.1 CARCINOMA IN SITU OF EYELID INCLUDING CANTHUS 232.2 232.3 CARCINOMA IN SITU OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 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". 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
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-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: 209.31, 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 "ICD- 9 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. Back to Top 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 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
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