Contractor Information

Local Coverage Determination (LCD): Removal of Benign Skin Lesions (L35498) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Printed on 10/4/2017. Page 1 of 10 Contract Type Contract Number Jurisdiction State(s) MAC - Part A 05101 - MAC A J - 05 Iowa MAC - Part B 05102 - MAC B J - 05 Iowa MAC - Part A 05201 - MAC A J - 05 Kansas MAC - Part B 05202 - MAC B J - 05 Kansas MAC - Part A 05301 - MAC A J - 05 MAC - Part B 05302 - MAC B J - 05 Missouri - Entire State Missouri - Entire State MAC - Part A 05401 - MAC A J - 05 Nebraska MAC - Part B 05402 - MAC B J - 05 Nebraska MAC - Part A 05901 - MAC A J - 05 Alaska Alabama Arkansas Arizona Connecticut Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maine Michigan Minnesota Missouri - Entire State Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey Ohio Oregon Rhode Island South Carolina South Dakota Tennessee Utah

Contractor Name Back to Top Contract Type Contract Number Jurisdiction State(s) Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming MAC - Part A 08101 - MAC A J - 08 Indiana MAC - Part B 08102 - MAC B J - 08 Indiana MAC - Part A 08201 - MAC A J - 08 Michigan MAC - Part B 08202 - MAC B J - 08 Michigan LCD Information Document Information LCD ID L35498 LCD Title Removal of Benign Skin Lesions Proposed LCD in Comment Period Source Proposed LCD AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2017 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 dispense medical services. The AMA assumes no liability for data contained or not contained herein. Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 03/01/2017 Revision Ending Date Retirement Date Notice Period Start Date 01/01/2015 Notice Period End Date 02/15/2015 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-2016 are trademarks of the American Dental Association. Printed on 10/4/2017. Page 2 of 10

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy CMS Pub.100-02 Medicare Benefit Policy Manual, Chapter 16 - General Exclusions From Coverage, Section 120 - Cosmetic Surgery CMS Pub. 100-03 Medicare National Coverage Determinations Manual-Chapter 1, Coverage Determinations, Part 4, Section 250.4 - Treatment of Actinic Keratosis Title XVIII of the Social Security Act, section 1862 (a)(1)(a). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity This policy addresses the Medicare coverage for the removal of benign skin lesions, such as seborrheic keratoses, sebaceous (epidermoid) cysts and skin tags. Benign skin lesions are common in the elderly and are frequently removed at the patient's request to improve appearance. Removal of certain benign skin lesions that does not pose a threat to health or function, are considered cosmetic and as such are not covered by the Medicare program. A. Medical Indications There may be instances in which the removal of non-malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record: Printed on 10/4/2017. Page 3 of 10

1. The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or 2. The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or 3. The lesion obstructs an orifice; or 4. The lesion clinically restricts vision; or 5. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the lesion appearance; or 6. A prior biopsy suggests or is indicative of lesion malignancy; or 7. The lesion is in an anatomical region subject to recurrent trauma, and there is documentation of such trauma. 8. Wart removals will be covered under the guidelines listed above. In addition, wart destruction will be covered when any one of the following clinical circumstances is present: a. Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding. b. Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients. c. Lesions are condyloma acuminata or molluscum contagiosum. d. Cervical dysplasia or pregnancy is associated with genital warts. An E&M service to determine a diagnosis of benign skin lesion(s) may be allowed (paid), even in the event the subsequent lesion(s) removal is determined to be cosmetic. B. Repair (Closure) With Excision of Benign Lesions Payment for the excision of benign lesions of skin includes payment for simple repairs. Separate payment may be made for medically necessary layered closures, adjacent tissue transfers, flaps and grafts. Limitations: Medicare will not pay for a separate E & M service on the same day as a dermatologic service unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient s medical record and a modifier 25 should be used. Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient s medical record. If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well. 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 lesion excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Each benign lesion excised should be reported separately. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised Printed on 10/4/2017. Page 4 of 10

diameter). The margins refer to the narrowest margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision. References to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. 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. 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. CPT/HCPCS Codes Group 1 Paragraph: NOTE: CPT codes 11300-11313 may also be covered for the removal of cancerous skin lesions which are not addressed in this LCD Group 1 Codes: 11200 Removal of skin tags 11201 Remove skin tags add-on 11300 Shave skin lesion 0.5 cm/< 11301 Shave skin lesion 0.6-1.0 cm 11302 Shave skin lesion 1.1-2.0 cm 11303 Shave skin lesion >2.0 cm 11305 Shave skin lesion 0.5 cm/< 11306 Shave skin lesion 0.6-1.0 cm 11307 Shave skin lesion 1.1-2.0 cm 11308 Shave skin lesion >2.0 cm 11310 Shave skin lesion 0.5 cm/< 11311 Shave skin lesion 0.6-1.0 cm 11312 Shave skin lesion 1.1-2.0 cm 11313 Shave skin lesion >2.0 cm 11400 Exc tr-ext b9+marg 0.5 cm< 11401 Exc tr-ext b9+marg 0.6-1 cm 11402 Exc tr-ext b9+marg 1.1-2 cm 11403 Exc tr-ext b9+marg 2.1-3cm 11404 Exc tr-ext b9+marg 3.1-4 cm 11406 Exc tr-ext b9+marg >4.0 cm 11420 Exc h-f-nk-sp b9+marg 0.5/< 11421 Exc h-f-nk-sp b9+marg 0.6-1 11422 Exc h-f-nk-sp b9+marg 1.1-2 11423 Exc h-f-nk-sp b9+marg 2.1-3 11424 Exc h-f-nk-sp b9+marg 3.1-4 Printed on 10/4/2017. Page 5 of 10

11426 Exc h-f-nk-sp b9+marg >4 cm 11440 Exc face-mm b9+marg 0.5 cm/< 11441 Exc face-mm b9+marg 0.6-1 cm 11442 Exc face-mm b9+marg 1.1-2 cm 11443 Exc face-mm b9+marg 2.1-3 cm 11444 Exc face-mm b9+marg 3.1-4 cm 11446 Exc face-mm b9+marg >4 cm 17106 Destruction of skin lesions 17107 Destruction of skin lesions 17108 Destruction of skin lesions 17110 Destruct b9 lesion 1-14 17111 Destruct lesion 15 or more ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: National Coverage Determination 250.4 outlines coverage for the treatment of actinic keratosis (AK) diagnosis code L57.0 Group 1 Codes: ICD-10 Codes Description A63.0 Anogenital (venereal) warts B07.0 Plantar wart B07.8 Other viral warts B07.9 Viral wart, unspecified B08.1 Molluscum contagiosum D10.0 Benign neoplasm of lip D10.39 Benign neoplasm of other parts of mouth D17.0 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck D17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk D17.21 Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm D17.22 Benign lipomatous neoplasm of skin and subcutaneous tissue of left arm D17.23 Benign lipomatous neoplasm of skin and subcutaneous tissue of right leg D17.24 Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg D17.39 Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites D18.01 Hemangioma of skin and subcutaneous tissue D22.0 Melanocytic nevi of lip D22.11 Melanocytic nevi of right eyelid, including canthus D22.12 Melanocytic nevi of left eyelid, including canthus D22.21 Melanocytic nevi of right ear and external auricular canal D22.22 Melanocytic nevi of left ear and external auricular canal D22.39 Melanocytic nevi of other parts of face D22.4 Melanocytic nevi of scalp and neck D22.5 Melanocytic nevi of trunk D22.61 Melanocytic nevi of right upper limb, including shoulder D22.62 Melanocytic nevi of left upper limb, including shoulder D22.71 Melanocytic nevi of right lower limb, including hip D22.72 Melanocytic nevi of left lower limb, including hip D23.0 Other benign neoplasm of skin of lip D23.11 Other benign neoplasm of skin of right eyelid, including canthus D23.12 Other benign neoplasm of skin of left eyelid, including canthus D23.21 Other benign neoplasm of skin of right ear and external auricular canal D23.22 Other benign neoplasm of skin of left ear and external auricular canal D23.39 Other benign neoplasm of skin of other parts of face D23.4 Other benign neoplasm of skin of scalp and neck D23.5 Other benign neoplasm of skin of trunk D23.61 Other benign neoplasm of skin of right upper limb, including shoulder D23.62 Other benign neoplasm of skin of left upper limb, including shoulder D23.71 Other benign neoplasm of skin of right lower limb, including hip D23.72 Other benign neoplasm of skin of left lower limb, including hip D23.9 Other benign neoplasm of skin, unspecified D28.0 Benign neoplasm of vulva Printed on 10/4/2017. Page 6 of 10

ICD-10 Codes Description D28.1 Benign neoplasm of vagina D29.0 Benign neoplasm of penis D29.4 Benign neoplasm of scrotum D37.01 Neoplasm of uncertain behavior of lip D37.02 Neoplasm of uncertain behavior of tongue D37.04 Neoplasm of uncertain behavior of the minor salivary glands D37.05 Neoplasm of uncertain behavior of pharynx D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity D40.8 Neoplasm of uncertain behavior of other specified male genital organs D48.5 Neoplasm of uncertain behavior of skin H00.11 Chalazion right upper eyelid H00.12 Chalazion right lower eyelid H00.14 Chalazion left upper eyelid H00.15 Chalazion left lower eyelid H02.61 Xanthelasma of right upper eyelid H02.62 Xanthelasma of right lower eyelid H02.64 Xanthelasma of left upper eyelid H02.65 Xanthelasma of left lower eyelid H02.821 Cysts of right upper eyelid H02.822 Cysts of right lower eyelid H02.824 Cysts of left upper eyelid H02.825 Cysts of left lower eyelid H61.011 Acute perichondritis of right external ear H61.012 Acute perichondritis of left external ear H61.013 Acute perichondritis of external ear, bilateral H61.021 Chronic perichondritis of right external ear H61.022 Chronic perichondritis of left external ear H61.023 Chronic perichondritis of external ear, bilateral H61.031 Chondritis of right external ear H61.032 Chondritis of left external ear H61.033 Chondritis of external ear, bilateral I78.1 Nevus, non-neoplastic K13.21 Leukoplakia of oral mucosa, including tongue K13.3 Hairy leukoplakia K13.5 Oral submucous fibrosis K64.4 Residual hemorrhoidal skin tags L11.0 Acquired keratosis follicularis L11.8 Other specified acantholytic disorders L66.4 Folliculitis ulerythematosa reticulata L72.0 Epidermal cyst L72.11 Pilar cyst L72.12 Trichodermal cyst L72.2 Steatocystoma multiplex L72.3 Sebaceous cyst L72.8 Other follicular cysts of the skin and subcutaneous tissue L82.0 Inflamed seborrheic keratosis L82.1 Other seborrheic keratosis L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palmaris et plantaris) L85.8 Other specified epidermal thickening L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.1 Reactive perforating collagenosis L87.2 Elastosis perforans serpiginosa L87.8 Other transepidermal elimination disorders L90.3 Atrophoderma of Pasini and Pierini L90.4 Acrodermatitis chronica atrophicans L90.5 Scar conditions and fibrosis of skin Printed on 10/4/2017. Page 7 of 10

ICD-10 Codes Description L90.8 Other atrophic disorders of skin L91.0 Hypertrophic scar L91.8 Other hypertrophic disorders of the skin L91.9 Hypertrophic disorder of the skin, unspecified L92.2 Granuloma faciale [eosinophilic granuloma of skin] L92.3 Foreign body granuloma of the skin and subcutaneous tissue L92.8 Other granulomatous disorders of the skin and subcutaneous tissue L98.0 Pyogenic granuloma L98.5 Mucinosis of the skin L98.6 Other infiltrative disorders of the skin and subcutaneous tissue L99 Other disorders of skin and subcutaneous tissue in diseases classified elsewhere N75.0 Cyst of Bartholin's gland N84.3 Polyp of vulva N90.0 Mild vulvar dysplasia N90.1 Moderate vulvar dysplasia Q18.1 Preauricular sinus and cyst Q82.1 Xeroderma pigmentosum Q82.3 Incontinentia pigmenti Q82.5 Congenital non-neoplastic nevus Q82.8 Other specified congenital malformations of skin Q85.01 Neurofibromatosis, type 1 Q85.03 Schwannomatosis Q85.09 Other neurofibromatosis R22.0 Localized swelling, mass and lump, head R22.1 Localized swelling, mass and lump, neck R22.2 Localized swelling, mass and lump, trunk R22.31 Localized swelling, mass and lump, right upper limb R22.32 Localized swelling, mass and lump, left upper limb R22.33 Localized swelling, mass and lump, upper limb, bilateral R22.41 Localized swelling, mass and lump, right lower limb R22.42 Localized swelling, mass and lump, left lower limb R22.43 Localized swelling, mass and lump, lower limb, bilateral ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: Group 1 Codes: ICD-10 Codes Description Z41.1 Encounter for cosmetic surgery ICD-10 Additional Information Back to Top General Information Associated Information Documentation Requirements 1. Physicians services must be submitted with a diagnosis code to support medical necessity and must be coded to the greatest level of accuracy and highest level of digit completeness. In the absence of signs, symptoms, illness or injury, Z41.1 should be reported, and payment will be denied. (Ref. CMS Pub.100-04 Medicare Claims Processing Manual, Ch. 23 10.1-10.1.7) 2. Medical records maintained by the physician must clearly document the medical necessity for lesion(s) removal if Medicare is billed for the service. The relevant history and physical finding conforming to the criteria stated in the Indication and Limitations of Coverage and/or Medical Necessity section above must be made available to the Contractor on request. Printed on 10/4/2017. Page 8 of 10

3. Surgical Procedures Lesions and Closures: Operative note(s) for surgical procedures performed in the office location may be contained in the patient s medical record for the date of service or as a separate report maintained within the patients chart. The operative note for the procedure performed must be of significant detail to support the surgical procedure billed. The surgical technique used should be described. Surgical procedures should include the lesion size(s) location(s) and number. Layered closures should include the length recorded in centimeters. Add together the length of multiple closures from all anatomical sites grouped together in the same code descriptor. (See the American Medical Associations Physicians Current Procedural Terminology, CPT subsection instructions for Removal of Skin Tags, Shaving of Epidermal or Dermal Lesions, Excisions - Benign Lesions, Repairs (Closures) and Destruction.) 4. The decision to submit a specimen for pathological interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that the pathology description and tissue diagnosis will be part of the medical record if a specimen is submitted to pathology. 5. 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 diagnosis code L82.0, inflamed seborrheic keratosis, is insufficient to justify lesion removal without medical documentation of the patient s symptoms and physical findings. 6. 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. 7. Providers should bill the appropriate CPT code and match the diagnosis code to the procedure code. 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 lesion 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 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. Sources of Information and Basis for Decision Henry, Ginard, I., & Caputy, Gregory, G. (Feb. 19, 2015). Benign Skin Lesions Overview of Benign Skin Lesions. Retrieved from http://emedicine.medscape.com/article/1294801-overview. Mulheim, E. & Pinelis, S. (Aug 1, 2011). Treatment of Nongenital Cutaneous Warts. American Family Physician, 84(3), 288-293. Scheinfeld, N., & Elston, D., & et al. (Feb.5, 2014). Laser Treatment of Benign Pigmented Lesions. Retrieved from http://emedicine.medscape.com/article/1120359-overview Back to Top Revision History Information Revision History Date 03/01/2017 R5 12/01/2016 R4 02/01/2016 R3 Revision History Number Printed on 10/4/2017. Page 9 of 10 Revision History Explanation 03/01/2017 CPT/HCPCS short description change CPT code 11403 per Quarter 2017 CPT/HCPCS and Revenue Code update. Added LCD 35498 to Billing & Coding Guidelines Title. No change in coverage. 12/01/2016-Annual Review completed 11/08/2016; no changes in coverage Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes Other (Annual Review) Other (Annual Review )

Revision History Date 10/01/2015 R2 10/01/2015 R1 Back to Top Revision History Number Revision History Explanation 02/01/2016-Annual Review 12/15/2015, removed CAC information, removed ICD-9 code V50.1 no change in coverage. 07/01/2015- Policy Clarification-added the following statement to Group 1 Paragraph: CPT codes 11300-11313 may also be covered for the removal of cancerous skin lesions which are not addressed in this LCD; added dx codes I78.1, H61.011- H61.013, H61.021-H61.023, H61.031- H61.033. 03/01/2015- added L91.9 to list of covered diagnosis codes. Effective 02/16/2015. Reason(s) for Change Other (Other- Clarification Dx code addition ) Revisions Due To ICD-10-CM Code Changes Other (DX code addition) Revisions Due To ICD-10-CM Code Changes Associated Documents Attachments Billing & Coding Guidelines (PDF - 16 KB ) Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 03/02/2017 with effective dates 03/01/2017 - Updated on 11/22/2016 with effective dates 12/01/2016-02/28/2017 Updated on 01/18/2016 with effective dates 02/01/2016-11/30/2016 Some older versions have been archived. Please visit the MCD Archive Site to retrieve them. Back to Top Keywords Read the LCD Disclaimer Back to Top Printed on 10/4/2017. Page 10 of 10