Skin Lesion Excision: Documentation Quick Tips
When performing excision of benign (11400-11471) or malignant (11600-11646) skin lesions, physicians must document the location of the lesion, and should measure the lesion and margins prior to excision. The lesion will “shrink” when the incision releases the tension on the skin, which may lead to a lower-level code selection and lost reimbursement.
Because CPT® codes for lesion excision (as well as ICD-9-CM diagnostic codes) require that you identify a lesion as either benign or malignant, you should wait for pathology results before assigning a code (unless the diagnosis is confirmed in a previous biopsy of the lesion). Only those lesions specifically identified as malignant may be coded as such.
If a surgeon performs a re-excision to obtain clear margins at a later operative session, you may report the same malignant diagnosis linked to the initial excision because the reason for the re-excision is malignancy.
When the surgeon removes multiple lesions, treat each as a separate procedure. Append modifier 59 Distinct procedural service to the second and subsequent codes for excisions in the same general location.
Example: The physician removes three lesions from the right arm: sizes 1 cm (benign), 1.5 cm (benign), and 2.5 cm (malignant). Report: 11603 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm with diagnosis 173.6 Other malignant neoplasm of skin, skin of upper limb, including shoulder; 11402-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm with 216.6 Benign neoplasm of skin; skin of upper limb, including shoulder, and; 11401-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm with 216.6.
Per CPT® guidelines, all lesion excision codes include simple wound closure. CPT® allows separate coding for intermediate (12031-12057) and complex (13100-13153) repairs; however, payers who follow National Correct Coding Initiative (NCCI) edits will bundle intermediate and complex repairs into excision of benign lesions of 0.5 cm or less (11400, 11420 and 11440).