SUPERSEDED Local Coverage Determination (LCD)

Removal of Benign Skin Lesions

L35498

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L35498
Original ICD-9 LCD ID
Not Applicable
LCD Title
Removal of Benign Skin Lesions
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL35498
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/28/2021
Revision Ending Date
10/25/2023
Retirement Date
N/A
Notice Period Start Date
01/01/2015
Notice Period End Date
02/15/2015
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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.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

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

CMS Pub.100-04 Medicare Claims Processing Manual, Ch. 23 Fee Schedule Administration and Coding Requirements, Section 10.1-10.1.7 – Reporting ICD Diagnosis and Procedure Codes

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.

CMS Transmittal No, 857, effective date October 3, 2018, Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.

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.

  1. 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:
    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:
      1. Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding.
      2. Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients.
      3. Lesions are condyloma acuminata or molluscum contagiosum.
      4. 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.
  2. 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 narrowest margins required equals the excised 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.

Summary of Evidence

NA

Analysis of Evidence (Rationale for Determination)

NA

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

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.
  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.
  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 patient’s 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, inflamed seborrheic keratosis, is insufficient to justify lesion removal without medical documentation of the patient’s symptoms and physical findings.

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.

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
N/A
Bibliography

Henry, G. and Caputy, G., Benign skin lesions. Medscape.com. Published June 14, 2021. Accessed September 9, 2021. https://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., Contestable, J., et al. 2021. Laser treatment of benign pigmented lesions. Medscape.com. Published December 13, 2019. Accessed September 9, 2021. https://emedicine.medscape.com/article/1120359-overview

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/28/2021 R9

10/28/2021 Moved sources of information to Bibliography and updated format to AMA. Formatting, punctuation, and typographical errors were corrected throughout the article. Review completed 9/14/2021.

  • Other (Review)
10/31/2019 R8

10/31/2019 Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS, ICD-10 codes, and Billing and Coding Guidelines have been removed from this LCD and placed in Billing and Coding: Removal of Benign Skin Lesions linked to this LCD. Consistent with Change Request 10901 language from IOMs and/or regulations have been removed and the applicable manual/regulation has been referenced. Review completed 10/08/2019

  • Other (Changes in response to CMS Change Request 10901, Review completed.)
10/01/2018 R7

10/01/2018 ICD-10 CM Code update: Group 1 Codes: removed D22.11, D22.12, D23.11, and D23.12. Group 1 Codes added D22.111, D22.112, D22.121, D22.122, D23.111, D23.112, D23.121, and D23.122. Added NCD 250.4 to Related NCD. Annual review completed 09/05/2018.

  • Revisions Due To ICD-10-CM Code Changes
  • Other (Annual Review)
12/01/2017 R6

 

12/01/2017: Annual review completed 11/03/2017. Verbiage corrected to match IOM references. Typo grammatical corrections made. No change in coverage. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Other (Annual review)
03/01/2017 R5 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.
  • Revisions Due To CPT/HCPCS Code Changes
12/01/2016 R4 12/01/2016-Annual Review completed 11/08/2016; no changes in coverage
  • Other (Annual Review)
02/01/2016 R3 02/01/2016-Annual Review 12/15/2015, removed CAC information, removed ICD-9 code V50.1 no change in coverage.
  • Other (Annual Review )
10/01/2015 R2 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.
  • Other (Other-Clarification
    Dx code addition
    )
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 03/01/2015- added L91.9 to list of covered diagnosis codes. Effective 02/16/2015.
  • Other (DX code addition)
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A57482 - Billing and Coding: Removal of Benign Skin Lesions
Related National Coverage Documents
NCDs
250.4 - Treatment of Actinic Keratosis
Public Versions
Updated On Effective Dates Status
10/17/2023 10/26/2023 - N/A Currently in Effect View
10/19/2021 10/28/2021 - 10/25/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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