Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27527

Removal of Benign or Premalignant Skin Lesions

L27527

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Indications

Benign or premalignant lesions may be removed in a variety of ways. These methods can be grouped into one of the following three categories.

Shaving of Epidermal or Dermal Lesions
Shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision. This includes local anesthesia, chemical or electrocauterization. The wound does not require suture closure.

Excision – Benign Lesions
Excision of benign lesions of skin includes local anesthesia. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed.

Destruction, Benign or Premalignant Lesions
Destruction means the ablation of benign or premalignant tissues by any method, with or without curettement, including local anesthesia, and not usually requiring closure.

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 do not pose a threat to health or function are considered cosmetic, and as such, are not covered by the Medicare program.

However, in selected circumstances, the removal of lesions (e.g., seborrheic keratoses, epidermoid cysts, moles (nevi), acquired hyperkeratosis, molluscum contagiosum, milia, viral warts, benign neoplasms, hemangiomas, lipomas, and pyogenic granulomas) is medically appropriate. Therefore, Medicare will 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:

• The lesion has one or more of the following characteristics:
  • bleeding
  • itching
  • pain
  • change in appearance.
• The lesion has physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.
• The lesion obstructs an orifice.
• The lesion clinically restricts eye function. For example the lesion:
  • restricts eyelid function
  • causes misdirection of eyelashes or eyelid
  • restricts lacrimal puncta and interferes with tear flow
  • touches the globe
  • interferes with vision.
• There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance.
• A prior histological exam or biopsy suggests or is indicative, of atypia (e.g.: atypical nevus) or malignancy.
• The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has occurred.
• Wart removals will be covered under guidelines (1-7) above. In addition, wart destruction will be covered when any of the following clinical circumstances are present:
  • Periocular warts associated with chronic recurrent conjunctivitis thought to be secondary to lesion virus shedding.
  • Warts showing evidence of spread from one body area to another.
  • Lesions are condyloma acuminata.
• Removal of molluscum contagiosum
• Benign epidermal or pilar cyst with history of infection, drainage, or multiple ruptured cysts.

Treatment of Actinic Keratosis

Medicare covers the destruction of actinic keratosis without restrictions based on lesion or patient characteristics. Actinic keratoses (AKs), also known as solar keratoses, are common, sun-induced skin lesions that are confined to the epidermis and have the potential to become a skin cancer. Various options exist for treating AKs. Clinicians should select an appropriate treatment based on the patient’s medical history, the lesion’s characteristics, and on the patient’s preference for a specific treatment. Commonly performed treatments for AKs include cryosurgery with liquid nitrogen, topical drug therapy, and curettage. Less commonly performed treatments for AK include dermabrasion, excision, chemical peels, laser therapy, and photodynamic therapy (PDT). An alternative approach to treating AKs is to observe the lesions over time and remove them only if they exhibit specific clinical features suggesting possible transformation to invasive squamous cell carcinoma (SCC).

Limitations

1. 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.

2. 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.

3. Removal of certain benign skin lesions that do not pose a threat to health or function is considered cosmetic, and as such, are not covered by the Medicare program. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone. 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. Such claims billed to Medicare should append the –GY modifier to the CPT/HCPCS code billed.

Surgical Services

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. 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 the lesion merits removal.  However, when a benign lesion is removed by excision (CPT 1400-11446) the medical record documentation must indicate why excision was the procedure of choice.  Furthermore, excision is defined as full thickness (through the dermis) removal of the lesion, including margins, and includes simple (non-layered) closure.
    
5. A statement of "irritated skin lesion" will be insufficient justification for lesion removal when used solely to refer a patient, describe a complaint or the physician's physical findings. Similarly, use of an ICD-9 code 702.11 (inflamed seborrheic keratosis) will be insufficient to justify lesion removal, without the medical record documentation of the patients' symptoms and physical findings. It is important to document the patient’s signs and symptoms as well as the physician’s physical findings.
   
   
6. Drawings or diagrams to describe the precise anatomical location of the lesion are helpful. A procedural note, protocol describing indications, diagnosis, methodology of treatment, or modality is advised.
   
   
7. 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.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27527

05/22/2008

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