CPT code 11403 is for the excision of a benign skin lesion, including margins, measuring 2.1 to 3 cm.
CPT code 11403 is used to describe the excision of a benign (non-cancerous) skin lesion, including the margins, with a diameter of 2.1 to 3 centimeters. This code is specifically for procedures where the lesion is removed from areas other than the face, ears, eyelids, nose, lips, or genitalia. The code ensures that the healthcare provider is accurately reimbursed for the complexity and extent of the procedure.
For CPT code 11403, which involves excision of a benign lesion including margins, measuring 2.1 to 3.0 cm, the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: Used when the work required to provide a service is substantially greater than typically required.
2. Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: Used when an evaluation and management (E/M) service is performed on the same day as the procedure.
3. Modifier 50 - Bilateral Procedure: Used when the procedure is performed on both sides of the body.
4. Modifier 51 - Multiple Procedures: Used when multiple procedures are performed during the same surgical session.
5. Modifier 59 - Distinct Procedural Service: Used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
6. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: Used when the same procedure is repeated by the same provider.
7. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional: Used when the same procedure is repeated by a different provider.
8. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: Used when a related procedure is performed during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: Used when an unrelated procedure is performed during the postoperative period.
10. Modifier LT - Left Side: Used to indicate that the procedure was performed on the left side of the body.
11. Modifier RT - Right Side: Used to indicate that the procedure was performed on the right side of the body.
12. Modifier GA - Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case: Used when a waiver of liability statement is issued as required by payer policy.
13. Modifier GX - Notice of Liability Issued, Voluntary Under Payer Policy: Used when a voluntary notice of liability is issued under payer policy.
14. Modifier GY - Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit: Used when the item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
15. Modifier GZ - Item or Service Expected to Be Denied as Not Reasonable and Necessary: Used when the provider expects that the item or service will be denied as not reasonable and necessary.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
When determining if CPT code 11403 is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the guidelines provided by your regional Medicare Administrative Contractor (MAC). The MPFS is a comprehensive listing of the payment rates used by Medicare to reimburse physicians and other healthcare providers for services rendered. Each MAC may have specific guidelines and policies that can affect reimbursement.
For CPT code 11403, you would first check the MPFS to see if the code is listed and what the reimbursement rate is. Additionally, it is crucial to review any local coverage determinations (LCDs) or national coverage determinations (NCDs) issued by your MAC, as these documents provide detailed information on the conditions under which Medicare will reimburse for specific services.
In summary, to determine if CPT code 11403 is reimbursed by Medicare, you need to reference the MPFS and consult the relevant policies and guidelines from your MAC.
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