CPT code 11406 is for the excision of a benign skin lesion, including margins, that is greater than 4.0 cm in size.
CPT code 11406 is used to describe the excision of a benign (non-cancerous) skin lesion, including the margins, that is greater than 4.0 centimeters in size. This code is specifically for procedures where the lesion is removed from areas other than the face, ears, eyelids, nose, lips, or mucous membrane. The code ensures that the healthcare provider is accurately reimbursed for the complexity and extent of the procedure.
When using CPT code 11406 for excision of a benign lesion including margins greater than 4.0 cm, the following modifiers may be applicable:
1. Modifier 22 (Increased Procedural Services): Use this modifier if the procedure required significantly greater effort than typically required. Documentation must support the substantial additional work.
2. Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service): Apply this modifier if an evaluation and management (E/M) service was performed on the same day as the procedure and was distinct and separately identifiable from the procedure.
3. Modifier 50 (Bilateral Procedure): Use this modifier if the procedure was performed on both sides of the body during the same operative session.
4. Modifier 51 (Multiple Procedures): Apply this modifier when multiple procedures, other than E/M services, are performed at the same session by the same provider.
5. Modifier 59 (Distinct Procedural Service): Use this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day. This is particularly relevant if the procedure was performed on a different site or through a separate incision.
6. Modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional): Apply this modifier if the same procedure was repeated by the same provider on the same day.
7. Modifier 77 (Repeat Procedure by Another Physician or Other Qualified Health Care Professional): Use this modifier if the same procedure was repeated by a different provider on the same day.
8. Modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period): Apply this modifier if the patient required an unplanned return to the operating room for a related procedure during the postoperative period.
9. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): Use this modifier if an unrelated procedure or service was performed by the same provider during the postoperative period of the initial procedure.
10. Modifier 80 (Assistant Surgeon): Apply this modifier if an assistant surgeon was required for the procedure.
11. Modifier 81 (Minimum Assistant Surgeon): Use this modifier if a minimum assistant surgeon was required for the procedure.
12. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)): Apply this modifier if an assistant surgeon was necessary because a qualified resident surgeon was not available.
13. Modifier 91 (Repeat Clinical Diagnostic Laboratory Test): Use this modifier if the same laboratory test was repeated on the same day to obtain subsequent (multiple) test results.
14. Modifier LT (Left Side): Apply this modifier if the procedure was performed on the left side of the body.
15. Modifier RT (Right Side): Use this modifier if the procedure was performed on the right side of the body.
These modifiers help provide additional information about the circumstances of the procedure, ensuring accurate billing and reimbursement. Always ensure that documentation supports the use of any modifiers applied.
When determining if CPT code 11406 is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the guidelines provided by the Medicare Administrative Contractor (MAC) for your specific region. The MPFS is a comprehensive listing of the maximum fees Medicare will pay for various services, and it is updated annually. Each MAC may have specific local coverage determinations (LCDs) that can affect reimbursement.
To verify if CPT code 11406 is reimbursed, you should:
1. Check the MPFS: Access the latest MPFS to see if CPT code 11406 is listed and to review the associated reimbursement rates.
2. Consult Your MAC: Review any LCDs or other guidance documents issued by your MAC, as these can provide additional context or restrictions related to the reimbursement of CPT code 11406.
By following these steps, you can determine whether Medicare will reimburse for CPT code 11406 in your specific situation.
Discover the power of MD Clarity's RevFind software to ensure you're getting paid what you deserve. With RevFind, you can effortlessly read your contracts and detect underpayments down to the CPT code level, including specific codes like 11406. Schedule a demo today to see how RevFind can help you identify and address underpayments by individual payer, maximizing your revenue and streamlining your financial operations.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
