CPT code 11463 is for the removal of a sweat gland lesion. It specifies the procedure for excising these types of skin lesions.
CPT code 11463 is used to describe the surgical procedure for the removal of a sweat gland lesion. This code specifically pertains to the excision of benign (non-cancerous) lesions from the sweat glands, which are typically found in areas like the armpits, groin, or other parts of the body where sweat glands are concentrated. The procedure involves surgically cutting out the lesion and may include a margin of normal tissue around it to ensure complete removal. This code is essential for accurate billing and documentation in the healthcare revenue cycle.
When billing for the procedure associated with CPT code 11463, various modifiers may be required to provide additional information about the service rendered. Below is a list of potential modifiers that could be used and the reasons for each:
1. Modifier -50 (Bilateral Procedure): Used if the procedure was performed on both sides of the body.
2. Modifier -51 (Multiple Procedures): Applied when multiple procedures are performed during the same surgical session.
3. Modifier -52 (Reduced Services): Used if the procedure was partially reduced or eliminated at the physician's discretion.
4. Modifier -59 (Distinct Procedural Service): Indicates that the procedure is distinct or independent from other services performed on the same day.
5. Modifier -76 (Repeat Procedure by Same Physician): Used if the same procedure is repeated by the same physician on the same day.
6. Modifier -77 (Repeat Procedure by Another Physician): Applied if the same procedure is repeated by a different physician on the same day.
7. Modifier -78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period): Used if the patient returns to the operating room for a related procedure during the postoperative period.
8. Modifier -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): Indicates that an unrelated procedure was performed by the same physician during the postoperative period of the initial procedure.
9. Modifier -LT (Left Side): Used to specify that the procedure was performed on the left side of the body.
10. Modifier -RT (Right Side): Used to specify that the procedure was performed on the right side of the body.
11. Modifier -GA (Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case): Indicates that an Advance Beneficiary Notice (ABN) was issued to the patient.
12. Modifier -GY (Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit): Used when the service is statutorily excluded from Medicare coverage.
13. Modifier -GZ (Item or Service Expected to Be Denied as Not Reasonable and Necessary): Indicates that an ABN was not issued, but the provider expects that Medicare will deny the service as not reasonable and necessary.
These modifiers help provide clarity and additional context to the payer, ensuring accurate billing and reimbursement for the services rendered.
The CPT code 11463 is reimbursed by Medicare, but the reimbursement is subject to specific conditions outlined in the Medicare Physician Fee Schedule (MPFS). The MPFS provides the payment rates for services covered by Medicare, and it is essential to verify the current rates and any applicable guidelines.
Additionally, Medicare Administrative Contractors (MACs) play a crucial role in determining the local coverage and reimbursement policies for this CPT code. Providers should consult their respective MAC for detailed information on coverage criteria and any documentation requirements to ensure proper reimbursement.
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