CPT code 11604 is for the excision of a malignant skin lesion, including margins, measuring 3.1 to 4 cm.
CPT code 11604 is used to describe the excision of a malignant skin lesion, including margins, that measures between 3.1 to 4.0 centimeters in diameter. This code is typically utilized by healthcare providers to document and bill for the surgical removal of cancerous skin growths within the specified size range.
For CPT code 11604, which pertains to the excision of a malignant lesion including margins, with a diameter of 3.1 to 4.0 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. This could be due to increased complexity or difficulty of the procedure.
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 a significant, separately identifiable evaluation and management (E/M) service is performed by the same physician on the same day as the procedure.
3. Modifier 50 (Bilateral Procedure): Used when the same procedure is performed on both sides of the body during the same operative session.
4. Modifier 51 (Multiple Procedures): Used when multiple procedures are performed during the same session by the same provider. This modifier indicates that the procedure is one of several performed.
5. Modifier 58 (Staged or Related Procedure or Service by the Same Physician During the Postoperative Period): Used when a procedure or service during the postoperative period was planned or anticipated (staged), more extensive than the original procedure, or for therapy following a surgical procedure.
6. 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. This modifier is often used to identify procedures that are not normally reported together but are appropriate under the circumstances.
7. Modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional): Used when a procedure or service is repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service.
8. Modifier 77 (Repeat Procedure by Another Physician or Other Qualified Health Care Professional): Used when a procedure or service is repeated by another physician or other qualified healthcare professional subsequent to the original procedure or service.
9. 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 when a patient requires a return to the operating room for a related procedure during the postoperative period of the initial procedure.
10. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): Used when an unrelated procedure or service is performed by the same physician during the postoperative period of the initial procedure.
11. Modifier 90 (Reference (Outside) Laboratory): Used when laboratory procedures are performed by a party other than the treating or reporting physician.
12. Modifier 91 (Repeat Clinical Diagnostic Laboratory Test): Used when a clinical diagnostic laboratory test is repeated on the same day to obtain subsequent (multiple) test results.
13. Modifier 99 (Multiple Modifiers): Used when two or more modifiers are necessary to describe the service provided.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
The CPT code 11604 is reimbursed by Medicare, but the reimbursement is subject to specific conditions outlined in the Medicare Physician Fee Schedule (MPFS). The MPFS provides a comprehensive list of services covered by Medicare, along with the corresponding payment rates.
Additionally, Medicare Administrative Contractors (MACs) play a crucial role in determining the reimbursement for CPT code 11604. MACs are responsible for processing Medicare claims and can provide further guidance on any regional variations or additional documentation requirements that may affect reimbursement.
Therefore, it is essential to consult both the MPFS and your local MAC to ensure compliance and accurate reimbursement for CPT code 11604.
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