States Applicable to Alert:
Hawaii, Nevada, American Samoa, Guam, the Northern Mariana Islands, Northern and Southern California.
Background Information:
Palmetto GBA has determined that the range of CPT codes, listed below, were not updated in the computer system to be valid when submitted with stand alone diagnosis - 078.12 - in the LCD Policy - #L28300 – Skin Lesion (Non-Melanoma) Removal for claims with dates of service on or after October 1, 2008.
Therefore, services might have been denied in error for these specific CPT codes when diagnosis 078.12 was indicated on the claim as a covered diagnosis.
Note: For HI/NV – LCD Policy number applicable in October 2008 was L27721. The policy number was changed to L28300 in February 2009 for standardization purposes only for J1.
Applicable CPT Codes:
11300 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less
11301 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
11302 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms, or legs; lesion diameter 1.1 cm to 2.0 cm
11303 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms, or legs; lesion diameter over 2.0 cm
11305 – Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
11306 – Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 cm to 1.0 cm
11307 – Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 cm to 2.0 cm
11308 – Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm
11310 – Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less
11311 – Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
11312 – Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
11313 - Shaving of epidermal or dermal lesion, single lesion, face, ears,
eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm
Modifier(s):
N/A
Remark /Reason Codes:
50 - These are non-covered services because this is not deemed a medical necessity by the payer.
N115 - This decision was based on a Local Medical Review Policy (LMRP) or Local Coverage Determination (LCD). An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.hhs.gov/mcd or if you do not have Web access, you may contact the contractor to request a copy of the LMRP/LCD.
MAC Action:
Palmetto GBA will identify claims with dates of service on or after October 1, 2008, which have been denied incorrectly for CPT Codes 11300-11313 when covered diagnosis 078.12 was indicated on the claim. When the system is updated a mass adjustment will be performed.
Mass adjustment was completed on June 30, 2009. No claims were found for Hawaii or Nevada. Thirteen claims were found for Northern California and five for Southern California.
Provider Action:
No action is required.
Date Reported: June 22, 2009
Date Resolved: June 30, 2009