Internal Medicine Coding Alert

Question: What is the appropriate code for "removal of mole"? I've searched the entire CPT manual and can find nothing that fits.


Arkansas Subscriber

Answer: For simple removal (without destruction) of a mole, you should choose from among the codes for "excision of a benign lesion" (11400-11446). You should select the appropriate code according to both the location and size of the lesion. You should measure the size of the lesion, including margins, prior to removal.
 
For example, if the internist removed a 0.7-cm lesion from the left cheek, you would report 11441 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm).

But if the internist removed a 1.5-cm lesion from the neck, you would report 11422 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm). All excisions include simple closure.

If the physician had to perform a more difficult (intermediate or complex) closure, you may report the closure separately, but only if the wound is larger than 0.5 cm. The National Correct Coding Initiative bundles intermediate (12031-12057) and complex (13100-13153) repairs to all excisions of benign lesions of 0.5 cm or less (11400, 11420 and 11440).

Example: In the second example above (a 1.5-cm lesion of the neck), the internist must use a layered closure to close the wound after excision. In this case, you would report both 12041 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less) for the closure and 11422 for the excision.

Documentation tip: Many payers will consider mole removal to be a cosmetic (and therefore noncovered) procedure unless the physician can document the suspicious (that is, potentially cancerous) nature of the mole.