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2025 CPT code 11400

Excision of a benign skin lesion (excluding skin tags) with a diameter of 0.5 cm or less, including margins, from the trunk, arms, or legs, with simple closure.

Adhere to the official CPT guidelines for the selection of codes based on lesion size.Accurate measurement of the lesion plus the margin is crucial for proper code selection.

Modifier 59 (Distinct Procedural Service) may be applied if multiple lesions of different diameters are excised during the same encounter.

The medical necessity for excision of a benign lesion will typically be based on cosmetic concerns, patient preference, or suspicion of malignancy despite the benign appearance of the lesion. The documentation should justify the medical necessity based on these factors.

The physician is responsible for pre-operative preparation, local anesthesia administration, complete excision of the lesion including appropriate margins, hemostasis, and simple wound closure.Pathology specimen submission may also be part of the physician’s responsibility.

IMPORTANT:For lesions larger than 0.5 cm, refer to codes 11401-11406. For shave removal, see codes 11300 and following. For electrosurgical or other methods, see codes 17000 and following. For excision requiring more than simple closure, report codes 11400-11446 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes.

In simple words: The doctor removes a non-cancerous growth from your skin (on your torso, arms, or legs) that is 0.5 cm or smaller, including a little extra skin around it.They then stitch it up with a simple closure.

This CPT code encompasses the complete excision of a benign lesion (excluding skin tags) measuring 0.5 cm or less in diameter, including the necessary margins, from the skin of the trunk, arms, or legs.The procedure involves full-thickness removal through the dermis and includes a simple, non-layered closure.The excised diameter includes the lesion and the margin required for complete excision.More complex closures require additional coding.

Example 1: A 45-year-old female presents with a 0.4 cm benign nevus on her left arm.The physician excises the nevus with a 2 mm margin, resulting in a 0.8 cm excised diameter. Simple closure is performed., A 60-year-old male presents with a 0.3 cm seborrheic keratosis on his back. The physician excises the lesion, including a 1 mm margin (resulting in a 0.5 cm excised diameter) with simple closure., A 22-year-old female presents with two benign lesions on her right leg, one measuring 0.4 cm and the other 0.2 cm.Both are excised with simple closures. Modifier 59 is added to the second lesion.

The medical record should include:* Detailed description of the lesion (location, size, type)* Documentation of the margin(s) used during excision* Confirmation of simple closure* Pathologic findings (if applicable)* Pre-operative and post-operative photographs (if applicable)

** The use of local anesthesia is implied by the code description.If a different type of anesthesia is used, it should be documented but does not require separate coding unless significant additional work was involved. Remember to consider the size of the excised area, not just the size of the lesion itself, when selecting the appropriate code.

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