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2025 CPT code 11446

Excision of benign lesion, including margins, from face, ears, eyelids, nose, lips, or mucous membrane; excised diameter over 4.0 cm with simple closure.

Adhere to CPT guidelines for excisions, including proper measurement techniques and documentation requirements. Ensure accurate representation of the excised diameter, closure technique, and anatomical location. Appropriate modifiers should be used as needed.For lesions involving structures beyond the skin, consult the CPT guidelines for additional coding.

Modifier 22 (Increased procedural services) may be applied if the excision is unusually complex or extensive beyond the typical scope of 11446. Modifier 59 (Distinct procedural service) is used for multiple lesions excised during the same session. Anatomic modifiers may be required to specify the location.

Medical necessity is established when the lesion poses a functional or cosmetic impairment, presents a significant risk of bleeding or infection, or necessitates biopsy to rule out malignancy.Clinical documentation should clearly articulate the rationale for surgical intervention based on these factors.

The clinical responsibility includes pre-operative assessment, outlining the lesion, prepping the surgical site with antiseptic, administering local anesthesia, performing the excision with precise technique to remove the lesion and surrounding margins, hemostasis (controlling bleeding),histological sample collection for pathology, and wound closure with simple sutures. Postoperative care instructions should also be provided.

IMPORTANT:For smaller lesions, use CPT codes 11441-11445.For lesions requiring more than simple closure, use CPT codes 11400-11446 in conjunction with appropriate codes for intermediate (12031-12057) or complex closure (13100-13153).For shave removal, refer to CPT codes 11300 et seq. For electrosurgical or other methods, see CPT codes 17000 et seq.If multiple lesions are excised during the same session, modifier 59 (Distinct procedural service) should be applied to the additional lesion(s).

In simple words: This code describes the surgical removal of a non-cancerous growth and a small amount of surrounding skin from areas like the face, ears, or inside the mouth. The doctor cuts out the growth completely, and then stitches the skin closed with a simple stitch. This is only used when the total area removed is larger than 4 centimeters (about 1.6 inches).

This CPT code encompasses the surgical excision of a benign lesion (non-cancerous growth) and surrounding margins from specific anatomical locations: face, ears, eyelids, nose, lips, or mucous membranes. The procedure involves full-thickness removal (through the dermis) of the lesion,including necessary margins for complete excision. The excised diameter is determined by the greatest clinical diameter of the apparent lesion plus the narrowest margin required for complete removal.Simple (non-layered) closure of the surgical defect is included.The code is applicable only when the excised diameter of the lesion plus margins exceeds 4.0 cm.For lesions requiring more complex closure techniques, additional codes must be appended.

Example 1: A 65-year-old male presents with a 5 cm benign nevus on his left cheek. The physician performs an elliptical excision with a 2mm margin, resulting in a 7cm excised diameter. Simple closure is performed., A 42-year-old female has a 4.5 cm fibroma on her right earlobe.The physician excises the lesion with a 3mm margin, achieving an excised diameter slightly above 4.0 cm. Simple closure was used., A 28-year-old patient presents with a 6 cm benign lesion on their upper lip.A full-thickness excision is performed with a 2 mm margin, with the excised diameter measuring over 6 cm. Simple closure of the wound is performed.

Detailed medical history, physical examination findings documenting the lesion's location, size, and characteristics; photographs of the lesion pre- and post-excision; operative report with precise measurements of the lesion and excised tissue; pathology report confirming the benign nature of the excised tissue; and appropriate postoperative care documentation.

** Accurate measurement of the lesion and excised tissue is crucial for proper code selection.Pathology confirmation of the benign nature of the lesion is essential for reimbursement.Understanding the distinction between excision and shave removal is critical for appropriate coding.Consider payer-specific policies regarding medical necessity for excision of benign lesions.

  • Revenue Code: P5A (Ambulatory Procedures - Skin)
  • Payment Status: Active
  • Modifier TC rule: Not applicable.
  • Specialties:Dermatology, Plastic Surgery, Otolaryngology, Oral and Maxillofacial Surgery
  • Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department
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