Summary & Overview
CPT 11105: Punch Biopsy of Skin for Additional Lesions
CPT code 11105 represents the punch biopsy of skin for each separate or additional lesion, a procedure widely utilized in dermatology and integumentary surgery to diagnose skin disorders and neoplasms. This code is essential for clinicians seeking to obtain tissue samples for histopathological analysis, which informs patient management and treatment decisions. The procedure is typically performed in office or hospital outpatient settings, reflecting its accessibility and routine use in clinical practice.
Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, provide coverage for services billed under CPT code 11105. Understanding payer policies and coding requirements is crucial for accurate billing and reimbursement. Readers will gain insights into clinical benchmarks, policy updates, and the broader context of skin biopsy procedures, including how this code fits within dermatology workflows and its relationship to related CPT codes. The summary also highlights common modifiers and associated taxonomies relevant to billing and compliance.
This publication offers a comprehensive overview of CPT code 11105, equipping healthcare professionals, billing specialists, and policy analysts with the information needed to navigate coding, payer coverage, and clinical applications for punch biopsy procedures.
CPT Code Overview
CPT code 11105 is used to report a punch biopsy of the skin for each separate or additional lesion, including simple closure when performed. This procedure is commonly performed in dermatology and integumentary surgery settings to obtain tissue samples for diagnostic evaluation. Typical sites of service include the office (Place of Service 11) and hospital outpatient departments. The punch biopsy is a minimally invasive technique that allows clinicians to assess a variety of skin conditions and lesions, supporting accurate diagnosis and treatment planning.
Clinical & Coding Specifications
Clinical Context
A patient presents to a dermatology or primary care office with multiple suspicious skin lesions. The provider determines that a punch biopsy is necessary to obtain tissue samples for diagnostic evaluation. The initial lesion is biopsied using procedure code 11104, and for each additional lesion biopsied during the same encounter, code 11105 is reported. The workflow includes local anesthesia, obtaining a cylindrical sample of skin, and performing a simple closure if needed. The tissue samples are sent to pathology for further analysis. This procedure is commonly performed in the office setting (Place of Service 11) or hospital outpatient department.
Coding Specifications
-
Modifier
59: Used to indicate a distinct procedural service, such as when a punch biopsy is performed on a separate anatomical site or during a different session from other procedures. -
Modifier
51: Used to denote multiple procedures performed during the same encounter, such as when several biopsies are taken from different lesions.
| Modifier Code | Description |
|---|---|
59 | Distinct Procedural Service |
51 | Multiple Procedures |
- Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207N00000X | Dermatology Physician |
207Q00000X | Family Medicine Physician |
207R00000X | Internal Medicine Physician |
These taxonomies represent the specialties commonly performing punch biopsies of the skin.
Related Diagnoses
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L98.9: Disorder of the skin and subcutaneous tissue, unspecified- Used when the skin lesion's nature is unclear and further investigation is needed.
-
D48.5: Neoplasm of uncertain behavior of skin- Applied when a lesion is suspected to be a neoplasm but its behavior (benign or malignant) is not yet determined.
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L82.1: Other seborrheic keratosis- Used for biopsies of seborrheic keratosis lesions that are atypical or require confirmation.
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L91.8: Other hypertrophic disorders of the skin- Relevant for biopsies of thickened or hypertrophic skin lesions to establish diagnosis.
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C44.99: Other specified malignant neoplasm of skin- Used when a lesion is suspected or confirmed to be a malignant neoplasm not otherwise specified.
Each diagnosis code represents a clinical scenario where a punch biopsy may be necessary to obtain tissue for definitive diagnosis.
Related CPT Codes
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11104: Punch biopsy of skin (including simple closure, when performed)- Used for the first lesion biopsied during an encounter.
11105is reported for each additional lesion.
- Used for the first lesion biopsied during an encounter.
-
11106: Incisional biopsy of skin (eg, wedge) (including simple closure, when performed)- Used when a larger or wedge-shaped incisional biopsy is required instead of a punch biopsy. May be used as an alternative to
11104/11105depending on clinical need.
- Used when a larger or wedge-shaped incisional biopsy is required instead of a punch biopsy. May be used as an alternative to
11104 and 11105 are commonly used together when multiple punch biopsies are performed in a single session. 11106 is an alternative procedure for different biopsy techniques.
National Reimbursement Benchmarks
For CPT code 11105, the national mean rate for Medicare is $62.61, closely aligned with the BUCA (average commercial) mean rate of $62.36. Commercial payers such as UnitedHealth Group and Cigna report higher mean rates, at $83.28 and $73.76 respectively, while Aetna and Blue Cross Blue Shield are lower, at $56.08 and $58.84.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range ($7.00), indicating relatively consistent reimbursement. In contrast, UnitedHealth Group shows the widest spread ($44.00), followed by Cigna ($36.25), reflecting greater variability in commercial rates. The table and chart below present the full breakdown of national benchmarks for each payer.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska's reimbursement rates for CPT code 11105 are notably higher than national averages across all major payers. The mean rates for commercial payers such as Aetna, Blue Cross Blue Shield, Cigna, UnitedHealth Group, and BUCA are substantially above their respective national benchmarks, with Aetna's mean rate in Alaska more than triple its national mean. Medicare's mean rate in Alaska is slightly below the national average, but still within a comparable range.
The rate spread, calculated as the difference between the 75th and 25th percentiles, varies by payer. Aetna shows no spread, with all percentiles at $200, indicating uniform reimbursement. Cigna exhibits the widest spread among commercial payers at $56.83, suggesting greater variability in rates. The table and chart below present the full breakdown of payer-specific reimbursement rates in Alaska.
Key Insights for Alaska
- Aetna is the highest paying payer for CPT 11105 in Alaska, with a mean rate of $184.20, while Medicare is the lowest at $60.46.
- All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with Aetna's mean rate more than triple the national mean.
- The rate spread (difference between 75th and 25th percentiles) is largest for Aetna ($0.00, as all percentiles are $200), indicating uniformity, while Cigna shows the widest spread among commercial payers ($56.83), reflecting greater variability.
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