Summary & Overview
CPT 11106: Incisional Biopsy of Skin with Simple Closure
CPT code 11106 is a nationally recognized billing code for the incisional biopsy of skin, including simple closure when performed. This surgical procedure is commonly used to diagnose skin lesions or abnormalities that require tissue sampling for further evaluation. The code is relevant across a wide range of clinical settings, particularly in office-based practices, and is covered by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare.
This publication provides a comprehensive overview of CPT code 11106, detailing its clinical context, payer coverage, and associated benchmarks. Readers will gain insight into the procedural specifics, typical site of service, and the importance of accurate coding for reimbursement and compliance. The analysis also highlights relevant policy updates and trends affecting the use of this code, as well as its relationship to common modifiers and related codes. By understanding the nuances of CPT code 11106, healthcare professionals and billing specialists can stay informed about current practices and requirements for skin biopsy procedures.
CPT Code Overview
CPT code 11106 describes an incisional biopsy of skin, such as a wedge biopsy, including simple closure when performed. This procedure is classified under surgery and is typically conducted in an office setting (Place of Service 11). The incisional biopsy is used to obtain a sample of skin tissue for diagnostic purposes, often when a lesion or abnormality requires further evaluation. The inclusion of simple closure means that the wound is closed in a straightforward manner following the biopsy. This code is essential for clinicians who need to investigate skin conditions that cannot be diagnosed through less invasive methods.
Clinical & Coding Specifications
Clinical Context
A patient presents to the office with a suspicious skin lesion, such as a nodule or plaque, that may represent a neoplasm or other abnormality. The provider determines that an incisional biopsy is necessary to obtain a tissue sample for diagnostic purposes. Using a wedge technique, the provider removes a portion of the lesion, including some normal tissue, and performs a simple closure of the biopsy site. The procedure is typically performed in an office setting and is used to evaluate lesions with uncertain behavior, possible malignancy, or other skin disorders.
Coding Specifications
-
Modifier
59: Used to indicate a distinct procedural service, such as when the incisional biopsy is performed on a separate lesion or anatomical site from other procedures on the same day. -
Modifier
51: Used to denote multiple procedures performed during the same session, such as when more than one biopsy or other surgical procedure is performed.
| Modifier Code | Description |
|---|---|
59 | Distinct Procedural Service |
51 | Multiple Procedures |
- Provider Taxonomies: Data not available in the input.
Related Diagnoses
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D48.5- Neoplasm of uncertain behavior of skin- Used when the lesion's nature is unclear and further diagnostic evaluation is needed.
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L98.9- Disorder of the skin and subcutaneous tissue, unspecified- Applied when the skin abnormality does not fit a specific diagnosis and requires biopsy for clarification.
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L82.1- Other seborrheic keratosis- Relevant for biopsies of seborrheic keratosis variants to rule out malignancy or confirm diagnosis.
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L91.8- Other hypertrophic disorders of the skin- Used for lesions characterized by abnormal skin thickening, where biopsy helps determine the underlying cause.
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C44.99- Other specified malignant neoplasm of skin- Indicates biopsy of a lesion suspected to be a malignant skin neoplasm not otherwise specified.
Related CPT Codes
11107: Each separate or additional lesion (list separately in addition to code for primary procedure)
11107 is used in conjunction with 11106 when the provider performs incisional biopsies on more than one lesion during the same session. The primary procedure is coded with 11106, and each additional lesion is reported with 11107. These codes are commonly used together when multiple biopsies are required for diagnostic evaluation.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT 11106 is $157.19, while the BUCA (average commercial) mean rate is $147.05. This places Medicare slightly above the commercial average for this code. UnitedHealth Group has the highest mean rate among all payers at $205.64, and Aetna has the lowest at $114.46.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare shows the tightest range at $18.00, indicating relatively consistent reimbursement rates. In contrast, UnitedHealth Group exhibits the widest range at $107.83, reflecting greater variability in rates. Cigna and Blue Cross Blue Shield also display substantial dispersion, with ranges of $93.25 and $65.13, respectively.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a wide spread in reimbursement rates for CPT code 11106, with the largest difference between the 75th and 25th percentiles seen in Aetna ($13.00) and BUCA ($142.89). Commercial payers such as Aetna and UnitedHealth Group offer substantially higher rates compared to Medicare, with Aetna's mean rate nearly triple that of Medicare. The rate spread among payers highlights significant variability, especially between the lowest and highest quartiles for BUCA and Cigna.
Compared to national averages, Alaska's commercial payers consistently reimburse at much higher levels. For example, Aetna's mean rate in Alaska is over $330 above its national mean, and UnitedHealth Group's mean rate is more than $130 above its national average. The table and chart below present the full breakdown of payer-specific rates in Alaska for CPT code 11106.
Key Insights for Alaska
- Aetna is the highest paying payer for CPT 11106 in Alaska, with a mean rate of $446.69.
- Medicare is the lowest paying payer, with a mean rate of $151.44.
- All commercial payers in Alaska reimburse significantly above their respective national averages, with Aetna's mean rate more than 3 times the national mean.
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