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    v1.0.30
    OpenPayerBilling CodesBiopsy Procedures on the SkinCPT cpt-11104-punch-biopsy-skin-lesion
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    CPT 11104: Punch Biopsy of Skin Lesion

    Medicare pays $126 and commercial payers pay $221 on average nationally for this procedure.

    CPT code 11104 describes a punch biopsy of a skin lesion using a sharp hollow instrument to obtain a deeper, circular full-thickness tissue sample; this is a biopsy procedure typically performed in an ambulatory procedure room or dermatology clinic and is used to diagnose or evaluate suspicious or deeper cutaneous lesions.

    For related coverage guidance, see recent payer policy updates: Mohs Micrographic Surgery, Mohs Micrographic Surgery, Mohs Micrographic Surgery.

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    National Reimbursement Benchmarks

    Nationally, Medicare’s mean reimbursement for CPT 11104 sits at $126, while BUCA’s mean commercial rate is $220.8, meaning BUCA averages about $94.8 higher than Medicare. This gap highlights a substantial differential between a broad commercial benchmark and the federal program’s mean for this code.

    Dispersion (P75–P25) varies across payers: Blue Cross Blue Shield has the widest interquartile spread at $113 (P75 $356.7 minus P25 $225.4), followed by UnitedHealth Group at $109.1, and BUCA at $124 (P75 $281.3 minus P25 $158.7) — BUCA’s numeric range is actually the largest of these. Aetna and Cigna show tighter spreads of $88 and $118.1 respectively, indicating relatively more concentrated commercial pricing for CPT 11104.

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A 62-year-old patient presents to a dermatology clinic with a 6-mm raised, erythematous papule on the forearm that has changed in color and occasionally bleeds. The dermatologist performs a focused skin exam, documents lesion size, morphology, and clinical concern for possible neoplasm, and obtains informed consent. The provider prepares the site using antiseptic, administers local anesthesia, and performs a 11104 punch biopsy to obtain a full-thickness circular specimen down into subcutaneous fat for histopathologic diagnosis. The specimen is placed in formalin, labeled, and sent with a requisition to dermatopathology. The patient receives wound care instructions and a follow-up plan for pathology results and possible further treatment depending on diagnosis (benign lesion, premalignant, or malignant). Typical workflow participants include a Dermatology Physician (207N00000X) or Family Medicine Physician (207Q00000X) performing the procedure, and a Dermatopathology Physician (208D00000X) interpreting the biopsy specimen. Typical site of service is an outpatient dermatology clinic, ambulatory surgery center, or office-based procedure room.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    11105

    Related Modifiers

    6 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    51Modifier –51 (Multiple Procedures) is used when the same provider performs multiple procedures in the same session to identify secondary, non‑exempt procedures and indicate payment reduction logic…- Use modifier -51 when the same provider performs multiple distinct procedures during the same patient encounter: report the highest‑valued procedure first (no modifier) and append -51 to…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207N00000X
    207Q00000X
    208D00000X
    207XX0005X
    286500000X
    213ES0103X
    251K00000X
    3336S0011X

    Related ICD-10-CM Codes

    30 rows

    ICD-10-CM CodeDescription
    A60.9Anogenital herpesviral infection, unspecified
    B35.1Tinea unguium
    C43.9Malignant melanoma of skin, unspecified
    C44.319Basal cell carcinoma of skin of other parts of face
    C44.91Basal cell carcinoma of skin, unspecified
    C44.99Other specified malignant neoplasm of skin, unspecified
    D22.9Melanocytic nevi, unspecified
    D48.5Neoplasm of uncertain behavior of skin
    L21.0Seborrhea capitis
    L29.9Pruritus, unspecified

    Showing 1–10 of 30

    Related Payer Policy Updates

    Specialty: Dermatology1 / 3

    10 rows

    PolicyPayerEffective Date
    Mohs Micrographic Surgerypremerabluecrossofwashington2027-02-05
    Mohs Micrographic Surgerypremerabluecrossofwashington2027-02-05
    Mohs Micrographic Surgerypremerabluecrossofwashington2027-02-05
    FilsuvezCigna2026-11-01
    Destruction of Pre-Malignant Skin LesionsAnthem2026-10-01
    Onychomycosis diagnostic testing and coverageOscar Health2026-10-01
    Treatment of Capillary Malformations (Port Wine Stains)universityofutahhealthplans2026-09-28
    AnzupgoCigna2026-09-15
    Hyperhidrosispriority_health_medicare2026-09-01
    Zevaskyn Coverage for Recessive Dystrophic Epidermolysis BullosaCigna2026-09-01

    Related Codes

    CPT-11102-TANGENTIAL-SHAVE-SKIN-BIOPSY-SINGLE-LESION

    CPT 11102: Tangential (Shave) Biopsy of Single Skin Lesion

    CPT-11103-TANGENTIAL-SHAVE-BIOPSY-ADDITIONAL-LESION

    CPT 11103: Additional Tangential (Shave/Curette) Skin Biopsy

    CPT-11105-ADDITIONAL-PUNCH-BIOPSY-SKIN-LESION

    CPT 11105: Punch Biopsy of Additional Skin Lesion

    CPT-11106-INCISIONAL-WEDGE-SKIN-BIOPSY

    CPT 11106: Incisional or Wedge Biopsy of Skin Lesion

    CPT-11107-ADDITIONAL-SKIN-LESION-INCISIONAL-WEDGE-BIOPSY

    CPT 11107: Additional Incisional or Wedge Skin Lesion Biopsy

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion
    Billed in addition to 11104 when multiple separate lesions are biopsied in the same encounter