Summary & Overview
CPT 1110F: Clinical Documentation Performance Measure
CPT code 1110F is recorded as an encounter-level entry with no accompanying descriptive summary. As a CPT-format code, it represents a clinical reporting element used in documentation of patient care rather than a discrete procedure. Nationally, such codes matter because they support quality measurement, claims accuracy, and administrative reporting across payers. Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. This publication outlines the role of the code in clinical documentation, summarizes payer inclusion, and highlights what readers will learn: how this code is classified, where it would typically be applied in clinical workflows, and what contextual items are available or missing for billing and policy interpretation. The report provides benchmarks and policy discussion where available, notes data limitations when input information is not provided, and offers clinical context to help coders and policy analysts interpret the entry. Data not available in the input is identified explicitly to avoid assumptions about service type, site of service, associated diagnoses, modifiers, or related codes.
Billing Code Overview
CPT code 1110F is listed with no summary available. Based on the code pattern and typical use of CPT Category II–style numeric format, this entry represents a performance or encounter-related measure recorded in clinical documentation. Service Type: Data not available in the input. Typical Site of Service: Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult presenting to an outpatient dermatology or primary care clinic for evaluation and management of a suspicious skin lesion identified on routine exam or reported by the patient for change in size, color, or texture. The clinician documents the lesion, discusses risks/benefits of diagnostic options, and proceeds with a skin biopsy or lesion removal procedure during the same visit. The workflow includes history and focused skin exam, informed consent, local anesthesia administration, performance of the biopsy or minor surgical excision, specimen labeling and submission to pathology, and post-procedure wound care instructions. Typical site of service is an outpatient clinic, dermatologist’s office, or ambulatory surgical center. Patient scenarios often involve lesions suspected for basal cell carcinoma, squamous cell carcinoma, or atypical nevi requiring histologic diagnosis.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when an E/M visit beyond pre- and post-procedure work is medically necessary and documented on the same day as the biopsy/excision |
59 | Distinct procedural service | Use when two procedures on the same day are distinct and not usually reported together |
26 | Professional component | Use when billing only the professional component of a diagnostic service |
TC | Technical component | Use when billing only the technical component of a diagnostic service |
57 | Decision for surgery | Use when the E/M visit results in the initial decision to perform surgery on the same day |
52 | Reduced services | Use when a procedure is partially reduced or eliminated at the physician’s discretion |
78 | Return to OR for a related procedure during the postoperative period | Use when a related procedure is performed in the operating room for complications of the initial procedure |
79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global period |
RT | Right side | Use to indicate a procedure performed on the right side of the body |
LT | Left side | Use to indicate a procedure performed on the left side of the body |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207N00000X | Dermatology | Dermatologists commonly perform skin biopsies and excisions |
| 208000000X | Family Medicine | Primary care clinicians often perform minor skin procedures in-office |
| 207R00000X | General Surgery | General surgeons perform excisions of larger or complex cutaneous lesions |
| 2080S0102X | Internal Medicine | Internists may perform simple skin biopsies in ambulatory settings |
| 363A00000X | Pathology | Pathologists interpret the submitted specimens and provide diagnostic reports |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
L57.0 | Actinic keratosis | Common reason for biopsy or removal due to risk of progression to squamous cell carcinoma |
D22.9 | Melanocytic nevus, unspecified | Evaluation of atypical nevi to rule out melanoma |
C44.9 | Squamous and basal cell carcinoma of skin, unspecified | Diagnostic biopsy or excision used to confirm and stage non-melanoma skin cancers |
L82.1 | Lentigo maligna | Lesions suspicious for melanoma in situ that require biopsy |
R23.3 | Discoloration of skin | Non-specific presentation prompting biopsy when etiology is uncertain |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
11102 | Tangential biopsy of skin (e.g., shave, scoop), single lesion | Performed for superficial lesions when a shave biopsy is appropriate; alternative biopsy technique |
11104 | Tangential biopsy of skin, multiple lesions, up to 14 | Used when multiple shave biopsies are performed during the same session |
11107 | Tangential biopsy, each additional lesion (List separately in addition to code for primary procedure) | Billed for each additional lesion beyond the primary code when multiple tangential biopsies are performed |
11600 | Excision, benign lesion including margins, trunk, arms or legs; 0.5 cm or less | Used when an excisional approach is selected for presumed benign lesions |
11606 | Excision, benign lesion, face, ears, eyelids, nose, lips; over 2.0 cm up to 3.0 cm | Used for benign lesion excisions in cosmetically sensitive areas requiring specific sizing codes |
88305 | Level IV pathology; surgical pathology, gross and microscopic examination | Typical pathology code for histologic evaluation of skin biopsy specimens |