CurrentBlue KCPolicy POL-PP-235

Excision and Biopsy of Benign and Malignant Lesions

Payment and coding guidance for excision and biopsy procedures of benign and malignant skin lesions, including code selection, reporting of repairs and biopsies, and when additional codes are or are not separately reportable. Applies to providers submitting claims to Blue KC.

Policy Summary

PayerBlue KC

PolicyExcision and Biopsy of Benign and Malignant Lesions

Policy CodePolicy POL-PP-235

Change TypeNo material change

Effective DateNov 1, 2020

Next Review DateNov 1, 2026

Key ActionVerify member eligibility, benefit limits, and provider agreement; contact Blue KC provider hotlines for coverage questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT rangesExcision & biopsy code examples

7Revision history entries

07Current version

11/1/2026Next review

Excision and Biopsy Coverage Criteria

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Excision and Biopsy Coding and Billing Criteria

Coding and billing rules for excision and biopsy procedures — report codes according to lesion type, location, excised diameter, and biopsy technique.

Select excision code based on lesion type (benign vs malignant), anatomic location, and maximum excised diameter (lesion plus the narrowest required margins).

When the lesion is clearly benign, the excision may be coded as benign at the time of surgery (CPT 11400-11471); when a prior biopsy shows malignancy, the excision may be coded as malignant at the time of surgery (CPT 11600-11646).

When removing two adjacent lesions through the same excision, add the diameters of the lesions and report a single excision code based on the combined size (do not bill two separate excisions).

If lesion behavior is unspecified, delay final coding until pathology confirms benign versus malignant to avoid miscoding.

If intraoperative frozen section shows inadequate margins and additional excision is performed in the same operative session, report a single code based on the final widest excised diameter required for complete tumor removal; for re‑excisions at a subsequent session report CPT 11600-11646 and append modifier 58 if within the postoperative period.

Code selection uses the greatest clinical diameter of the apparent lesion plus the narrowest margin required (measured prior to excision); the excised diameter is the lesion diameter plus margin and is used regardless of how the defect is closed.

For unusual or complicated excisions add modifier 22; for bilateral procedures add modifier 50.

Obtaining tissue for pathology during excision, destruction, or shave removals is a routine component and is not separately reportable as a biopsy.

Wound repair and reconstructive closure reporting: intermediate and complex repair codes may be reported with excisions of benign and malignant lesions, but wound repair codes (CPT 12001-13153) shall not be reported with excisions of benign lesions with an excised diameter of 0.5 cm or less (e.g., CPT 11400, 11420, 11440). For reconstructive closure report CPT codes 15002-15261 and 15570-15770 as applicable. Wound repair codes (12001-13153) shall not be reported separately to describe closure of surgical incisions for procedures 21012-21088.

When excision is performed in conjunction with adjacent tissue transfer, report only the adjacent tissue transfer code; excision (11600-16302) is not separately reportable with adjacent tissue transfer.

Biopsy technique distinctions — report biopsy codes according to technique and add‑on conventions: tangential (shave), punch, and incisional biopsies are separate techniques with specific primary and add‑on codes.

When multiple biopsy techniques are performed during the same encounter, report only one primary lesion biopsy code (11102, 11104, or 11106) and use the corresponding add‑on codes for additional procedures of the same type per CPT conventions and provided examples.

Partial thickness biopsies sample skin/mucosa without penetrating below the dermis/lamina propria; full thickness biopsies penetrate into subcutaneous/submucosal tissue; sampling only stratum corneum is not a biopsy and is not reportable.

CPT/Repair/Reporting Guidance

Primary excision and biopsy code rangesCPTCovered

11400-11471	Excision of benign lesion including margins (site-specific ranges)
11600-11646	Excision of malignant lesion including margins (site-specific ranges)
11102-11107	Skin biopsy codes (tangential, punch, incisional and add-on codes)

Repair and closure codes guidanceCPT

12001-13153	Wound repair codes — not separately reportable with excisions of benign lesions with excised diameter ≤ 0.5 cm (CPT 11400, 11420, 11440) and not separately reportable to describe closure of surgical incisions for procedures 21012-21088
15002-15261,15570-15770	Reconstructive closure codes (report as applicable)

Additional repair guidanceCPT

12001-13153

Simple, intermediate, and complex wound repair codes may be reported with Mohs surgery (CPT 17311-17315)

Excised diameter threshold for separate wound repair reporting

Policy thresholdDo not report wound repair codes (CPT 12001-13153) with excisions of benign lesions when the excised diameter is 0.5 cm or less for specified benign excision codes (e.g., 11400, 11420, 11440)

Affected codesWound repair CPT codes 12001-13153 (not separately reportable under threshold)

Relevant excision codesBenign lesion excision CPT codes 11400, 11420, 11440 (examples cited for threshold application)

Context for measurementExcised diameter = lesion greatest clinical diameter plus the narrowest margin required for completion of excision (measure prior to excision)

Repair vs reconstructive closureReconstructive closure codes (CPT 15002-15261, 15570-15770) remain reportable as applicable; wound repair codes are distinct and limited by threshold

Provider Responsibilities and Eligibility

Prior Authorization

Confirm member eligibility, benefits, and provider agreement

Verify member eligibility, benefit limits, and that the Provider Service Agreement covers the service prior to performing or billing for excision or biopsy procedures. For confirmation of coverage or questions about medical necessity, contact the appropriate Blue KC provider hotline listed below.

Blue KC Provider Hotline for Commercial lines of Business: 816-395-3929
Affordable Care Act Provider Hotline: 866-859-3822
Blue Medicare Advantage Provider Hotline: 866-508-7140

Key Definitions

Benign lesion — definition

DefinitionBenign lesions are non-cancerous abnormal cell growths that typically grow locally, are usually slow-growing, and do not spread to other parts of the body.

Coding implicationWhen lesion is clearly benign (e.g., cyst, lipoma, prior biopsy of benign lesion), excision may be coded as benign at time of surgery (CPT 11400-11471).

ExamplesIncludes neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic lesions per policy wording.

Malignant lesion — definition

DefinitionMalignant lesions are cancerous growths that can invade and spread to other organs through metastasis due to rapid and uncontrolled cell division.

Coding implicationWhen prior biopsy shows malignancy, the excision can be coded as malignant at time of surgery (CPT 11600-11646).

Clinical distinctionMalignant lesions contrast with benign by potential to metastasize and aggressive behavior.

Excised diameter — definition

DefinitionExcised diameter = greatest clinical diameter of the apparent lesion plus the narrowest margin required for completion of excision (lesion diameter plus margin).

Measurement timingThe measurement of lesion plus margin is made prior to excision and determines code selection.

ApplicationExcised diameter is used to select appropriate excision CPT code and is the same whether defect is repaired linearly or reconstructed.

Partial thickness biopsy — definition

DefinitionPartial thickness biopsies sample a portion of the thickness of skin or mucous membrane and do not penetrate below the dermis or lamina propria.

Examples/techniquesTangential (shave, scoop, saucerize, curette) techniques are considered partial-thickness in many contexts and have distinct coding conventions.

Reporting noteSample of stratum corneum only does not constitute a biopsy and is not separately reportable.

Full thickness biopsy — definition

DefinitionFull thickness biopsies penetrate tissue deep to the dermis or lamina propria, into the subcutaneous or submucosal space.

Clinical selectionAn appropriate biopsy technique is selected based on optimal tissue-sampling considerations for the lesion requiring diagnosis.

Reporting distinctionFull-thickness biopsies are distinct from partial-thickness and from non-biopsy sampling like stratum corneum scrapings which are not reportable.