CPT 11104Surgery

Punch bx skin single lesion

CPT code 11104 covers a punch biopsy of a single skin lesion, where a circular blade removes a small cylinder of tissue for examination. This is the initial or only lesion biopsied during the encounter.

Showing rates for

National Average

Base Medicare rate

$119.36

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.83

PE RVU (NF)

2.76

MP RVU

0.1

Total RVU

3.69

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Bill 11104 only once per encounter regardless of number of punch biopsies from same lesion; use 11105 for each additional separate lesion
Impact: Prevents $119.36 denial for duplicate billing. Proper sequencing with 11105 (pays ~$15-20 per additional lesion) maximizes appropriate reimbursement
Always append modifier 25 to same-day E/M when biopsy decision was made during that visit; document medical necessity separately in E/M note
Impact: Recovers $75-$200 in E/M reimbursement that would otherwise be denied as bundled; ensure E/M documentation is distinct from procedure note
Verify place of service code accuracy: POS 11 (office) yields $119.36 vs POS 22 (hospital outpatient) yields $45.29 to provider
Impact: $74.07 difference in physician reimbursement based on facility vs non-facility status; verify contracted rates align with service location
Do not separately bill for local anesthesia (64400-64530) or simple closure—these are bundled into 11104 payment
Impact: Prevents unbundling denials and potential fraud flags; anesthesia and simple closure already reflected in $119.36 rate
Link appropriate ICD-10 code indicating medical necessity (e.g., D22.x for nevus, L82.x for seborrheic keratosis, C44.x for skin malignancy); cosmetic biopsies not covered
Impact: Medical necessity documentation prevents complete denial; cosmetic indication results in $119.36 patient responsibility or denial
Document lesion location, size, appearance, and clinical indication in procedure note; photograph when possible for appeal support
Reduces audit risk and strengthens appeals; inadequate documentation is primary reason for post-payment recoupment of $119.36

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Frequently asked questions

What is the difference between CPT 11104 and 11105?

CPT 11104 is used for the first punch biopsy lesion performed during an encounter and reimburses at $119.36 (non-facility). CPT 11105 is an add-on code used for each additional lesion biopsied during the same session and pays approximately $15-20 per lesion. You must bill 11104 first, then 11105 for subsequent lesions—never bill 11104 more than once per date of service.

How much does Medicare pay for CPT code 11104 in 2025?

Medicare pays $119.36 for CPT 11104 in non-facility settings (physician office) and $45.29 in facility settings (hospital outpatient) based on the 2025 Physician Fee Schedule. These are national averages; actual payment varies by geographic locality and MAC jurisdiction.

Can I bill an E/M visit with CPT 11104 on the same day?

Yes, you can bill an E/M service with 11104 on the same day using modifier 25 on the E/M code, but the E/M must be separately identifiable and medically necessary beyond the decision to perform the biopsy. Documentation must clearly support distinct evaluation and management services, such as addressing other conditions or a comprehensive skin examination that led to discovering the lesion requiring biopsy.

Is local anesthesia included in CPT 11104 reimbursement?

Yes, local anesthesia is bundled into CPT 11104 and cannot be billed separately. The $119.36 Medicare payment includes the anesthetic administration, so billing codes like 64400-64530 or drug administration codes with 11104 will result in denials for unbundling.

What is the global period for CPT 11104?

CPT 11104 has a 10-day global period, meaning routine post-operative care within 10 days of the biopsy is included in the reimbursement. Separate E/M services during this period require modifier 24 (unrelated) or 25 (significant, separately identifiable) to receive payment, and complications may require modifier 78 or 79 depending on circumstances.

What are the RVUs for CPT code 11104 in 2025?

The 2025 RVUs for CPT 11104 are: Work RVU 0.83, Practice Expense RVU 2.76 (non-facility) or 0.47 (facility), Malpractice RVU 0.10, for a total of 3.69 non-facility RVUs. These are multiplied by the 2025 conversion factor of 32.3465 to determine Medicare payment.

Should I use CPT 11104 or 11102 for a skin biopsy?

Use CPT 11104 for punch biopsies (circular blade technique) and CPT 11102 for tangential biopsies including shave, scoop, or saucerization techniques. The distinction is based on the biopsy method used, not the lesion type. Punch biopsies obtain a cylindrical full-thickness sample, while tangential biopsies remove tissue parallel to the skin surface. Incorrect code selection can result in payment differences and denials.