CPT 11426Surgery

Exc h-f-nk-sp b9+marg >4 cm

CPT 11426 covers the surgical removal of a benign (non-cancerous) skin growth larger than 4 centimeters from the head, face, neck, hands, feet, or genitalia, including margins to ensure complete removal.

Showing rates for

National Average

Base Medicare rate

$321.85

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

4.09

PE RVU (NF)

5.22

MP RVU

0.64

Total RVU

9.95

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

NCCI bundling edits

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Billing tips

Measure and document the excised diameter (including margins), not the lesion diameter alone. The excised specimen size determines the code level.
Impact: Correct measurement documentation prevents downcoding from 11426 ($321.85) to 11424 ($198.77), protecting $123.08 per procedure
Verify the anatomic site qualifies for the head-face-neck-hands-feet-genitalia designation. Lesions on trunk or extremities use different codes (11403-11406) with lower reimbursement.
Impact: Incorrect site coding can result in $100+ underpayment; 11426 pays significantly more than 11406 ($241.61 non-facility)
Document benign pathology diagnosis clearly. Malignant lesions require different CPT codes (11640-11646) with different reimbursement structures.
Impact: Using excision codes for proven malignancies invites denials; ensure pathology report confirms benign nature for claim support
Bill intermediate or complex repair codes (12031-12057, 13100-13153) separately only when closure is significantly more complex than simple closure included in 11426.
Impact: Appropriate complex closure coding can add $150-$400, but documentation must justify closure complexity beyond simple layered closure
When multiple lesions are excised, list 11426 first if it is the highest RVU code, then append modifier 51 to subsequent procedures to maximize reimbursement.
Impact: Proper sequencing ensures full payment for highest-value procedure; reverse sequencing can cost 50% of 11426 payment ($160.93)
Submit pathology report with initial claim for commercial payers to prevent medical necessity denials, especially for lesions described as cosmetic.

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Frequently asked questions

What is the Medicare reimbursement for CPT code 11426 in 2025?

Medicare pays $321.85 for CPT 11426 in non-facility settings and $264.27 in facility settings based on the 2025 national average rates. The code has 9.95 total RVUs (4.09 work RVU, 5.22 non-facility PE RVU, 0.64 MP RVU) using the 2025 conversion factor of 32.3465.

How large does a lesion need to be to qualify for CPT 11426?

The excised diameter (lesion plus margins) must exceed 4.0 centimeters. This measurement is based on the total specimen removed, not just the visible lesion. Documentation must clearly state the excised diameter measurement to support code selection.

What anatomic sites qualify for CPT 11426 versus other excision codes?

CPT 11426 applies only to lesions on the head, face, ears, eyelids, nose, lips, mucous membranes, neck, hands, feet, and genitalia. Lesions on the trunk, arms, legs, or other areas use codes 11403-11406 which have different reimbursement rates.

Can I bill CPT 11426 with a closure code on the same date?

Simple closure is included in CPT 11426 and cannot be billed separately. Intermediate (12031-12057) or complex (13100-13153) repairs can be billed separately only when the closure complexity significantly exceeds simple layered closure, with documentation supporting the additional work.

What modifier should I use when excising multiple benign lesions?

Use modifier 51 on the second and subsequent excision codes when multiple lesions are removed in the same session. List the highest RVU code first without a modifier, then append modifier 51 to additional procedures which will be reimbursed at 50% of the allowed amount.

Does CPT 11426 require pathology confirmation for payment?

While not universally required for payment, many payers request pathology reports to confirm benign diagnosis and verify specimen size. Submitting pathology with the initial claim significantly reduces denial rates and medical necessity challenges, especially for large lesions that might be questioned as cosmetic.

What is the difference between CPT 11426 and 11424?

The sole difference is excised diameter size: 11424 is for lesions 3.1-4.0 cm (pays $198.77 non-facility), while 11426 is for lesions exceeding 4.0 cm (pays $321.85 non-facility). Both apply to the same anatomic sites. Accurate measurement documentation is critical as the $123.08 payment difference makes this a common audit target.