CPT 11463Surgery

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CPT code 11463 is used when a surgeon removes diseased sweat glands and surrounding tissue in areas like the armpits or groin, typically for severe or recurring hidradenitis suppurativa (chronic painful lumps and abscesses). This is a complex excision that involves cutting away infected skin and tissue.

Showing rates for

National Average

Base Medicare rate

$510.43

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

4.43

PE RVU (NF)

10.47

MP RVU

0.88

Total RVU

15.78

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

NCCI bundling edits

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Billing tips

Always verify facility vs. non-facility status before billing; office-based procedures qualify for non-facility rate
Impact: $184.38 difference between non-facility ($510.43) and facility ($326.05) rates—ensure correct place of service code
Document complexity factors explicitly: depth of excision, involvement of sinus tracts, undermining required, layered closure technique
Impact: Prevents downcoding to simpler excision codes (11401-11406) which pay $150-250 less; complexity justifies the 4.43 work RVUs
For staged procedures, document in operative note that this is part of planned staged treatment and use modifier 58
Impact: Avoids global period denials; ensures full $510.43 payment for each stage rather than bundled denial
When billing with complex repair codes (13100-13133), ensure documentation supports separate procedures or use modifier 59 if at distinct sites
Impact: Complex closure is typically included in 11463; separate billing requires clear documentation to avoid $200-400 in bundled denials
Submit operative report with initial claim for commercial payers and Medicare when using modifier 22 for extensive disease
Impact: Increases approval rate for 20-30% additional payment ($102-153 extra); reduces appeal cycle time by 30-45 days
Link to appropriate ICD-10 code L73.2 (hidradenitis suppurativa) and specify site/severity to support medical necessity
Impact: Reduces medical necessity denials by 40%; some payers require pre-authorization for this code without proper diagnosis documentation

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Frequently asked questions

What is the CPT code 11463 used for?

CPT 11463 is used for excision of complex hidradenitis suppurativa in the inguinal (groin) region. This involves removing diseased sweat glands, infected tissue, and sinus tracts in cases of severe or recurrent chronic skin infection that hasn't responded to conservative treatment.

How much does Medicare pay for CPT code 11463 in 2025?

In 2025, Medicare pays $510.43 for CPT 11463 in non-facility settings (office or ASC) and $326.05 in facility settings (hospital outpatient). The non-facility rate is higher because it includes overhead costs for equipment and space.

What is the difference between CPT 11463 and simpler excision codes?

CPT 11463 is specifically for complex excision of hidradenitis suppurativa requiring removal of apocrine glands and deeper tissue structures with layered closure. Simple excision codes (11401-11406) are for benign lesions with simple margins and primary closure, paying significantly less ($150-280) and carrying fewer RVUs.

Can CPT 11463 be billed bilaterally?

Yes, CPT 11463 can be billed bilaterally using modifier 50 when both inguinal regions are excised during the same operative session. Most payers reimburse bilateral procedures at 150% of the base rate rather than 200%, resulting in approximately $765.65 total payment.

What documentation is required to bill CPT 11463?

Required documentation includes confirmed diagnosis of hidradenitis suppurativa, specific anatomic location, documented complexity (depth, sinus tracts, gland involvement), tissue dimensions, layered closure technique, failed conservative treatments, and operative time. The operative report must clearly distinguish this from simpler excisions to avoid downcoding.

Is pre-authorization required for CPT code 11463?

Pre-authorization requirements vary by payer. Many commercial insurance plans require pre-authorization for CPT 11463 due to its surgical nature and reimbursement level. Medicare typically doesn't require pre-auth but does require medical necessity documentation. Always verify with the specific payer before scheduling.

Can CPT 11463 be performed in an office setting?

Yes, CPT 11463 can be performed in an appropriately equipped office-based surgical suite, and doing so qualifies for the higher non-facility rate of $510.43. The facility must meet safety standards for surgical procedures, and the physician must have appropriate privileges and malpractice coverage for office-based surgery.