CPT 11604Surgery

Exc tr-ext mal+marg 3.1-4 cm

CPT code 11604 covers the surgical removal of a malignant (cancerous) skin lesion measuring 3.1 to 4.0 centimeters from the trunk, arms, or legs, including the margins around it. This is a full-thickness excision that removes the tumor and surrounding tissue to ensure complete removal.

Showing rates for

National Average

Base Medicare rate

$302.44

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

3.17

PE RVU (NF)

5.75

MP RVU

0.43

Total RVU

9.35

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 just the visible lesion diameter. For 11604, the total excised specimen must measure 3.1-4.0 cm.
Impact: Incorrect measurement documentation is the #1 cause of downcoding. If excised diameter is documented as 3.0 cm, payers will downcode to 11603, reducing reimbursement by approximately $77-87
Always document the specific anatomic location (trunk, arm, leg, hand, or foot) in the operative note. Generic terms like 'skin' are insufficient.
Impact: Missing anatomic location triggers audits and potential denials. Location determines code family (11600-series vs 11400-series); incorrect location coding can result in $50-150 payment variance
Bill facility vs non-facility based on actual place of service. Office-based procedures qualify for non-facility rate ($302.44), while ASC/HOPD use facility rate ($207.34).
Impact: Ensures correct reimbursement differential of $95.10. Incorrect POS code can trigger recoupment or underpayment
When pathology confirms benign findings contrary to clinical suspicion, do not retroactively change to benign excision code. Code based on pre-excision clinical indication.
Impact: Coding based on clinical presentation when malignancy is suspected is appropriate and defensible; recoding to benign (11423) reduces payment by approximately $100-120
For layered or complex closures exceeding simple closure, bill appropriate closure code (12031-12057) separately. Simple closure is included in 11604.
Impact: Complex closure codes add $150-400 to reimbursement when documented properly. Failing to bill separately leaves significant revenue on the table

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 11604 in 2025?

The 2025 Medicare national average reimbursement for CPT 11604 is $302.44 for non-facility settings (office-based) and $207.34 for facility settings (ASC/HOPD). Actual reimbursement varies by geographic location based on local GPCI adjustments. The code has a total RVU of 9.35 (Work RVU: 3.17, Non-facility PE: 5.75, Facility PE: 2.81, MP: 0.43).

How do I measure lesion size correctly for CPT 11604?

For CPT 11604, measure the total excised diameter including margins, not just the visible lesion. The excised specimen must measure 3.1 to 4.0 cm in greatest diameter. For example, a 2.5 cm lesion excised with 0.5 cm margins results in 3.5 cm excised diameter, appropriate for 11604. Measure before excision with calipers and document in the operative note; pathology specimen size can corroborate your measurements.

Can I bill CPT 11604 for multiple lesions on the same day?

Yes, you can bill 11604 multiple times for separate lesions excised during the same session, but you must use modifier 59 or XS on subsequent excisions to indicate distinct procedural services. The first excision receives 100% reimbursement ($302.44 non-facility), while additional excisions typically receive 50% reimbursement due to multiple procedure payment reduction. Each lesion must be separately documented with location and size.

What anatomic locations are appropriate for CPT 11604?

CPT 11604 applies to malignant lesion excisions on the trunk (chest, back, abdomen), arms, legs, hands, and feet. This code is NOT appropriate for scalp, neck, face, ears, eyelids, nose, lips, or mucous membranes - those locations use the 11640-11646 code series. Genitalia use 11620-11626 series. Accurate anatomic documentation is essential for correct code selection.

What if the pathology comes back benign after I coded for malignant excision?

Code based on clinical indication at the time of service, not final pathology results. If you had reasonable clinical suspicion of malignancy (based on appearance, dermoscopy, patient risk factors), coding 11604 is appropriate even if pathology shows benign findings. Document your clinical rationale for suspecting malignancy in the pre-operative note. Medicare and most payers support coding based on pre-excision clinical assessment.

Is closure included in CPT 11604 or billed separately?

Simple (single-layer) closure is included in CPT 11604 and should not be billed separately. However, intermediate closure (layered closure of subcutaneous tissue and skin) or complex closure (requiring undermining, stents, or retention sutures) should be billed separately using codes 12031-12057 based on location and length. Skin grafts and flaps also require separate codes (14000-14302, 15002-15261).

What ICD-10 diagnosis codes support medical necessity for CPT 11604?

Primary diagnosis codes include malignant melanoma (C43.5x-C43.9 for trunk/extremity sites), squamous cell carcinoma (C44.519, C44.529, C44.599, C44.619, C44.629), basal cell carcinoma (C44.511, C44.521, C44.591, C44.611, C44.621), and other malignant neoplasms of skin (C44.59, C44.69). Use the most specific code available with appropriate laterality and anatomic detail. Pre-malignant lesions (D04.x) may not support malignant excision codes.