CPT 11626Surgery

Exc s/n/h/f/g mal+mrg >4 cm

CPT 11626 covers surgical removal of a cancerous skin growth larger than 4 centimeters (about 1.6 inches) from the scalp, neck, hands, feet, or genitals, including a margin of healthy tissue around it.

Showing rates for

National Average

Base Medicare rate

$394.95

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

4.61

PE RVU (NF)

6.83

MP RVU

0.77

Total RVU

12.21

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Verify lesion size exceeds 4.0 cm in the operative report with exact measurements; lesions measuring 3.9-4.0 cm fall into 11624 ($296.51 non-facility), resulting in $98.44 underpayment if incorrectly coded
Impact: $98.44 revenue loss per case if downcoded; size threshold is strict and frequently audited
Bill in non-facility setting when appropriate (office-based surgical suite, ASC) to capture the full $394.95 versus facility rate of $283.03
Impact: $111.92 higher reimbursement per case in non-facility setting; verify payer policies and patient safety appropriateness
Document the specific anatomic site (scalp, neck, hands, feet, genitalia) explicitly in operative report; vague documentation may result in downcoding to lower-paying trunk/extremity codes (11606 series)
Impact: Potential $100+ revenue loss if reclassified to 11606 ($286.94 non-facility); anatomic specificity prevents arbitrary downcoding
Do not separately bill for simple or intermediate closure as it is included in the excision code; complex repair (13100 series) or flaps/grafts (14000-15000 series) may be separately billable
Impact: Simple/intermediate closure billing triggers 100% denial with potential fraud investigation; appropriate adjacent tissue transfer can add $400-1200+ in legitimate revenue
Capture all 12.21 total RVUs by ensuring place of service code accuracy; incorrect POS code can trigger facility rate payment even when performed in office
Impact: $111.92 per case loss if POS code error triggers facility rate; verify POS 11 for office, POS 22 for outpatient hospital, POS 24 for ASC
When pathology reveals positive margins requiring re-excision, bill subsequent procedure with modifier 58 if within global period and documented as staged; do not use modifier 76 which implies identical repeat

Live Field Datano reports yet

Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.

Working with CPT 11626?

Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.

Help build the field knowledge

MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.

Related actions

Frequently asked questions

What is the Medicare reimbursement for CPT 11626 in 2025?

Medicare pays $394.95 for CPT 11626 in non-facility settings and $283.03 in facility settings based on the 2025 Physician Fee Schedule. The rate varies by geographic location with locality-specific adjustments to the national average.

What size lesion qualifies for CPT code 11626?

CPT 11626 requires the excised malignant lesion to exceed 4.0 cm in greatest diameter. This measurement includes the lesion itself but the code also covers the excision of appropriate margins around the tumor. Lesions measuring exactly 4.0 cm or smaller fall into code 11624.

Can I bill 11626 with a closure code?

Simple and intermediate closures are included in CPT 11626 and cannot be separately billed. However, complex repairs (13100 series), adjacent tissue transfers (14000 series), or skin grafts (15000 series) may be separately billable when documentation supports the additional complexity and medical necessity.

What body areas are covered by CPT 11626?

CPT 11626 specifically covers malignant lesion excisions from the scalp, neck, hands, feet, and genitalia. These anatomic sites are designated as high-complexity areas. Lesions from the trunk, arms, legs, or face require different CPT codes (11600-11606 series).

How many RVUs is CPT code 11626 worth?

CPT 11626 has 12.21 total RVUs in 2025, consisting of 4.61 work RVUs, 6.83 non-facility practice expense RVUs (3.37 in facility setting), and 0.77 malpractice RVUs. This makes it a moderately high-value surgical procedure code.

Do I need a biopsy before billing CPT 11626?

While not absolutely required by CPT definitions, best practice and most payer policies expect pre-operative pathologic confirmation of malignancy before excision. Without prior biopsy proof, medical necessity may be questioned during claims review, though clinical diagnosis of obvious malignancy may be acceptable in some cases.

What modifier should I use for multiple lesion excisions with 11626?

Use modifier 59 when excising multiple distinct lesions in different anatomic locations during the same session to indicate separate procedures. Modifier 51 may be required by some payers for the secondary procedure. Always verify the lesions are truly separate and not connected, and document distinct anatomic sites clearly.