11602

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm

Current Procedural Terminology (CPT) code 11602 represents the surgical excision of a malignant skin lesion situated on the trunk, arms, or legs, where the total excised diameter measures between 1.1 and 2.0 centimeters. The excised diameter is calculated by measuring the maximum clinical diameter of the lesion plus the most narrow clinical margins required for adequate oncologic excision prior to the surgical intervention. This procedure is indicated for patients with histologically confirmed or highly suspected cutaneous malignancies, such as basal cell carcinoma, squamous cell carcinoma, or malignant melanoma, located on the specified anatomic areas. The excision encompasses a full-thickness removal of the skin and lesion, extending completely through the dermis and down into, or completely through, the subcutaneous adipose tissue to ensure clear, tumor-free margins. Proper surgical planning is essential to balance oncologic control with functional and aesthetic outcomes. The procedure is typically performed under local anesthesia. Following precise measurement and marking of the lesion and the predetermined surgical margins, the physician makes an elliptical incision around the target area. The tissue is carefully dissected and completely removed as a single specimen to allow for accurate pathologic evaluation of the deep and peripheral margins. After achieving adequate hemostasis utilizing electrocautery or ligation, the resulting surgical defect is typically closed using a simple, non-layered closure technique. It is important to note that CPT code 11602 inherently includes simple repair. If the defect requires an intermediate (layered) or complex closure, or reconstructive techniques such as an adjacent tissue transfer or flap, these additional procedures should be coded separately and the appropriate modifier applied if necessary. This excision code relies heavily on accurate presurgical measurement of the lesion and margins, not the size of the final histologic specimen, as tissue shrinkage occurs post-excision. Proper documentation of the initial dimensions in the operative report is critical for accurate code assignment. Proper execution of this procedure is fundamental to dermatologic surgery and oncology. Accurate selection of this code requires a thorough understanding of the anatomic site, the lesion's nature, and the precise measurements involved. Physicians must clearly document the presurgical dimensions in the medical record to substantiate the medical necessity and code selection in the event of an audit. Additionally, any adjunctive procedures such as frozen section pathology or Mohs micrographic surgery are governed by distinct CPT codes and should not be confused with the standard excision code 11602.

Clinical Indications

  • Presence of a confirmed or highly suspected malignant skin lesion (e.g., basal cell carcinoma, squamous cell carcinoma, malignant melanoma).
  • Lesion is anatomically located on the trunk, arms, or legs.
  • The total excised diameter (maximum diameter of the lesion plus the required narrowest surgical margins) measures between 1.1 cm and 2.0 cm.
  • Need for definitive oncologic surgical treatment to obtain clear histologic margins.

Procedure Steps

  1. Verify the patient's identity, confirm the site of the malignant lesion, and obtain informed surgical consent.
  2. Cleanse and prep the surgical site on the trunk, arm, or leg with an antiseptic solution.
  3. Measure the maximum clinical diameter of the lesion and determine the narrowest surgical margins required for adequate excision.
  4. Document that the total planned excised diameter is between 1.1 cm and 2.0 cm prior to administering anesthesia.
  5. Administer local anesthesia (e.g., lidocaine with or without epinephrine) to the targeted excision site.
  6. Mark the planned elliptical excision lines on the skin.
  7. Make a full-thickness incision through the dermis and into the subcutaneous tissue following the marked surgical lines.
  8. Dissect the tissue block containing the lesion and margins away from the underlying deep fascia or muscle bed.
  9. Achieve hemostasis using electrocautery, chemical hemostatics, or suture ligation.
  10. Send the excised tissue specimen to surgical pathology for histologic examination and margin evaluation.
  11. Close the resulting surgical defect using simple (non-layered) closure techniques.
  12. Apply an appropriate sterile dressing and provide post-operative wound care instructions.

Coding Guidelines

  • Report CPT 11602 specifically for malignant lesions located on the trunk, arms, or legs with a total excised diameter of 1.1 to 2.0 cm.
  • The excised diameter must be measured prior to excision. Do not base the code selection on the size reported in the pathology report, as tissue shrinkage inevitably occurs during formalin fixation.
  • Simple closure (repair) is inherently included in the excision code 11602 and should not be reported separately.
  • If intermediate repair (12031-12037) or complex repair (13100-13102) is medically necessary and performed, it may be reported separately in addition to the excision code.
  • If the final pathology report indicates a benign lesion, the billed code should generally be amended to the corresponding benign excision code (11400-11406 series), unless payer-specific guidelines allow coding based on high clinical suspicion of malignancy at the time of excision.
  • Each excised lesion must be reported separately. If multiple lesions are excised during the same operative session, append modifier 59 or 51 to subsequent procedures depending on individual payer guidelines.
  • Do not append modifier 50 for bilateral procedures; lesions are coded individually based on size and site.

Associated ICD-10 Codes