Medicare Advantage Medical Policy Bulletin
Section: CMS National Guidelines
Number: N-165
Topic: Treatment of Actinic Keratosis - NCD 250.4
Effective Date: December 12, 2008
Issued Date: March 9, 2009

General Policy

AKs, also known as solar keratoses, are common, sun-induced skin lesions that are confined to the epidermis and have the potential to become a skin cancer.

Various options exist for treating AKs. Clinicians should select an appropriate treatment based on the patient's medical history, the lesion's characteristics, and on the patient's preference for a specific treatment. Commonly performed treatments for AKs include cryosurgery with liquid nitrogen, topical drug therapy, and curettage. Less commonly performed treatments for AK include dermabrasion, excision, chemical peels, laser therapy, and photodynamic therapy. An alternative approach to treating AKs is to observe the lesions over time and remove them only if they exhibit specific clinical features suggesting possible transformation to invasive squamous cell carcinoma.

Indications and Limitations of Coverage

The destruction of actinic keratoses (702.0) is covered without restrictions based on lesion or patient characteristics.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

114001140111402114031140411406
114201142111422114231142411426
114401144111442114431144411446
157801578115782157831578615787
157881578915792157931700017003
1700496567J7308   

Coding Guidelines

 

Use codes 11400 – 11446 to report excisions.

Use codes 15780 – 15783, 15786 - 15787 to report dermabrasion.

Use codes 15788 – 15793 to report chemical peels.

Use codes 17000 – 17004 to report the destruction of actinic keratosis by any of the following methods:  laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettment.

Use codes 96567 with code J7308 to report photodynamic therapy.

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub 100-03, Part 4, Section 250.4

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

702.0   

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.