Special Alert August 2025 - Benign Skin Lesion Removal Billing Guidelines

Immediately: Billing team must implement diagnosis code validation for all benign skin lesion removal claims submitted to Providence Health Plan (Commercial and Medicare lines). REQUIREMENTS: (1) For Commercial plans: Configure billing software to require either a Group 1 diagnosis code alone, OR a Group 1 + Group 2 diagnosis code combination, OR Group 3 malignant diagnosis codes (for CPT 11300-11313 only) when submitting CPT codes 11300-11313, 11400-11446, 17110-17111. (2) For Medicare plans: Ensure CPT codes are billed only with diagnosis codes listed in Providence's Medicare Local Coverage Article. (3) Obtain the complete "Billing Guideline Appendix" from Providence (contact PHPMedicalPolicyInquiry@providence.org) to identify all valid diagnosis codes in Groups 1, 2, and 3. (4) Update all billing system rules, claim scrubbing logic, and provider encounter forms to enforce these diagnosis code requirements before claims are submitted. (5) Train providers and front-desk staff on the new diagnosis code pairing requirements. CONSEQUENCE: Claims billed with diagnosis codes not listed in Groups 1-3 will be denied as not medically necessary, resulting in payment denials and potential rework.