Billing skin lesion treatment and biopsy items under Medicare

Make sure you read the relevant MBS item descriptions and explanatory notes on the MBS Online website.

Skin or mucous membrane biopsies for diagnosis - item 30071 and 30072

You can bill MBS item 30071 for a diagnostic biopsy of skin or item 30072 for a diagnostic biopsy of mucous membrane. Use this item when you:

• perform the biopsy as an independent procedure
• send the specimen for pathological examination
• decide the biopsy is necessary to confirm the diagnosis, so you can manage the lesion.

You can bill item 30071 or 30072 if the shave biopsy results in definitively excising a lesion. Select additional item numbers if biopsy results show that the patient needs further treatment. Select the item numbers based on the results and treatment method.

If you perform multiple biopsies on separate lesions on the one day, make sure you note on the claim or account either:

• ‘separate sites’
• the exact location of the biopsy.

Administrative requirements for skin services

Determining lesion size for MBS item selection

To determine the necessary excision diameter or defect size, you should include:

• the lesion size
• an appropriate margin of healthy tissue needed for complete surgical excision.

Make sure you take measurements before excision. You’ll need to determine the margin size in line with these National Health and Medical Research Council guidelines:

• Clinical practice guide: Basal cell carcinoma, squamous cell carcinoma (and related lesions) - a guide to clinical management in Australia. November 2008. Cancer Council Australia
• Clinical practice guidelines for the management of melanoma in Australia and New Zealand. 2008. Ministry of Health, New Zealand.

The image below shows the area of the lesion, margin and closure.

For items 31356 to 31383, you can calculate the defect size using:

• the average width
• the length of the skin lesion
• an appropriate margin.

Calculate the necessary excision diameter as follows:

Histology requirements for skin service items

Keeping evidence for skin services

You must keep copies of histological reports and any other supporting evidence. This includes patient notes and photographs. If you take photographs, you should include scale. You can keep electronic records.

Read more about administrative record keeping guidelines for health professionals on the Department of Health and Aged Care (Health and Aged Care) website.

Read the guideline for substantiating proof of malignancy for items 30196 and 30202 on the Department of Health and Aged Care website.

Billing multiple services

You can bill multiple items if you treat more than one lesion on the same patient, and it’s on the same occasion.

Some skin service items are for treating multiple lesions. If you treat lesions described in one of these items, the item covers all lesions of that type.

If you bill for 2 or more procedures on the same occasion, note the location of each on the claim or account. For electronic claims, use the appropriate indicator as well as service text.

An episode of care includes both the excision and closure for the same defect. This is true even when excision and closure are at separate attendances.

Read more about billing multiple MBS items.

If you bill multiple items, they may be subject to the multiple operation rule.

Scenario 1 - Billing multiple skin flap items

A patient is present with a torn earlobe. You perform a flap repair on both the front and rear of the earlobe.

The patient also mentions a lesion on their cheek. The lesion appears to be a small malignant melanoma. You calculate the defect size as 11 mm, excise it and send the specimen for histology.

The next day you receive the histology report, and it confirms malignancy. You bill item 45206 for each of the skin flaps. You also bill item 31372 for the excision as a separate defect.

The description of item 45206 says ‘not in association with any of items 31356 to 31376’.

You can bill all 3 items because the defect you’re repairing with the local flaps was not created by the excision.

You should note ‘separate sites’ or the location of each procedure on the account to help us assess the claim.

Scenario 2 - Billing for multiple lesions

You surgically excise 6 cysts from your patient’s mouth on one occasion. Five of the cysts are under 10 mm in diameter and one is 14 mm in diameter.

Items 31206 to 31225 are for excising cysts.

Item 31221 is for removing 4 to 10 lesions that are less than 10 mm in diameter on a mucous membrane. You bill one item 31221 for removing all 5 small lesions.

Item 31211 is for removal of one lesion that’s over 10 mm and not more than 20 mm on a mucous membrane. You bill item 31211 for removing the large lesion.

Billing for excision and re-excision of suspected and confirmed malignant lesions

You surgically excise a lesion that you clinically suspect is a melanoma and send the specimen for histopathology.

Histopathology confirms the lesion is a melanoma and you perform a definitive wider excision to remove all cancerous tissue. You send the specimen for histopathology to confirm all cancerous tissue has been removed.

Histopathology confirms further excision is needed to remove cancerous remnants and you perform a definitive wider excision.

Items 31377 to 31383 can be claimed for the excision of a clinically suspected melanoma.

Items 31371 to 31376 can be claimed for a definitive excision of a confirmed malignancy. These items can be claimed twice where additional definitive excision is required.

In all cases you must send the specimen for histopathology in order to bill for these items.

You might need to re-excise a malignant skin lesion:

• if the original surgical excision was incomplete
• to make sure you remove an adequate margin of healthy tissue around an excised malignant skin lesion to prevent reoccurrence.

If you perform an excision or re-excision, select the item for the excision diameter based on the defect size and an appropriate margin of healthy tissue needed for complete surgical excision.

Billing derived fee item 31340

You can bill item 31340 where treatment for a skin malignancy requires the excision of muscle, bone or cartilage. It must also be covered by one of these base items:

• 31000 to 31005
• 31356
• 31358 and 31359
• 31361
• 31363
• 31365
• 31367
• 31369
• 31371 to 31376.

Item 31340 has a 75% derived fee calculation. This means that we’ll calculate the schedule fee at 75% of the fee of the associated base item.

When you bill item 31340, list it under the base item. If that’s not possible, note the associated base item.

If you bill 2 base items with 2 item 31340, you must list each under its associated base item. If that’s not possible, you should note the base item and site of the procedure for each item 31340.

Skin services covered by attendance items

If you treat seborrheic keratoses, by any means, they’ll attract benefits under attendance items.

If you’re treating fewer than 10 solar keratoses by ablative techniques, they’ll attract benefits under attendance items.

If you’re treating warts and molluscum contagiosum, they attract benefits under attendance items. There may be some exceptions. There’s more information in the 30187 and 30189 item descriptions, and MBS explanatory notes.

Lesion treatment methods other than excision

Laser treatments for vascular lesions, items 14100 to 14124

Items 14100 to 14124 are for treating vascular lesions by laser photocoagulation using laser radiation. These items also include any consultation associated with the treatment. If the patient needs a second consultation for a different condition on the same day, you’ll need to note:

• that the consultation is for an unrelated issue
• the separate times you provided the services.

Items 14100 to 14118 have a maximum number of sessions in a 12 month period. This starts on the date of the first session.

Maximum numbers stated in item descriptions include all sessions to which items 14100 to 14118 apply.

You can use the MBS Items Online Checker in Health Professional Online Services (HPOS) to:

• view and check patient eligibility based on their MBS history
• check your own eligibility for claiming MBS items
• check claiming conditions for MBS items.

You can also call us to check eligibility.

If you bill item 14100 or 14124, you need to keep photographs on the patient’s record.

Laser treatments for severely disfiguring lesions

Items 30190 and 30191 are for removing or treating severely disfiguring or recurrently bleeding tumours, usually by laser ablation. The items don’t include treating:

• melanocytic naevi
• sebaceous hyperplasia
• dermatosis papulosa nigra
• Campbell De Morgan angiomas
• seborrheic or viral warts.

These items require a specialist dermatologist to confirm the diagnosis.

Other laser skin treatments

The following items are for treatment using either:

• carbon dioxide laser
• erbium laser.

Items 45025 and 45026 are for resurfacing severely disfiguring scarring of the face or neck.

Item 45652 is for treating moderate or severe rhinophyma.

Item 45669 is for a vermilionectomy of cellular abnormalities of the lip that were confirmed through a biopsy.

Treatment for malignant neoplasms

Items 30196 and 30202 are for removing malignant neoplasms from skin or mucous membranes.

These items require that either:

• a specialist dermatologist or plastic surgeon has confirmed the diagnosis
• histopathology has proven the diagnosis.

Item 30196 still requires histopathology even if a specialist dermatologist or plastic surgeon has confirmed the diagnosis. However, you don’t need the results before billing this item.

Injections of glucocorticoid preparations

Items 30207 and 30210 are to treat skin lesions by injecting glucocorticoid preparations.

Item selection for excision of skin lesions

Removal of tumour, cyst, ulcer or scar items 31206 to 31225

These MBS items are for removing a tumour, cyst, ulcer or scar using surgical excision. They don’t include scars removed either:

• during the surgical approach at an operation
• using shave excision.

You must send the specimen for histological examination for these item numbers.

Items 31220 and 31225 don’t attract benefits for excising viral verrucae - common warts - and seborrheic keratoses.

Excision of non-malignant skin lesions - items 31357, 31360, 31362, 31364, 31366, 31368 and 31370

These MBS items are for excising non-malignant skin lesions such as:

• suspicious pigmented lesions
• solar keratoses - where clinically indicated
• cysts
• ulcers
• scars other than a scar removed during the surgical approach at an operation.

They aren’t for viral verrucae such as common warts, or seborrheic keratoses.

You must send the specimen for histological examination for these item numbers.

Excision of malignant skin lesions - items 31356, 31358, 31359, 31361, 31363, 31365, 31367, 31369

These MBS items are for excising malignant skin lesions such as:

• basal cell carcinomas
• squamous cell carcinomas, including keratoacanthoma
• cutaneous deposit of lymphoma
• cutaneous metastasis from an internal malignancy.

You must get histological malignancy confirmation before billing the relevant skin malignancy item.

You can bill an incomplete surgical excision of a malignant skin lesion as a malignant skin lesion excision item if you performed it with curative intent. You can bill this item even when the patient needs further surgery.

You might need to re-excise:

• if the original excision was incomplete
• to ensure you remove an adequate margin of healthy tissue to prevent reoccurrence.

You can bill a second item in this range of items if re-excision is necessary. You should base the item you choose on the size of the necessary excision diameter and the item descriptor.

Excision of malignant melanoma - items 31371 to 31376

These MBS items are for excising:

• malignant melanoma
• appendageal carcinoma
• malignant connective tissue tumour of skin
• merkel cell carcinoma of skin.

You must get histological malignancy confirmation before billing the relevant item.

You can bill an incomplete surgical excision of a malignant melanoma performed with curative intent as a malignant melanoma excision item. You can do this even when the patient needs further surgery.

You might need to re-excise:

• if the original excision was incomplete
• to ensure you remove an adequate margin of healthy tissue to prevent reoccurrence.

You can bill a second item in this range of items if re-excision is necessary. You should base the item you choose on the size of the necessary excision diameter and the item descriptor.

Excision of clinically suspected melanoma items 31377-31383

Health professionals can claim these items for clinically suspected melanoma service before histological confirmation of malignancy. Once malignancy is confirmed you can perform a wide excision and claim an existing definitive excision item.

The MBS items in the following table are for excising clinically suspected melanoma.

You must send the specimen for histological examination but these items can be billed regardless of the histopathological findings.

Item selection for skin flaps

When you perform a skin flap procedure with a skin lesion excision, consider the restrictions outlined in the item descriptions.

When you perform multiple excisions or flap items on the same occasion, you should note the associated excision item on the claim or account. If you include 2 or more skin flap items, you should note the exact location of each.

Item selection for Mohs surgery

Only approved Mohs surgeon specialists can perform Mohs surgery. The surgeon must be recognised by the Australasian College of Dermatologists. To bill these items, you must map and histologically examine all tissue you excise.

When you excise more than 1 lesion on the same occasion, you should notate separate sites. This applies to multiple lesions treated by Mohs surgery, as well as lesions treated by other methods.

Post-operative treatment - aftercare

The skin service procedures covered in this guide include:

• all professional attendances for a patient’s post-operative treatment until they recover
• the final check or examination.

Medicare benefits aren’t payable if the practitioner who performed the procedure provides routine post-operative care.

When the patient can’t return to the treating practitioner for post-operative care, the general practitioner providing the aftercare can bill for it. They should use attendance items.

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