Education guide - Billing skin lesion excision and biopsy items under Medicare

Information for billing skin biopsy, skin lesion excision and associated skin flap MBS items.

Make sure you also read the relevant Medicare Benefits Schedule (MBS) item descriptions and explanatory notes on the MBS Online website.

This is an education guide only. The treating practitioner is responsible for making sure any services billed to Medicare meet:

  • the item descriptions in the MBS, and
  • any eligibility requirements in full

Biopsy of skin or mucous membrane for diagnostic purposes (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 when the biopsy:

  • is performed as an independent procedure
  • specimen is sent for pathological examination, and
  • is clinically necessary to confirm the diagnosis for appropriate management of the lesion

If a shave biopsy results in the definitive excision of a lesion, you can only bill MBS item 30071 or 30072. If biopsy results show further, clinically relevant treatment is needed, select additional item numbers based on the results and treatment method.

If you perform multiple biopsies on separate lesions on the one day, make sure the claim or account notes ‘separate sites’ or the exact location of the biopsy.

Administrative requirements for skin services

Determining lesion size for MBS item selection

The necessary excision diameter (or defect size) is the lesion size plus a clinically appropriate margin of healthy tissue needed for complete surgical excision. Make sure you take measurements before excision. Margin size should be determined in line with NHMRC 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, and
  • Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand (2008)

Lesion, margin and closure diagram

For the purpose of Items 31356 to 31376 the defect size by:

  • the average width
  • the length of the skin lesion, and
  • an appropriate margin

Calculate the necessary excision diameter as follows:

Histology requirements for skin service items

These item numbers require that the specimen be sent for histological examination.

Description MBS item
Excision of tumour, cyst, ulcer or scar items 31206 – 31225
Excision of bone or cartilage item 31340
Non-malignant skin lesion items 31357, 31360, 31362, 31364, 31366, 31368 and 31370

These item numbers require that the specimen is sent for histological examination for confirmation of malignancy and any subsequent specimens are sent for histological examination.

Description MBS item
Malignant skin lesion items 31356, 31358, 31359, 31361, 31363, 31365, 31367 and 31369
Malignant melanoma items 31371 to 31376

Note: You must get histological confirmation of malignancy before claiming the relevant skin malignancy item. If histological confirmation of malignancy is not ready at the time of issuing an account, use the appropriate non-malignant item.

Retention of evidence for skin services

You must keep copies of histological reports and any other supporting evidence, such as patient notes and photographs.

Photographs should include scale.

You can keep electronic records.

Read more about Administrative record keeping guidelines for health professionals on the Department of Health website.

Read the Guideline for substantiating proof of malignancy for items 30196 to 30205 on the Department of Health website.

Billing multiple services

For items that don’t cover multiple lesions, multiple skin service items can be billed where more than 1 lesion is treated on the same patient on the same occasion.

If you bill multiple procedures to Medicare, the procedures are subject to the multiple operations rule.

There are restrictions included in specific item descriptions that exclude other services from being performed together. If you bill restrictive items for services performed on the same day, endorse the account with additional information. This may include:

  • the time of service for separate occasions
  • separate sites if the procedure is an independent procedure, or
  • not in association with another item

If more than 2 procedures are performed on the same occasion, note the exact location.

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, even when excision and closure occur at separate attendances.

Billing re-excision of malignant lesions

You can bill a malignant excision item twice for the same skin lesion where further excision is required. This means malignant skin items can be used for the initial excision of the lesion and where clinically relevant, the re-excision.

Re-excision of a malignant skin lesion may be required if:

  • the original surgical excision was incomplete, or
  • to ensure an adequate margin of healthy tissue around an excised malignant skin lesion is achieved to prevent reoccurrence

Where a re-excision is performed, select the relevant MBS item for the size of excision diameter required as though no previous excision has occurred.

Billing derived fee item 31340

Item 31340 requires that the patient must be undergoing treatment for a skin malignancy covered by item 31000, 31001, 31002, 31356, 31358, 31359, 31361, 31363, 31365, 31367, 31369, 31371, 31372, 31373, 31374, 31375 or 31376 and requires the excision of muscle, bone or cartilage for completion of the procedure.

Item 31340 has a 75% derived fee calculation. This means that the schedule fee for item 31340 will be calculated at 75% of the schedule fee of the associated excision item.

In order for the system to calculate the correct schedule fee, you must claim item 31340 with 1 of the items in its description.

When claiming item 31340, list items directly under the base item, or if that isn’t possible note the associated base item.

If you bill two base items with two items 31340, list each 31340 directly under its associated base item or if that isn’t possible, note the base item and site of the procedure for each item 31340.

Skin services covered by attendance items

The treatment of seborrheic keratosis, by any means, attracts benefits on an attendance basis only.

Treatment of fewer than 10 solar keratoses by ablative techniques attracts benefits on an attendance basis only.

The treatment of warts and molluscum contagiosum attract benefits on an attendance basis. There are some exceptions. See item descriptions for 30185 to 30189 and MBS explanatory notes for more information.

Item selection for excision of skin lesions

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

These MBS items are for removal of tumour, cyst, ulcer or scar (other than scars removed during the surgical approach at an operation) by surgical excision (other than by shave excision).

These item numbers require that the specimen be sent for histological examination.

Items 31220 and 31225 do not attract benefits for excision of viral verrucae (common warts) and seborrheic keratoses.

MBS item Description Size of lesion
31206 removal from a mucous membrane by surgical excision <10mm
31211 removal from a mucous membrane by surgical excision 10 to 20mm
31216 removal from a mucous membrane by surgical excision >20mm
31220 removal from cutaneous or subcutaneous tissue - 4 to 10 lesions <10mm
31221 removal from a mucous membrane - 4 to 10 lesions <10mm
31225 removal from cutaneous, subcutaneous tissue or mucous membrane - more than 10 lesions <10mm

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

These MBS items are for the excision of non-malignant skin lesions such as suspicious pigmented lesion, solar keratosis (where clinically indicated), cyst, ulcer, or scar (other than a scar removed during the surgical approach at an operation) not including viral verrucae (common warts) and seborrheic keratosis.

These item numbers require that the specimen be sent for histological examination.

MBS item Description Size of lesion
31357 Nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area <6mm
31360 Nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area >6mm
31362 Face, neck, scalp, nipple-areola complex, distal limb (upper & lower) <14mm
31364 Face, neck, scalp, nipple-areola complex, distal limb (upper & lower) >14mm
31366 Any part of the body other than above <15mm
31368 Any part of the body other than above 15 to 30mm
31370 Any part of the body other than above >30mm

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

These MBS items are for the excision of malignant skin lesions such as basal cell carcinoma, squamous cell carcinoma (including keratoacanthoma), cutaneous deposit of lymphoma or cutaneous metastasis from an internal malignancy.

You must get histological malignancy confirmation before billing the relevant skin malignancy item. If histological confirmation of malignancy is not ready at the time of issuing an account, bill the appropriate non-malignant item.

MBS item Description Size of lesion
31356 Nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area <6mm
31358 Nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area >6mm
31359 Nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area At least one third of the surface area
31361 Face, neck, scalp, nipple-areola complex, distal limb (upper & lower) <14mm
31363 Face, neck, scalp, nipple-areola complex, distal limb (upper & lower) >14mm
31365 Any part of the body other than above <15mm
31367 Any part of the body other than above 15 to 30mm
31369 Any part of the body other than above >30mm

An incomplete surgical excision of a malignant skin lesion with curative intent can be billed as a malignant skin lesion excision item even when further surgery is needed. If re-excision is necessary, because the original excision was incomplete or to ensure an adequate margin of healthy tissue to prevent reoccurrence, a second item in this range of items can be billed based on the size of the necessary excision diameter and ensuring the item descriptor has been met in full.

Excision of malignant melanoma (items 31371 to 31376)

These MBS items are for excision of malignant melanoma, appendageal carcinoma, malignant connective tissue tumor of skin or merkel cell carcinoma of skin.

You must get histological malignancy confirmation before billing the relevant item. If histological confirmation of malignancy is not ready at the time of issuing an account, bill the appropriate non-malignant item.

MBS item Description Size of lesion
31371 Nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area >6mm
31372 Face, neck, scalp, nipple-areola complex, distal limb (upper & lower) <14mm
31373 Face, neck, scalp, nipple-areola complex, distal limb (upper & lower) >14mm
31374 Any part of the body other than above <15mm
31375 Any part of the body other than above 15 to 30mm
31376 Any part of the body other than above >30mm

You can bill an incomplete surgical excision of a malignant melanoma with curative intent as a malignant melanoma excision item, even when further surgery is needed. If re-excision is necessary, because the original excision was incomplete or to ensure an adequate margin of healthy tissue to prevent reoccurrence, you can bill a second item in this range of items based on the size of the necessary excision diameter. You must meet the item descriptor in full.

Item selection for skin flaps

When performing a skin flap procedure in association with a skin lesion excision, you need to consider the restrictions outlined in the item descriptions.

When multiple excisions or flap items are performed on the same occasion, the claim or account should note the associated excision item, if applicable. If 2 or more skin flap items are itemised, note the exact location.

MBS item Association with excision item
45200
45203
45206
45207
Is not payable in association with any item in the skin lesion excision item range 31356 – 31376
45201

Is only payable in association with:

  • mohs micrographic surgery items 31000 to 31002
  • malignant skin lesion items 31358, 31359, 31363 or 31369
  • non-malignant skin lesion items 31360, 31364 or 31370
  • malignant melanoma items 31371, 31373 or 31376
45202

Payable only when the clinical relevance of the procedure is clearly annotated in the patient’s record and either:

  • item 45201 applies and additional flap repair is required for the same defect, or
  • item 45201 does not apply and either:
    • the patient has severe pre-existing scarring, severe skin atrophy or sclerodermoid changes, or
    • the repair is contiguous with a free margin

Post-operative treatment (Aftercare)

Skin service procedures outlined in this guide include all professional attendances necessary for the purpose of post-operative treatment of a patient until recovery from the procedure, plus the final check or examination.

Medicare benefits are not payable where routine post-operative care is provided by the practitioner who performed the procedure. When the patient is not able to return to the treating practitioner to receive post-operative care, the medical practitioner providing the aftercare may bill for the aftercare on an attendance basis. This only applies where the aftercare is provided by a medical practitioner who did not perform the procedure.

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Page last updated: 9 October 2018