L28932-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Mohs Micrographic Surgery (MMS) (L28932)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28932

LCD Title Mohs Micrographic Surgery (MMS)

Contractor's Determination Number A17311

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011

Revision Ending Date

CMS National Coverage Policy

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). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Indications and Limitations of Coverage and/or Medical Necessity

Medicare will consider reimbursement for Mohs Micrographic Surgery for accepted diagnoses and indications. The current accepted diagnoses and indications are listed in this policy. The physician must document in the patient’s medical record that the diagnosis is appropriate for MMS and that MMS is the most appropriate choice for the treatment of the particular lesion.

The majority of simple skin cancers can be managed by simple excision or destruction techniques. While simple excision and destruction techniques have lower cure rates than those of Mohs surgery, the dermatological community’s standard of care is that it is acceptable to manage the majority of simple skin cancers by simple excision or destruction. The medical records should clearly show that Mohs surgery was chosen because of the type, complexity, size, or location of the lesion.

MMS is usually an office procedure done under local anesthesia and/or sedation. Current accepted diagnoses and indications for Mohs Micrographic Surgery are:

• Basal cell carcinomas, squamous cell carcinomas, basalosquamous/basosquamous cell carcinomas in anatomic locations where they are prone to recur:

- Central facial areas, nose, and temple areas of the face (the so-called “mask area” of the face) which includes the eyebrows and periobital areas, the superolateral temple areas, -and the preauricular and postauricular areas;

- Lips, cutaneous and vermillion;

- Eyelids;

- The entire external ear and ear canal; and

- Auricular helix and canal.

• Other Skin Lesions:

- Angiosarcoma of the skin

- Keratoacanthoma, recurrent

- Dermatofibrosarcoma protuberans

- Malignant fibrous histiocytoma

- Sebaceous gland carcinoma

- Microsysistic adnexal carcinoma

- Extramammary Paget’s Disease

- Bowenoid papulosis

- Merkel cell carcinoma

- Bowen’s disease (squamous cell carcinoma in situ)

- Adenoid type of squamous cell carcinoma

- Rapid growth in a squamous cell carcinoma

- Longstanding duration of a squamous cell carcinoma

- Verrucous carcinoma

- Atypical Fibroxanthoma

- Leiomyosarcoma or other spindle cell neoplasms of the skin

- Adenocystic carcinoma of the skin

- Erythroplasia of Queryrat

- Oral and central facial, paranasal sinus neoplasm

- Apocrine carcinoma of the skin

- Malignant melanoma or melanoma-in-situ (facial, auricular, genital and digital) when anatomical or technique difficulties do not allow conventional excision with ppropriate margins

- Rare, biopsy-proven skin malignancies not otherwise addressed in the section; and

- Basal cell carinomas, squamous cell carcinomas, or basalosquamous/basosquamous carcinomas that have one or more of the following features:

• Recurrent

• Biopsy proven lesions with aggressive pathology

- Sclerotic

- Fibrosing

- Morphealike

- Metatypical/infiltrative/spikey shaped cell groups

- Perineural or perivascular invasion

- Nuclear pleomorphism

- High mitotic activity

- Superficial multicentri

• Located in the genitalia, digits, or nail unit/periungual

• Large size (1.0 cm or greater in the non-mask areas of the face and 2.0 cm or greater in other areas)

• Positive margins on recent excision

• Poorly defined borders

• In the very young (< 40 yr. age)

• Radiation-induced

• In patients with proven difficulty with skin cancers or who are immunocompromised

• Basal Cell Nevus Syndrome

• In an old scar (e.g., a Marjolin’s ulcer)

• Associated with xeroderma pigmentosum

• Perineural invasion on biopsy

• Difficulty estimating depth of lesion

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

013x Hospital Outpatient

021x Skilled Nursing - Inpatient (Including Medicare Part A) 023x Skilled Nursing - Outpatient

071x Clinic - Rural Health

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0312 Laboratory Pathology - Histology 0314 Laboratory Pathology - Biopsy

0361 Operating Room Services - Minor Surgery

CPT/HCPCS Codes

MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF

17311 SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), HEAD, NECK, HANDS, FEET, GENITALIA, OR ANY

LOCATION WITH SURGERY DIRECTLY INVOLVING MUSCLE, CARTILAGE, BONE, TENDON, MAJOR NERVES, OR VESSELS; FIRST STAGE, UP TO 5 TISSUE BLOCKS

MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S)

17312 (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), HEAD, NECK, HANDS, FEET, GENITALIA, OR ANY LOCATION WITH SURGERY DIRECTLY INVOLVING MUSCLE, CARTILAGE, BONE, TENDON, MAJOR NERVES, OR VESSELS; EACH ADDITIONAL STAGE AFTER THE FIRST STAGE, UP TO 5 TISSUE BLOCKS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF

17313 SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; FIRST STAGE, UP TO 5 TISSUE BLOCKS

MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF

17314 SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; EACH ADDITIONAL

STAGE AFTER THE FIRST STAGE, UP TO 5 TISSUE BLOCKS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF

17315 SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), EACH ADDITIONAL BLOCK AFTER THE FIRST 5 TISSUE BLOCKS, ANY STAGE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity

140.0 - 140.9 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER

160.0 MALIGNANT NEOPLASM OF NASAL CAVITIES

160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS

160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS

173.00 - 173.09 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER SPECIFIED MALIGNANT

NEOPLASM OF SKIN OF LIP

173.10 - 173.19 UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS - OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS

173.20 - 173.29 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL

AUDITORY CANAL

173.30 - 173.39 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.40 - 173.49 UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK - OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK

173.50 - 173.59 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM

173.60 - 173.69 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB,

INCLUDING SHOULDER

173.70 - 173.79 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP -

173.80 - 173.89* OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN - OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN

209.31 MERKEL CELL CARCINOMA OF THE FACE

209.32 MERKEL CELL CARCINOMA OF THE SCALP AND NECK

209.33 MERKEL CELL CARCINOMA OF THE UPPER LIMB

209.34 MERKEL CELL CARCINOMA OF THE LOWER LIMB

209.35 MERKEL CELL CARCINOMA OF THE TRUNK

209.36 MERKEL CELL CARCINOMA OF OTHER SITES

232.1 CARCINOMA IN SITU OF SKIN OF LIP

232.2 CARCINOMA IN SITU OF EYELID INCLUDING CANTHUS

232.3 CARCINOMA IN SITU OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

232.4 CARCINOMA IN SITU OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

232.5 CARCINOMA IN SITU OF SCALP AND SKIN OF NECK

232.6 CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM

232.7 CARCINOMA IN SITU OF SKIN OF UPPER LIMB INCLUDING SHOULDER

232.8 CARCINOMA IN SITU OF SKIN OF LOWER LIMB INCLUDING HIP

232.9 CARCINOMA IN SITU OF OTHER SPECIFIED SITES OF SKIN

* If Mohs Micrographic Surgery is being submitted for one of the skin diagnoses listed under “Other Skin Lesions,” the claim must be submitted with diagnosis code 173.80-173.89 (Other and unspecified malignant neoplasm of other specified sites of skin). Documentation, referencing the number of designation of the appropriate lesion in the “Other Skin Lesions” category list and supporting medical necessity of the procedure must be available if requested by Medicare.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The operative notes and pathology documentation in the patient’s medical record should clearly show that Mohs micrographic surgery was performed using accepted Mohs technique, in which the physician acts in two integrated and distinct capacities: surgeon and pathologist (i.e., the medical records should demonstrate that true Mohs surgery was performed). In addition, there should be a pathologic description of slides described in the medical record and all slides should be retained.

Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is generally found in the office/progress notes, hospital notes, and/or laboratory results.

Documentation should support the criteria for coverage set forth in the “Indications and Limitations of Coverage and/or Medical Necessity “ section of this policy.

If a revenue code for skin biopsy/pathology code was billed on the same day the Mohs surgery was performed, the physician’s documentation should clearly indicate that:

• the biopsy was performed on a lesion other than the lesion that the Mohs surgery was performed upon; or

• if the biopsy is of the same lesion that the Mohs surgery was performed upon, a biopsy of that lesion had not been done within the previous 60 days; or

• if a recent (within 60 days) biopsy of the same lesion that Mohs surgery was performed on had been done, the results of that biopsy were unobtainable by the Mohs surgeon using reasonable effort.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

American Academy of Dermatology Guidelines. Practice Management: Guidelines of care for Mohs’ Micrographic Surgery. [On-line]. Available: www.aadassociation.org/Guidelines/ .

American Academy of Dermatology Guidelines. Practice Management: Guidelines of care for malignant melanoma. [On-line]. Available: www.aadassociation.org/Guidelines/ .

Alam, M., Ratner, D. (2002). Cutaneous squamous cell carcinoma. New England Journal of Medicine, 344 (13): 975-983.

Green, A., Marks, R. (2002). Squamous cell carcinoma of the skin: Non-metastatic. Clinical Evidence, 7: 1549- 1554.

Martinez, J.C., Otley, C.C. (2001). The management of melonoma and nonmelanoma skin cancer: A review of the primary care physician. Mayo Clinic Proceedings, 76(12): 1253-1265.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from The Florida Society of Dermatology.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 02/01/2010

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011

Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis codes 173.0, 173.1, 173.2, 173.3,

173.4, 173.5, 173.6, 173.7, and 173.8. Added new diagnosis codes 173.00-173.09, 173.10-173.19, 173.20-

173.29, 173.30-173.39, 173.40-173.49, 173.50-173.59, 173.60-173.69, 173.70-173.79, and 173.80-173.89.

The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:02/01/2010 Revised Effective Date: 10/01/2009

LCR A2010-016

January 2010 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added diagnosis code range 209.31-209.36 with descriptors for Merkel cell carcinoma. This revision is effective for claims processed on or after 01/28/2010 for dates of service on or after 10/01/2009.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28932) replaces LCD L862 as the policy in notice. This document (L28932) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 71 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0312 was changed 8/1/2010 - The description for Revenue code 0314 was changed 8/1/2010 - The description for Revenue code 0361 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

17311 descriptor was changed in Group 1 17313 descriptor was changed in Group 1 17314 descriptor was changed in Group 1 17315 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change