LCD/NCD Portal

L28932

 

MOHS MICROGRAPHIC SURGERY (MMS)

 

 

10/01/2011

 

 

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 performing the Mohs Micrographic Surgery must be trained and highly skilled in MMS technique and pathology identification.

• 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.

 

 

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:

o Lips, cutaneous and vermillion.

o Eyelids.

o The entire external ear and ear canal.

o Auricular helix and canal.

• Other Skin Lesions:

o Angiosarcoma of the skin.

o Keratoacanthoma, recurrent.

o Dermatofibrosarcoma protuberans.

o Malignant fibrous histiocytoma.

o Sebaceous gland carcinoma.

o Microsysistic adnexal carcinoma.

o Extramammary Paget’s Disease

o Bowenoid papulosis.

o Merkel cell carcinoma.

o Bowen’s disease. (Squamous cell carcinoma in situ).

o Adenoid type of squamous cell carcinoma.

o Rapid growth in a squamous cell carcinoma.

o Longstanding duration of a squamous cell carcinoma.

o Verrucous carcinoma.

o Atypical Fibroxanthoma.

o Leiomyosarcoma or other spindle cell neoplasms of the skin.

o Adenocystic carcinoma of the skin.

o Erythroplasia of Queryrat.

o Oral and central facial, paranasal sinus neoplasm.

o Apocrine carcinoma of the skin.

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

o Rare, biopsy-proven skin malignancies not otherwise addressed in the section.

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

o Recurrent.

o Biopsy proven lesions with aggressive pathology.

• Sclerotic.

o Fibrosing.

o Morphealike.

o Metatypical/infiltrative/spikey shaped cell groups.

o Perineural or perivascular invasion.

o Nuclear pleomorphism.

o High mitotic activity.

o 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.

 

13x Hospital Outpatient

21x Skilled Nursing - Inpatient (Including Medicare Part A)

23x Skilled Nursing - Outpatient

71x Clinic - Rural Health

85x 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

 

17311 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) (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

17312 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) (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)

17313 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) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; FIRST STAGE, UP TO 5 TISSUE BLOCKS

17314 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) (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)

17315 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) (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 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER

140.1 MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER

140.3 MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT

140.4 MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT

140.5 MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT

140.6 MALIGNANT NEOPLASM OF COMMISSURE OF LIP

140.8 MALIGNANT NEOPLASM OF OTHER SITES OF LIP

140.9 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 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP

173.01 BASAL CELL CARCINOMA OF SKIN OF LIP

173.02 SQUAMOUS CELL CARCINOMA OF SKIN OF LIP

173.09 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP

173.10 UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS

173.11 BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS

173.12 SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS

173.19 OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS

173.20 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

173.21 BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

173.22 SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

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

173.30 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.31 BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.32 SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

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

173.40 UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK

173.41 BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK

173.42 SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK

173.49 OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK

173.50 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM

173.51 BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM

173.52 SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM

173.59 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM

173.60 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

173.61 BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

173.62 SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

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

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

173.71 BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP

173.72 SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP

173.79 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP

173.80* UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN

173.81* BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN

173.82* SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN

173.89 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

232.0 CARCINOMA IN SITU OF SKIN OF LIP

232.1 CARCINOMA IN SITU OF EYELID INCLUDING CANTHUS

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

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

232.4 CARCINOMA IN SITU OF SCALP AND SKIN OF NECK

232.5 CARCINOMA IN SITU OF SKIN OF TRUNK EXCEPT SCROTUM

232.6 CARCINOMA IN SITU OF SKIN OF UPPER LIMB INCLUDING SHOULDER

232.7 CARCINOMA IN SITU OF SKIN OF LOWER LIMB INCLUDING HIP

232.8 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.

 

 

Documentation Requirements

• The surgeon’s documentation in the patient’s medical record should be legible and support the medical necessity of this procedure.

o 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.)

o In addition, there should be a pathologic description of slides described in the medical record and all slides should be retained.

• If the -59 modifier was used with a skin biopsy/pathology code on the same day the Mohs surgery was performed, the physician’s documentation should clearly indicate that:

o The biopsy was performed on a lesion other than the lesion that the Mohs surgery was performed upon.

o 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.

o 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.

Treatment Logic

• 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.

 

 

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.

 

FCSO LCD 29230, Mohs Micrographic Surgery (MMS), 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/

 

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 melanoma and nonmelanoma skin cancer: A review of the primary care physician. Mayo Clinic Proceedings, 76(12): 1253-1265.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD MOHS MICROGRAPHIC SURGERY (MMS)