1. Coding and Reimbursement for Mohs Micrographic Surgery
Presented by Lori Dafoe, CPC

2. References AMA – CPT and CPT Assistant CMS – Local MAC, Noridian
American College of Mohs Surgery
American Society for Mohs Surgery
American Academy of Dermatology
Dermatology Times
Derm Net NZ
Skin and Allergy News

3. The mission of mohs
To completely remove the tumor, thoroughly examine all margins, and preserve normal tissue to the greatest degree possible.
You’ve seen the before and after pictures and I think we can all agree that the advancements in medicine are amazing. I have a friend who had skin cancer removed from the tip of her nose 20 years ago and she has a rather large defect.

4. Mohs Micrographic Surgery
“Mohs micrographic surgery, for the removal of complex or ill-defined skin cancers, requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities are delegated to another physician who reports his services separately, these codes are not appropriate.”
(CPT© 2012)
Surgeon, plastics/reconstruction and pathology.

5. Mohs micrographic surgery
“The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus a tissue block in Mohs surgery is defined as an individual tissue piece embedded in a mounting medium for sectioning.”
(CPT© 2012)
The CPT code descriptors for Mohs surgery refer to “stages” and “blocks”. The removal of the tumor tissue is considered a “stage”, while the “block” is the mapping of the piece of tissue.

6. Mohs micrographic surgery
“If repair is performed, use separate repair, flap, or graft codes. If a biopsy of a suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report diagnostic skin biopsy (11100, 11101) and frozen section pathology (88331) with modifier -59 to distinguish from the subsequent definitive surgical procedure of Mohs surgery.”
(CPT© 2012)

7. Medicare diagnoses and indications
BCC, SCC, or Basosquamous Carcinomas that have one or more of the following features:
Recurrent
Aggressive pathology in the hands and feet, genitalia, nail unit/periungual
Large size (2.0 cm or greater)
Positive margins on recent excision
Poorly defined borders
In the very young (>40 yr age)
Periungual (around fingernails/toenails)

8. Medicare Diagnoses and Indications
BCC, SCC or Basosquamous Cell Carcinoma in anatomical locations where they are prone to recur:
Central facial area, nose, temple, and so- called “mask area” of the face
Lips, cutaneous, and vermillion
Eyelids
Auricular helix and canal
Laryngeal Carcinoma
Cutaneous refers to skin, vermilion refers to the lip (red colored area, not the oral mucosa or inside of lip)
Auricular helix and canal refer to the outer ear.

9. Medicare guidelines
The majority of simple skin cancers can be managed by simple excision or destruction techniques.
The medical records should clearly show the Mohs surgery was chosen because of the complexity or size or location of the lesion.
Mohs micrographic surgery is usually an outpatient procedure done under local anesthesia (with or without sedation).
Although Mohs surgery is not indicated for treating malignant melanoma, it may prove a useful technique for certain types and locations of melanoma.

10. Medicare guidelines
The codes for Mohs micrographic surgery are unique because they code for surgery and pathology services together.
Only when a single physician performs duties of both surgeon and pathologist can these codes be used.
If one physician excises and maps a skin cancer and another physician examines the tissue margins histologically, the excision and pathology codes must be used instead.
It would not be appropriate to bill for this service using modifier -62 for co-surgeons. Nor are assistant surgeons allowed for the Mohs surgery codes.

11. Medicare guidelines
Application of Multiple Procedure Reduction for Mohs Micrographic Surgery (CPT Codes through 17315) – Federal Register November 2007
Under the multiple procedure payment reduction policy, reimbursement for subsequent surgical procedures performed during the same operative session by the same physician is reduced by 50%
loads/CMS-1385-FC.pdf

12. Medicare guidelines
Repairs are paid at 100% - Unless the repair is <than 1st stage allowable
Mohs surgery global period – zero days
Post-op global period applicable to the repair, usually 90 days
Two repairs done on two Mohs defects – same date of service – both repairs can be subject to multiple surgery reduction rule
Highest repair – 100% (unless 1st stage is >)
Next repair reimbursed – 50%

13. Reasons for non-coverage
Claims will be denied when “Indications and Limitations” criteria are not met.
Claims will be denied when Medicare determines that the services were not medically reasonable and necessary, or that the services were determined to fall under one of the Medicare “Exclusions”, i.e., cosmetic surgery
Of course, Noridian has an LCD for this service (L23735, effective 04/01/2008)

14. Medicare diagnoses and indications
Medicare is aware that a biopsy of the skin lesion for the Mohs surgery planned is necessary in order for the physician to determine the exact nature of the lesions) to be removed. Occasionally, that biopsy may need to be done the same day that the Mohs surgery is planned to be done.
In order to allow separate payment for a biopsy and pathology on the same day as MMS, the -59 modifier is appropriate. The -59 modifier is also appropriate when a separate skin lesion is biopsied on the same day that the Mohs surgery is performed.
Example: Derm sees patient, feels lesion is suspicious, no biopsy performed, patient is sent directly over to Mohs surgeon. Mohs surgeon performs the biopsy (11100) and processes it by frozen section pathology (88331), determines that Mohs is needed and proceeds with the procedure on the same day.

15. Medicare diagnoses and indications
No payment will be allowed for the biopsy and pathology of a lesion which requires removal by the Mohs technique if a biopsy of that lesion has been performed within 60 days prior to Mohs surgery, unless the clinical record clearly shows that results were unable to be obtained by the Mohs surgeon using reasonable effort.

16. Mohs codes
17311
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding specimens, microscopic examination of the specimens by the surgeon, and histopathologic preparation including routine stain(s), head, neck, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels, first stage, up to 5 tissue blocks.
Codes are based on location and stages and include the preservice work of explanation of the procedure informed consent, and preparation of the patient for surgery. The intraservice work includes local anesthesia, debulking of the visible tumor, excision of the first Mohs layer, color-coding of the specimens, and mapping. It also includes the pathology services of tissue preparation, microscopic examination, and mapping of positive margins. Finally, the intraservice work includes final evaluation of the tumor-free wound to determine wound management. The postservice work includes the discussion of postoperative wound management
Remember the definition of “stage” vs. “block”? Stage = removal of tissue, Block = mapping the piece of tissue.
When two or more tumors are treated in one day, code each lesion separately. It is not appropriate to add/combine the first stages.

17. Mohs codes
17312
Each additional stage after the first stage, up to 5 tissue blocks (list separately in addition to code for primary procedure).
CPT SHOULD BE QUANTITY BILLED, AND IS ASSOCIATED ONLY WITH CODE 17311
Add on codes can be added together and quantity billed, or billed separately using modifier Be sure to check with your carriers to see how they want them handled. We have had some claims where we had multiple sites, with multiple stages. Medicare denied with a “Medically Unlikely Edit”. We submitted documentation and the claims were paid.

18. MOHS CODES
17313
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of the specimens by the surgeon, and histopathologic preparation including stain(s), of the trunk, arms or legs first stage, up to 5 tissue blocks.

19. Mohs codes
17314
East additional stage after the first stage, up to 5 tissue blocks (list separately in addition to code for primary procedure).
CPT SHOULD BE QUANTITY BILLED AND IS ONLY ASSOCIATED WITH CPT 17313

20. Mohs CODES
17315
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of the specimens by the surgeon, and histopathologic preparation including routine stain(s), each additional block after the first 5 tissue blocks, and stage (list separately in addition to code for primary procedure).
CPT should be quantity billed and is associated with both CPT and CPT
What happens if the provider divides the specimen/stage into more than 5 pieces/blocks?

21. Repairs Closure is reported separately and may include the following:
1.) Complex repair (13XXX)
2.) Adjacent tissue transfer or rearrangement (14XXX)
3.) Grafts or Flaps (15XXX)
The majority of repairs we see in our office are the adjacent tissue transfer or rearrangement.

22. Covered codes based on LCD include BCC/SCC: 173.00-173.99
Diagnoses
ICD-9 codes are determined based on the type and location of the malignancy.
Covered codes based on LCD include BCC/SCC:
Check policies for other carriers.
Noridian will also allow payment for other types of malignancies if the documentation supports medical necessity of using the Mohs technique due to complexity, size or location. Instead of coding the actual type of cancer, the LCD instructs providers to use 173.8X for Other malignant neoplasm as long as the documentation describes that particular lesion by name and supports the medical necessity of removal by Mohs. For example poorly defined clinical borders, possible deep invastion, prior exposure to radiation, or if there are anatomical or technical difficulties that do not allow conventional excision with appropriate margins.

23. Modifiers -57 Modifier decision for surgery
E/M services that result in decision to perform surgery are identified by adding the -57 modifier to the E/M service code
Mohs surgery codes have no global days, but most repair codes do. Depending on the global days, you may need to add either -57 or -25 to your E&M

24. (major surgery = 90 day post-op period)
Modifiers
-58 Staged/Related procedure or service, same physician during the post-op period
Attach this modifier to a staged or related procedure or service performed during the post- op period of a major surgery
(major surgery = 90 day post-op period)
Example – You return to the operating room to excise additional tissue on a large congenital nevus which is being removed in stages to minimize the resultant scar

25. modifiers -59 Distinct procedural service
Distinct or independent service performed on the same day
Designates different or separate site, incision, excision, lesion, or injury performed on the same day
Multiple surgery reimbursement reductions apply
Example – You perform Mohs on an ear and Mohs on a nose the same day
Your code for the initial stage for both of these procedures is the same (CPT 17311). Modifier -59 would be required to distinguish the two separate procedures.

26. modifiers
-78 Return to OR for a related procedure during post-op period
Used to indicate another procedure performed during post-op period related to the first procedure
Example – You return to the OR to revise a necrotic flap 60 days after it was placed

27. Modifiers -79 Unrelated procedure during post-op period
Used to indicate another procedure performed during the post-op period unrelated to the original procedure
Example: You perform MMS on the scalp and repair the defect with a FTSG – 3 weeks later you excise a cyst on the left buttock
MMS – Mohs Micro Surgery
FTSG – Full Thickness Skin Graft

28. MOHS coding tips
Code repair first, check RVU’s, verify documentation records the type of closure, the size and the location of the tissue transfer
Code Mohs, verify number of stages (each stage should be recorded separately within the body of the report), verify documentation includes the location of the malignancy, verify number of blocks for each stage (if exceeds 5, bill for additional blocks)
Code additional biopsies if supported by documentation
Code diagnosis
Although flaps/repairs usually have higher RVU’s, make sure you verify this, as it is not always the case!

29. CODE THIS!

30. Example #1 – BCC of the nose
Mohs surgery performed, requiring one layer (stage), and was processed as a single specimen. Margins were clear. The wound was allowed to heal by second-intention.
CPT – Stage I Mohs, no repair
ICD BCC (nose)

31. Example #2 – scc of the forehead, repair, and separate biopsy
Two stages of Mohs surgery were done, followed by repair of the 6 cm defect using complex closure. Provider noted and performed a biopsy of a lesion on the patient’s nose.
CPT Complex repair
CPT Stage I Mohs surgery
CPT Stage II Mohs surgery
CPT separate biopsy
ICD SCC(forehead), (nose)
In RVU order, you would actually list CPT first, followed by CPT 13132, then 17312, and last

32. Example #3 – BCC of chin with repair
Mohs surgery was performed with positive margins on Stages I through IV and clear margins on Stage V. No Stage required more than 5 specimens/blocks. Repair of the less than 10 sq cm defect was by rotation flap.
CPT Rotation flap, chin
Stage I Mohs
17312 x4 Stage II-V Mohs
ICD BCC (chin)

33. CPT 15220 Full thickness skin graft, scalp
Example #4 – SCC of cheek with complex closure, BCC of Scalp with skin graft
Tumor of the cheek was cleared in two stages, 5.1 cm defect repaired by complex closure. Tumor of the scalp was cleared in two stages, less than 20 sq cm defect repaired by a full thickness skin graft. No Stage required more than 5 specimens/blocks.
CPT Full thickness skin graft, scalp
CPT Stage I Mohs, cheek
CPT Complex closure, cheek
CPT Stage I Mohs, scalp
CPT x2 Stage II Mohs cheek and scalp
ICD SCC (cheek), BCC (scalp)
CPT is bundled into CPT So modifier -59 is required to show it is a separate repair. The second stages may be added together or billed separately depending on the payor.

34. Example #5 – Extensive melanoma of thigh with complex closure
Three stages of Mohs were required becuase of the complexity of deep invasion and poorly defined clinical borders with Stage I being divided into 8 pieces, Stage II into 6 pieces and Stage III into 3 pieces. The 14cm defect was repaired by complex closure.
CPT 13121, x2 Complex repair leg
CPT 17313, Stage I
CPT x2 Stage II and Stage III
CPT x4 3 extra specimens Stage I, 1 extra specimen Stage II
ICD Melanoma (thigh) OR per LCD
CPT describes 2.6 – 7.5 cm, CPT describes each additional 5 cm
In this scenario, CPT should be reported first per RVU order.
Diagnosis

35. THANK YOU! Next month – E&M Coding and Auditing by Renee Jones, CPC
and Marisa Clauson, CPC