Transcript Coding and Reimbursement for Mohs Micrographic Surgery

Presented by Lori Dafoe, CPC
 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
To completely remove the tumor,
thoroughly examine all margins, and
preserve normal tissue to the
greatest degree possible.
 “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)
 “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)
 “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)
 BCC,
SCC, or Basosquamous Carcinomas that
have one or more of the following features:
1. Recurrent
2. Aggressive pathology in the hands and feet,
genitalia, nail unit/periungual
3. Large size (2.0 cm or greater)
4. Positive margins on recent excision
5. Poorly defined borders
6. In the very young (>40 yr age)
 BCC,
SCC or Basosquamous Cell Carcinoma in
anatomical locations where they are prone to
recur:
1. Central facial area, nose, temple, and socalled “mask area” of the face
2. Lips, cutaneous, and vermillion
3. Eyelids
4. Auricular helix and canal
 Laryngeal Carcinoma
 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).
 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.

Application of Multiple Procedure Reduction for
Mohs Micrographic Surgery (CPT Codes 17311
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%
http://www.cms.hhs.gov/physicianfeesched/down
loads/CMS-1385-FC.pdf
 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%
 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
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.

 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.
 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.
 17312
Each additional stage after the first stage, up
to 5 tissue blocks (list separately in addition
to code for primary procedure).
CPT 17312 SHOULD BE QUANTITY BILLED,
AND IS ASSOCIATED ONLY WITH CODE 17311
 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.
 17314
East additional stage after the first stage, up
to 5 tissue blocks (list separately in addition
to code for primary procedure).
CPT 17314 SHOULD BE QUANTITY BILLED
AND IS ONLY ASSOCIATED WITH CPT 17313

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 17315 should be quantity billed and is
associated with both CPT 17311 and CPT
17313
 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)
 ICD-9
codes are determined based on the
type and location of the malignancy.
Covered codes based on LCD include BCC/SCC:
173.00-173.99
 Check
policies for other carriers.
 -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

-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 postop 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

-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
 -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
 -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
 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
 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
17311 – Stage I Mohs, no repair
 ICD-9 173.31 BCC (nose)
 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
13132 Complex repair
 CPT 17311 Stage I Mohs surgery
 CPT 17312 Stage II Mohs surgery
 CPT 11100-59 separate biopsy
 ICD-9 173.32 SCC(forehead), 239.2 (nose)
 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
14040 Rotation flap, chin
 17311 Stage I Mohs
 17312 x4 Stage II-V Mohs
 ICD-9 173.31 BCC (chin)
 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 15220 Full thickness skin graft, scalp
 CPT 17311 Stage I Mohs, cheek
 CPT 13132-59 Complex closure, cheek
 CPT 17311-59 Stage I Mohs, scalp
 CPT 17312 x2 Stage II Mohs cheek and scalp
 ICD-9 173.32 SCC (cheek), 173.41 BCC (scalp)
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, 13122 x2 Complex repair leg
 CPT 17313, Stage I
 CPT 17314 x2 Stage II and Stage III
 CPT 17315 x4 3 extra specimens Stage I, 1 extra
specimen Stage II
 ICD-9 172.7 Melanoma (thigh) OR 173.89 per LCD

Next month – E&M Coding and Auditing
by Renee Jones, CPC
and Marisa Clauson, CPC