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.Recurrent2.Aggressive pathology in the hands and

feet, genitalia, nail unit/periungual3.Large size (2.0 cm or greater)4.Positive margins on recent excision5.Poorly defined borders6. 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 so-called “mask area” of the face

2.Lips, cutaneous, and vermillion3.Eyelids4.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/downloads/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.

17311Mohs 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.

17312Each 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

17313Mohs 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.

17314East 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

17315Mohs 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 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

-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