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Date Printed: December 17, 2017: 04:30 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-10000-03

Original Effective Date: 05/15/02

Reviewed: 10/31/17

Revised: 11/15/17

Subject: Mohs Micrographic Surgery

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Mohs micrographic surgery is a microscopically controlled tissue-sparing surgical procedure used for the removal of complex or ill-defined cancerous neoplasms of the skin and histologic examination of the surgical margins. Mohs surgery uses precise measurements of tumor margins to remove cancerous cells and leave healthy tissue intact. The procedure is performed in successive stages to remove extensive tumors, as needed. Mohs surgery is primarily used to treat basal and squamous cell carcinomas, but can be used to treat less common tumors including but not limited to melanoma.

In performing Mohs micrographic surgery, the physician functions in two separate, but distinct capacities: as the surgeon and the pathologist. If either part of the procedure is delegated to another physician who reports his service separately (i.e., pathology delegated to another physician), the surgery should not be reported as Mohs.

POSITION STATEMENT:

NOTE: Mohs micrographic surgery requires the physician to function in two separate, but distinct capacities: as the surgeon and the pathologist. If either part of the procedure is delegated to another physician who reports his/her service separately (i.e., pathology delegated to another physician), the procedure should not be reported as Mohs’ micrographic surgery.

Mohs micrographic surgery meets the definition of medical necessity when performed for ONE of the following indications:

A) Basal cell carcinomas, squamous cell carcinomas, basalosquamous/basosquamous cell carcinomas in the following anatomic locations:

“Mask areas” of face (central face, eyelids-including inner/outer canthi, eyebrows, nose, lips-cutaneous/mucosal/vermillion, chin, ear and periauricular skin /sulci, temple)

Cheeks, forehead, scalp, neck, jawline, pretibial surface

Hands, feet, nail units

Ankles

Genitalia (including perineal and perianal)

Nipples/areola.

B) Basal cell carcinomas, squamous cell carcinomas, or basalosquamous/basosquamous cell carcinomas, regardless of subtype, size, or depth, in:

Prior radiated skin

Traumatic scar

Area of osteomyelitis

Area of chronic inflammation/ulceration

Members with genetic syndromes.

C) The following recurrent skin cancers:

Recurrent aggressive basal cell carcinomas (BCC)

Nodular BCC

Superficial (except on trunk and extremities ) BCC of any size or unexpected positive margin on recent excision

Recurrent aggressive squamous cell carcinomas (SCC)

Verrucous SCC

KA-type SCC (not central facial)

In situ/Bowen SCC of any size or unexpected positive margin on recent excision.

D) Lentigo maligna, melanoma in situ, non-lentigo maligna - primary or locally recurrent.

E) Less common skin cancers including:

Adenocystic carcinoma

Adnexal carcinoma

Angiosarcoma

Apocrine/eccrine carcinoma

Atypical Fibroxanthoma

Dermatofibrosarcoma protuberans

Extramammary Paget’s Disease

Leiomyosarcoma

Malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma

Merkel cell carcinoma

Microcystic adnexal carcinoma

Mucinous carcinoma

Sebaceous carcinoma.

Mohs Micrographic Surgery does not meet the definition of medical necessity for all other indications and including but not limited to:

Both recurrent and primary actinic keratosis (AK) with focal SCC in situ; Bowenoid AK; SCC in situ (AK type) of any size in all areas

Basal cell carcinoma (BCC) located on trunk and extremities (excluding pretibial surface, hands,feet, nail units, and ankles)

Squamous cell carcinoma (SCC) located on trunk and extremities (excluding pretibial surface,hands, feet, nail units, and ankles)

Desmoplastic trichoepithelioma located on trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles)

Bowenoid papulosis.

BILLING/CODING INFORMATION:

CPT Coding:

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 histopathology preparation including routine stain(s) (e.g., 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 histopathology preparation including routine stain(s) (e.g., 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 histopathology preparation including routine stain(s) (e.g., 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-10 Diagnoses Codes That Support Medical Necessity:

C00.0 – C00.9

Malignant neoplasm of lip

C21.1

Malignant neoplasm of anal canal

C30.0

Malignant neoplasm of nasal cavity

C31.0

Malignant neoplasm of maxillary sinus

C31.2

Malignant neoplasm of frontal sinus

C43.0 - C43.8

Malignant melanoma of lip

C44.01 -C44.09

Malignant neoplasm of skin of lip

C44.111 -C44.199

Malignant neoplasm of skin of eyelid

C44.211 -C44.299

Malignant neoplasm of skin of ear and external auricular canal

C44.310 -C44.399

Malignant neoplasm of skin of other and unspecified parts of face

C44.41 -C44.49

Malignant neoplasm of skin of scalp and neck

C44.510 -C44.599

Malignant neoplasm of skin of other part of trunk

C44.611 -C44.699

Malignant neoplasm of skin of left upper limb, including shoulder

C44.711 -C44.799

Malignant neoplasm of skin of left lower limb, including hip

C44.81 -C44.89

Malignant neoplasm of overlapping sites of skin

C4A.0 - C4A.9

Merkel cell carcinoma

C50.011 -C50.019

Malignant neoplasm of nipple and areola, female

C50.021 -C50.029

Malignant neoplasm of nipple and areola, male

C51.0 - C51.1

Malignant neoplasm of vulva

C52

Malignant neoplasm of vagina

C60.1, C60.2

Malignant neoplasm of penis

C63.2

Malignant neoplasm of scrotum

D03.0 - D03.8

Melanoma in situ

D04.0 - D04.8

Carcinoma in situ of skin

D07.4

Carcinoma in situ of penis

REIMBURSEMENT INFORMATION:

Mohs micrographic surgery requires the physician to function in two separate, but distinct capacities: as the surgeon and the pathologist. If either part of the procedure is delegated to another physician who reports his/her service separately (i.e., pathology delegated to another physician), the procedure should not be reported as Mohs’ micrographic surgery.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pathology Reports Sections

26439-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pathology Study Reports

27898-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Mohs Micrographic Surgery (MMS) (L33689) located at fcso.com.

DEFINITIONS:

Basal Cell Carcinoma: Cancer that begins in the lower part of the epidermis (the outer layer of the skin). It may appear as a small white or flesh-colored bump that grows slowly and may bleed. Basal cell carcinomas are usually found on areas of the body exposed to the sun. Basal cell carcinomas rarely metastasize (spread) to other parts of the body. They are the most common form of skin cancer. Also called basal cell cancer. Basalosquamous Cell Carcinoma: basal cell with squamous differentiation.

Melanoma: A form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines.

Squamous Cell Carcinoma: Cancer that begins in squamous cells. Squamous cells are thin, flat cells that look like fish scales, and are found in the tissue that forms the surface of the skin, the lining of the hollow organs of the body, and the lining of the respiratory and digestive tracts. Most cancers of the anus, cervix, head and neck, and vagina are squamous cell carcinomas.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Dermatology, Guidelines of Care for the Management of Primary Cutaneous Melanoma, 2011, accessed at aad.org 06/23/14.
  2. American College of Mohs' Surgery, About Mohs' Micrographic Surgery-Effectiveness, accessed at mohscollege.org 06/23/14.
  3. ClinicalTrials.gov, Checking Wether the m-ALA Cream Could Mark Correctly the Borders of BCC’s Tumors, sponsored by Assuta Hospital Systems, accessed 12/16/08.
  4. ClinicalTrials.gov, Effect of the Subconscious on Mohs' Micrographic Surgery, sponsored by Northwestern University, accessed 12/16/08.
  5. ClinicalTrials.gov, Mohs' Versus Traditional Surgery, Basal Cell Carcinomas (BCC) (BACHIMO), sponsored by Hospital Ambroise Pare’, accessed 12/16/08.
  6. ClinicalTrials.gov, Safety and Efficacy of Oral Midazolam for Perioperative Anxiety Relief of Patients Undergoing Mohs' Micrographic Surgery, sponsored by Mayo Clinic, accessed 12/16/08.
  7. Connolly SM, Baker DR, et al, AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012 Oct;67(4):531-50. doi: 10.1016/j.jaad.2012.06.009.
  8. First Coast Service Options, Inc.(FCSO), LCD for Mohs Micrographic Surgery (MMS), L33689; accessed at fcso.com.
  9. Lee KY, Roh MR, Chung WG, Chung KY, Comparison of Mohs' Micrographic Surgery and Wide Excision for Extramammary Paget’s Disease: Korean Experience, Dermatol Surg. 11/08.
  10. Mosterd K, Krekels GA, Nieman FH, et al, Surgical Excision Versus Mohs’ Micrographic Surgery for Primary and Recurrent Basal-Cell Carcinoma of the Face: A Prospective Randomized controlled Trial with 5-Years Follow-Up, Lancet Oncol. 2008 Dec; 9(12): 1149-56.
  11. National Cancer Institute (NCI). NCI Dictionary of Cancer Terms; accessed at cancer.gov 10/04/17.
  12. National Cancer Institute, Skin Cancer Treatment, updated 07/11/17, accessed at cancer.gov.
  13. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Basal Cell Skin Cancer Version 1.2018 accessed at nccn.org.
  14. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Melanoma Version 1.2017 accessed at nccn.org.
  15. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Squamous Cell Skin Cancer Version 1.2018 accessed at nccn.org.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/31/17.

GUIDELINE UPDATE INFORMATION:

09/11/00

New Medical Coverage Guideline.

04/25/02

Reviewed, reformatted, and revised to include applicable diagnosis codes.

01/01/03

2003 CPT Update.

06/15/04

Scheduled review and revision to guideline; consisting of updated references.

01/01/07

2007 HCPCS update: added 17311, 17312, 17313, 17314, and 17315; deleted 17304, 17305, 17306, 17307, and 17310; Medicare exceptions added.

02/15/09

Status changed from archived to active – position statements, reimbursement section, coding section and references updated.

02/15/10

Annual review: position statements maintained and references updated.

10/15/10

Revision; related ICD-10 codes added.

09/15/11

Revision; formatting changes.

10/01/11

Scheduled review; position statements maintained, ICD-9 codes updated, references updated and formatting changes.

11/15/12

Annual review; position statements maintained, coding and references updated; formatting changes.

10/15/13

Annual review; position statements maintained; reimbursement information and references updated.

01/01/14

Annual HCPCS update. Added code 88343.

08/15/14

Annual review; position statements maintained; coding section and references updated.

10/01/15

Revision; ICD9 and ICD10 coding sections updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; formatting changes.

11/15/17

Review; position statements, description, coding, and references updated.

Date Printed: December 17, 2017: 04:30 PM