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Date Printed: December 10, 2016: 11:30 AM

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This medical policy (medical coverage guideline) is Copyright 2016, 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 2016 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: 07/24/14

Revised: 10/01/16

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:

In 1941, Frederick Mohs described a microscopically guided method of tracing and removing basal cell carcinomas. Since then the technique, known as Mohs’ micrographic surgery, has been used to treat many contiguously spreading skin cancers (e.g., basal cell carcinoma, squamous cell carcinoma, basalosquamous cell carcinoma). Originally, a chemical fixative (zinc chloride paste) was applied to the lesion and allowed to penetrate the tissue, thus the procedure was referred to as Mohs’ chemosurgery. Today, the fixative step is omitted and the procedure is performed on fresh tissue in one day on an outpatient basis. Tissue is removed in thin layers, all margins of the specimen are mapped, and frozen sections are prepared and stained for microscopic (histopathologic) examination. Subsequent tissue removal may be necessary in order to obtain clear tumor-free margins. The defect is then closed using separate repair, flap, or graft procedures. Cure rates of 94% to 99% have been achieved. The technique is tissue-sparing in that the tumor is precisely identified and maximum amounts of normal skin can be retained.

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’ micrographic surgery technique.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Mohs’ Micrographic Surgery - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: Mohs micrographic surgery requires the physician 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 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 periorbital areas, the superolateral temple areas, and the preauricular and postauricular areas

• Lips, cutaneous and vermillion

• Eyelids

• The entire external ear and ear canal

• Auricular helix and canal.

B) Other skin lesions in areas where tissue preservation is essential for maximum functional result:

• Angiosarcoma of the skin

• Keratoacanthoma, recurrent

• Dermatofibrosarcoma protuberans

• Malignant fibrous histiocytoma

• Sebaceous gland carcinoma

• Microcystic adnexal carcinoma

• Extramammary Paget’s Disease

• Bowenoid papulosis

• Merkel cell carcinoma

• Bowen’s disease (squamous cell carcinoma in situ)

• Adenoid type of squamous cell carcinoma

• Rapid growth in a squamous cell carcinoma

• Longstanding duration of a squamous cell carcinoma

• Verrucous carcinoma

• Atypical Fibroxanthoma

• Leiomyosarcoma or other spindle cell neoplasms of the skin

• Adenocystic carcinoma of the skin

• Erythroplasia of Queyrat

• Oral and central facial, paranasal sinus neoplasm

• Apocrine carcinoma of the skin

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

• Rare, biopsy-proven skin malignancies not otherwise addressed; and

• Basal cell carcinomas, squamous cell carcinomas, or basalosquamous/basosquamous carcinomas that have ONE OR MORE of the following features:

1. Recurrent

2. Biopsy proven lesions with aggressive pathology as documented by at least ONE of the following microscopic characteristics:

• Sclerotic

• Fibrosing

• Morphea-like

• Metatypical/infiltrative/spikey shaped cell groups

• Perineural or perivascular invasion

• Nuclear pleomorphism

• High mitotic activity

• Superficial multicentric

• 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.

Mohs Micrographic Surgery does not meet the definition of medical necessity for all other indications not listed above. The standard of care is that it is acceptable to manage the majority of simple skin cancers by simple excision or destruction. Mohs surgery is best utilized to treat skin cancers that have recurred following previous treatment, or for cancers at high risk for recurrence.

BILLING/CODING INFORMATION:

The following codes may be used to describe Mohs’ micrographic surgery:

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

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

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: (Effective 10/01/15)

C00.0 – C00.9

Malignant neoplasm of lip

C4A.0
C4A.11, C4A.12
C4A.21, C4A.22
C4A.31, C4A.39
C4A.4

Merkel cell carcinoma

C44.00 – C44.09

Malignant neoplasm of skin of lip

C44.122, C44.129
C44.192, C44.199

Malignant neoplasm of skin of eyelid

C44.222, C44.229
C44.292, C44.299

Malignant neoplasm of skin of ear and external auricular canal

C44.391, 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

C44.60 – C44.62

Malignant neoplasm of skin of upper limb, including shoulder

C44.70 – C44.72

Malignant neoplasm of skin of lower limb, including hip

D04.0

Carcinoma in situ of skin of lip

D04.10 – D04.12

Carcinoma in situ of skin of eyelid, including canthus

D04.20 – D04.22

Carcinoma in situ of skin of ear and external auricular canal

D04.30

Carcinoma in situ of skin of unspecified part of face

D04.39

Carcinoma in situ of skin of other parts of face

D04.4

Carcinoma in situ of skin of scalp and neck

D04.5

Carcinoma in situ of skin of trunk

D04.60 – D04.62

Carcinoma in situ of skin of upper limb, including shoulder

D04.70 – D04.72

Carcinoma in situ of skin of lower limb, including hip

D04.8

Carcinoma in situ of skin of other sites

REIMBURSEMENT INFORMATION:

Based on Current Procedural Terminology (CPT):

  1. Procedure codes 17311 and 17313 are primary procedure codes and subject to multiple surgical reduction guidelines.
  1. The following are classified as add-on codes: 17312, 17314, and 17315.
  1. Procedure codes 17312 and 17314 should be used to report each additional stage of surgery, fixed or fresh tissue that also includes up to 5 specimens each.
  1. Procedure code 17315 should be reported for each additional specimen, after the first 5 specimens, fixed or fresh tissue. This code represents additional specimens at all stages of the Mohs’ surgery.

These procedures require the physician to act as both the surgeon and the pathologist. If either of these responsibilities is delegated to another physician who reports services separately, these codes are not applicable.

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) (L29230) located at fcso.com.

DEFINITIONS:

Basal Cell Carcinoma: a slow-growing, invasive, but usually non-metastasizing neoplasm of the epidermis or hair follicles, most commonly arising in sun-damaged skin of the elderly and fair-skinned.

Basalosquamous Cell Carcinoma: basal cell with squamous differentiation.

Squamous Cell Carcinoma: a malignant neoplasm derived from stratified squamous epithelium, which may also occur in sites where only glandular or columnar epithelium is normally present.

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. American Medical Association CPT, (current edition).
  4. 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.
  5. ClinicalTrials.gov, Effect of the Subconscious on Mohs' Micrographic Surgery, sponsored by Northwestern University, accessed 12/16/08.
  6. ClinicalTrials.gov, Mohs' Versus Traditional Surgery, Basal Cell Carcinomas (BCC) (BACHIMO), sponsored by Hospital Ambroise Pare’, accessed 12/16/08.
  7. 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.
  8. 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.
  9. First Coast Service Options, Inc., LCD for Mohs' Micrographic Surgery (MMS), L29230. 10/01/11, accessed at fcso.com 06/23/14.
  10. Habif: Clinical Dermatology, 3rd edition (Copyright 1996 Mosby-Year Book, Inc.)
  11. 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.
  12. 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.
  13. National Cancer Institute, Skin Cancer Treatment, updated 10/25/13 , accessed at cancer.gov 06/23/14.
  14. National Comprehensive Cancer Network (NCCN), Clinical Practice Guidelines in Oncology- Basal Cell and Squamous Cell Skin Cancers, V. 2.2014.
  15. Skin Care Foundation, Mohs Surgery, accessed at skincare.org 06/23/14.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/24/14.

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.

Date Printed: December 10, 2016: 11:30 AM