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SUPERSEDED Local Coverage Determination (LCD)

Mohs Micrographic Surgery (MMS)

L33436

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33436
Original ICD-9 LCD ID
Not Applicable
LCD Title
Mohs Micrographic Surgery (MMS)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 07/01/2021
Revision Ending Date
11/15/2023
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis and/or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(10) where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §120, Cosmetic Surgery

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Medicare will consider reimbursement for Mohs micrographic surgery (MMS) for accepted diagnoses and indications. Current accepted diagnoses and indications are listed in this LCD. The physician performing the MMS must be trained and highly skilled in MMS techniques, and pathology identification. The physician must document in the patient's medical record that the diagnosis is appropriate for MMS and that MMS is the most appropriate choice as the treatment of the particular lesion.

Medicare is aware that a biopsy of the skin lesion for which Mohs surgery is planned is necessary in order for the physician to determine the exact nature of the lesion(s) to be removed. Occasionally, that biopsy may need to be done on the same day that the Mohs surgery is planned to be done.

No payment will be allowed for the biopsy and pathology of a lesion, which requires removal by the MMS technique, if a biopsy of that lesion has been performed within 60 days prior to MMS. An exception exists when a biopsy has been performed within that period and the biopsy results could not be obtained by the Mohs surgeon using reasonable effort. The clinical record must clearly show that this situation existed.

Current accepted diagnoses and indications for MMS are:

Basal cell carcinomas, squamous cell carcinomas or basalosquamous 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 vermilion.
  • Eyelids.
  • The entire external ear and ear canal.

Other skin lesions:

  • Angiosarcoma of the skin.
  • Keratoacanthoma, recurrent or rapidly growing destructive variants.
  • 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.
  • Adenoid Cystic carcinoma of the skin.
  • Erythroplasia of Queryrat.
  • Oral and central facial, and paranasal sinus neoplasm.
  • Apocrine carcinoma of the skin.
  • Malignant melanoma or melanoma in situ (facial, auricular, genital and digital) when anatomical or technical difficulties do not allow conventional excision with appropriate margins.
  • Rare, biopsy-proven skin malignancies not otherwise addressed in this section.
  • Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas having one or more of the following features:
    • Are recurrent.
    • 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 or superficial multicentric.
    • Located in the following areas: 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.
    • Present in the very young (less than 40 years of age).
    • Radiation-induced.
    • In patients with proven difficulty with skin cancers or who are immunocompromised.
    • Basal cell nevus syndrome.
    • Present in an old scar (e.g., Marjolin's ulcer).
    • Associated with xeroderma pigmentosum or difficulty estimating depth of lesion.
    • Laryngeal carcinoma in certain limited clinical situations.
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

The physician must document in the patient's medical record that the diagnosis is appropriate for MMS and that MMS is the most appropriate choice as the treatment of the particular lesion.

The surgeon's documentation in the patient's medical record should be legible and support the medical necessity of this procedure. Operative notes and pathology documentation in the patient's medical record should clearly show MMS was performed using accepted Mohs technique, in which the physician acts in two integrated and distinct capacities: surgeon and pathologist (e.g., should show that true Mohs surgery was performed).

If the 59 modifier is used with a skin biopsy/pathology code on the same day the MMS was performed, physician documentation should clearly indicate:

  • That the biopsy was performed on a lesion other than the lesion on which the MMS was performed;
  • That if the biopsy is of the same lesion on which the MMS was performed, a biopsy of that lesion had not been done within the previous 60 days; or
  • If a recent (within 60 days) biopsy of the same lesion that MMS was performed or had been done, the results of that biopsy were unobtainable by the Mohs surgeon using reasonable effort.

At this time, all laboratory tests covered under CLIA are edited at the CLIA certificate level. The previously mentioned Mohs micrographic surgery HCPCS codes would require either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid current CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2), or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) must not be permitted to bill for these tests.

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to the A/B MAC upon request.
Sources of Information
N/A
Bibliography
  1. Bichakjian CK, Halpern AC, Johnson TM, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2011;65(5):1032-1047.
  2. Clark D. Cutaneous Micrographic Surgery. Otolaryngol Clin North Amer. 1993;26(2):185-202.
  3. Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for malignant melanoma. J Am Acad Dermatol. 1993;28(4):638-641.
  4. Drake LA, Dinehart SM, Goltz RW, et al. Guidelines of care for Mohs micrographic surgery. J Am Acad Dermatol. 1995;33(2)(Pt 1):271-278.
  5. Dzubow LM. Mohs Surgery. Lancet. 1994;343(8895):433-434.
  6. Finley EM. The principles of mohs micrographic surgery for cutaneous neoplasia. The Ochsner Journal. 2003;5(2):22-33.
  7. McGillis ST, Wheeland RG, Sebben JE. Current issues in the performance of mohs micrographic surgery. J Dermatol Surg Oncol. 1991;17(8):681-684.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/01/2021 R10

Under CMS National Coverage Policy deleted the verbiage regarding italicized text in the policy. Under Bibliography changes were made to citations to reflect AMA citation guidelines and removed references that are no longer applicable. Formatting was revised throughout the LCD where needed.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
10/24/2019 R9

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Billing and Coding: Mohs Micrographic Surgery (MMS) A56732 article. Typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
08/23/2019 R8

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Mohs Micrographic Surgery (MMS) A56732 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
10/01/2018 R7

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes deleted ICD-10 codes C43.11, C43.12, C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, C4A.11, C4A.12, D03.11, D03.12, D04.11, D04.12 and added ICD-10 codes C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D22.111, D22.112, D22.121, D22.122, D23.111, D23.112, D23.121 and D23.122. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/07/2018 R6

Under CMS National Coverage Policy deleted the verbiage “NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860 (b) and 42 CFR 426 (Subpart D)). In addition, an administrative law judge may not review a NCD. See section 1869 (f)(1)(A)(l) of the Social Security Act” from the first paragraph. The word “/or” was added before the word “treatment” in the first regulation. Under Coverage Indications, Limitations and/or Medical Necessity added the verbiage “Mohs micrographic surgery” before the acronym MMS and placed parentheses around the acronym in the first sentence of the first paragraph. Under Associated Information – Documentation Requirements replaced the word “will” with the word “must” in the last sentence of the next to last paragraph. Information under Sources of Information was moved to the Bibliography section and changes were made to the citations to reflect AMA citation guidelines. The reference journal information was corrected in the first, fifth, sixth, seventh and ninth citations. Formatting, punctuation and typographical errors were corrected throughout the policy.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
  • Typographical Error
02/26/2018 R5 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
07/07/2016 R4 Punctuation was corrected throughout the LCD. Under CMS National Coverage added the first paragraph and added the verbiage “for the diagnoses and treatment of illness or injury or to improve the functioning of a malformed body member” to the Title XVIII of the Social Security Act, §1862(a)(1)(A). The words “Cosmetic Surgery” were removed and added the verbiage “where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member” to the Title XVIII of the Social Security Act, §1862(a)(10). Revised the verbiage for Title XVIII of the Social Security Act, §1833(e) to read “prohibits Medicare payment for any claim which lacks the necessary information to process the claim”. Under Sources of Information and Basis for Decision added issue numbers and corrected capitalization. Under ICD-10 Codes that Support Medical Necessity deleted the note.
  • Provider Education/Guidance
  • Typographical Error
07/07/2016 R3 Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes C44.510 and C44.520 as requested.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2015 R2 Under Coverage Indications, Limitations and/or Medical Necessity made a few grammatical and punctuation corrections.
Under Sources of Information and Basis for Decision corrected all sources to AMA formatting.
  • Provider Education/Guidance
  • Typographical Error
  • Other (Annual validation)
10/01/2015 R1 Under CMS National Coverage Policy removed CMS Manual System and inserted Internet-Only Manuals.
  • Other (Updated source location of manuals)
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56732 - Billing and Coding: Mohs Micrographic Surgery (MMS)
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/10/2023 11/16/2023 - N/A Currently in Effect View
06/23/2021 07/01/2021 - 11/15/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Moh's
  • Mohs
  • MMS

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