Local Coverage Determination (LCD)

Mohs Micrographic Surgery

L34195

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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.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34195
Original ICD-9 LCD ID
Not Applicable
LCD Title
Mohs Micrographic Surgery
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 04/27/2023
Revision Ending Date
N/A
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

Annual review was performed and no changes were made.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. 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 an NCD. See section 869(f)(1)(A)(i) of the Social Security Act.

Title XVIII of the Social Security Act (SSA):

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)
This section allows coverage and payment for only those services considered medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833 (e)
This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
    30 Physician Services

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16:
    120 Cosmetic Surgery

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
    40-40.6 Surgeons and Global Surgery

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
    60 Payment for Pathology Services

CMS Transmittal No. 434, Publication 100-04, Medicare Claims Processing Manual, Change Request #3458, January 14, 2005, Addition of CLIA Edits to Certain Health Care Procedure Coding System (HCPCS) Codes for Mohs Surgery.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Mohs micrographic surgery (MMS) is an approach to the excision of skin cancers that aims to achieve the highest possible cure rates and to minimize wound size and consequent distortions at critical sites such as the eyes, ears, nose and lips. Mohs micrographic surgery is a two-step process: the tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s). Further excision is performed until all margins are clear. The physician performing MMS furnishes both the surgical and pathological services, i.e., the excision and the histologic evaluation of the specimen(s).

Indications:

Medicare will consider reimbursement for Mohs micrographic surgery for the following indications:

Basal cell, squamous cell, or basalosquamous cell carcinomas in anatomic locations where they are prone to recur:

  • Mask area of the face (central face, eyelids, eyebrows, periorbital areas, nose, lips, chin, mandible, periauricular areas, ear, temple, sulci);
  • Forehead, cheeks, and neck;
  • Genitalia;
  • Hands & feet;
  • Scalp.

Basal cell carcinomas, squamous cell carcinomas, or basalosquamous carcinomas that have one or more of the following features:

  • Recurrent tumor;
  • Aggressive pathology;
  • Large size (2.0 cm or greater);
  • Positive margins on recent excision;
  • Poorly defined borders;
  • In the very young (
  • Radiation-induced;
  • In patients with proven difficulty with skin cancers or who are immunocompromised;
  • In an old scar (e.g., a Marjolin's ulcer);
  • Associated with xeroderma pigmentosum;
  • Deeply infiltrating lesion or difficulty estimating depth of lesion;
  • Perineural invasion on biopsy.

Squamous cell carcinoma exhibiting any of the following:

  • Acantholytic histology;
  • Rapid growth;
  • Longstanding duration.

Basal cell nevus syndrome

Other Skin Lesions:

  • Angiosarcoma of the skin;
  • Keratoacanthoma;
  • 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);
  • Verrucous carcinoma;
  • Atypical fibroxanthoma;
  • Leiomyosarcoma or other spindle cell neoplasms of the skin;
  • Adenocystic carcinoma of the skin;
  • Erythroplasia of Queryrat;
  • Apocrine or eccrine carcinoma of the skin;
  • Malignant melanoma and lentigo maligna when anatomical or technical difficulties do not allow conventional excision with appropriate margins.

Limitations:

The physician performing Mohs micrographic surgery must be specifically trained and highly skilled in MMS techniques and pathologic identification.

If a surgeon performs an excision using Mohs surgical techniques, but does not personally provide the histologic evaluation of the specimen(s), the CPT codes for MMS included in this LCD may not be used. Standard excision codes should be chosen for such services.

Other Comments:


Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. When billing for MOHS on the trunk or extremities, please insert one or more of the qualifying terms in the notepad of the electronic claim. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The majority of skin cancers can be managed by simple excision or destruction techniques. The medical records should clearly show that Mohs surgery was chosen because of the complexity, size and/or location of the lesion.

The operative notes and pathology documentation in the patient's medical record must clearly show that Mohs micrographic surgery was performed using accepted Mohs technique, with the physician performing both the surgical and pathology services. The notes should also contain the location, number and size of the lesion(s), the number of stages performed, and the number of specimens per stage.

If reporting the -59 modifier with a skin biopsy/pathology code on the same day the Mohs surgery was performed, the physician's documentation should clearly indicate:

  • that the biopsy was performed on a lesion other than the one on which Mohs surgery was performed;
  • if the biopsy is of the same lesion as the Mohs lesion, that a biopsy of that lesion had not been done within the previous 60 days; or
  • if there has been a recent (within 60 days) biopsy of the same lesion as the Mohs lesion, the results of that biopsy were unobtainable despite reasonable effort by the Mohs surgeon.

Sources of Information
This bibliography presents those sources that were obtained during the development of this policy. CGS Administators, LLC is not responsible for the continuing viability of Web site addresses listed below.

Bowen GM, White GL, Gerwells JW. Mohs Micrographic Surgery. American Family Physician. 2005;72(5):845-848.

Bricca GM, Brodland DG, Ren, D, Zitelli JA. Cutaneous head and neck melanoma treated with Mohs micrographic surgery. J American Academy Dermatol. 2005;52(1):92-99.

Habif TP. Mohs micrographic surgery. Habif: Clinical Dermatology. 4th Edition. Philadelphia, P.A. Mosby, Inc. 2004.

Habif TP. Squamous cell carcinoma. Habif: Clinical Dermatology, 4th Edition. Philadelphia, P.A. Mosby, Inc. 2004.

Lang PG. Indications and limitations of Mohs micrographic surgery. Dermatologic Clinics. 1989;7(4):627-640.

Lang PG. Mohs micrographic surgery fresh-tissue technique. Dermatologic Clinics. 1989;7(4):613-625.

Lang PG. The role of Mohs’ micrographic surgery in the management of skin cancer and a perspective on the management of the surgical defect. Clinics in Plastic Surgery. 2004;31(1):5-31.

Mohs FE. Chemosurgery in cancer, gangrene, and infections, featuring a new method for the microscopically controlled excision of cancer. Springfield, Ill. Thomas. 1956.

Mohs FE. Chemosurgery: a microscopically controlled method of cancer excision. Archives of Surgery. 1941;42:279-295.

Mohs FE. Chemosurgery: microscopically controlled surgery for skin cancer. Springfield, Ill. Thomas. 1978.

Motley R, Kersey P, Lawrence C. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Dermatol. 2002;1446(1):18-25.

Scheinfeld N, Yu T, Weinberg J, et al. Cutaneous oncologic and cosmetic surgery in geriatric patients. Dermatologic Clinics of North America. 2004;22:97-113.
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
04/27/2023 R18

R18

Revision Effective: 4/27/2023

Revision Explanation: Annual review, no changes were made.

04/27/2023: 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.

  • Other (Annual Review)
04/14/2022 R17

Revision Effective: 04/14/2022

Revision Explanation: Annual review, no changes were made.

  • Other (Annual Review)
04/29/2021 R16

R16

Revision Effective: 4/29/2021

Revision Explanation: Annual review, no changes were made.

04/19/2021: 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.

  • Other (Annual Review)
08/08/2019 R15

R15

Revision Effective: n/a

Revision Explanation: Correction to review date, no changes

04/30/2020: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.

  • Typographical Error
08/08/2019 R14

R14

Revision Effective: n/a

Revision Explanation: Annual review, no changes made

04/30/2020: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.

  • Other (Annual review)
08/08/2019 R13

R13

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019: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.

  • Revisions Due To Code Removal
08/08/2019 R12

R12

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019: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.

  • Revisions Due To Code Removal
08/08/2019 R11

Revision#:R11
Revision Effective date:08/08/2019
Revision Explanation: Removed coding from policy and placed in billing and coding article related to the policy as instructed in CR 10901.

08/01/2019 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.

  • Other (Code Migration)
10/01/2018 R10

Revision#:R10
Revision Effective date: N/A
Revision Explanation: Annual Review, no changes made. Added 21 Century Cures Act

04/15/2019 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.

  • Other (Annual Review, no changes made. Added 21 Century Cures Act.)
10/01/2018 R9

Revision#:R9
Revision Effective date: N/A
Revision Explanation: Annual review no changes made.

  • Other (Annual review, no changes made.)
10/01/2018 R8

Revision#:R8
Revision Effective date: 10/01/2018
Revision Explanation: During ICD-10 annual review the following codes were deleted: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, and D04.12. The following codes were added during the ICD-10 annual update: C43.111, C43.112, C43.121, C43.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1921, C44.1922, C44.1991, C44.1992, C4A.111, C4A.112, C4A.121, C4A.122, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, and D04.122

  • Revisions Due To ICD-10-CM Code Changes
03/01/2017 R7 Revision#:R7
Revision Effective date: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
03/01/2017 R6 Revision#:R6
Revision Effective date: 03/01/2017
Revision Explanation: Added other skin lesions to information in the group one asterisk paragraph with BCC, SCC BSC.
  • Reconsideration Request
10/01/2015 R5 Revision#:R5
Revision Effective date: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
10/01/2015 R4 Revision#:R4
Revision Effective date: 10/01/2015
Revision Explanation: Added D00.01 to group one.
  • Reconsideration Request
10/01/2015 R3 Revision#:R3
Revision Effective date: 10/01/2015
Revision Explanation: added C44.702 to the asterisk note test. Left of in error.
  • Typographical Error
10/01/2015 R2 Revision#:R1
Revision Effective date: 10/01/2015
Revision Explanation: Accepted revenue code description changes.
  • Other (revenue code)
10/01/2015 R1 Revision#:R1
Revision Effective date: N/A
Revision Explanation: Corrected the typo in the general information section in the first paragraph to insert the see indication and limitations section after the second sentence instead of before.
  • Typographical Error
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56836 - Billing and Coding: Mohs Micrographic Surgery
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
04/19/2023 04/27/2023 - N/A Currently in Effect You are here
04/08/2022 04/14/2022 - 04/26/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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