LCD : Mohs Micrographic Surgery (MMS) (L13225)

LCD for Mohs Micrographic Surgery (MMS) (L13225)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L13225

LCD Title

Mohs Micrographic Surgery (MMS)

Contractor's Determination Number

L13225

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

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

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 09/30/2003

Original Determination Ending Date

Revision Effective Date

For services performed on or after 12/09/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Indication Summary

Mohs Micrographic Surgery is covered for basal cell, squamous cell and basalosquamous cell carcinomas of the face and ears. It is also covered for these carcinomas and selected other neoplasms characterized by recurrence, aggressive pathology, location that requires tissue sparing (genitalia, digits) or other characteristics (such as size > 2cm or poorly defined borders) that would preclude simple excision.

Mohs Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin. The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation.

MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by frozen section for microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist, trained and highly skilled in MMS techniques and pathology identification.

Current accepted diagnoses and indications for MMS are:

1. 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; and
Auricular helix and canal

2. Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas having one or more of the following features:

Recurrent
Biopsy proven lesions with aggressive pathology with at least one of the following microscopic characteristics:

a. Sclerotic;
b. Fibrosing;
c. Morphealike;
d. Metatypical/infiltrative/spikey shaped cell groups;
e. Perineural or perivascular invasion;
f. Nuclear pleomorphism;
g. High mitotic activity;
h. 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;
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
Difficulty estimating depth of lesion

3. Laryngeal carcinoma

4. 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;
Adenocystic 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; and
Rare, biopsy-proven skin malignancies not otherwise addressed in this section.

Majority of simple skin cancers can be managed by simple excision or destruction techniques. Medical records should therefore support the complexity, size or location of the lesion to justify performing Mohs micrographic surgery.

Coverage Topic

Outpatient Hospital Services
Surgical Services

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0312	Laboratory pathological-histology
0314	Laboratory pathological-biopsy
0360	Operating room services-general classification
0361	Operating room services-minor surgery

CPT/HCPCS Codes

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 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; 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 HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, 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 HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, 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-9 Codes that Support Medical Necessity

140.0	MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER
140.1	MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER
140.9	MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER
160.0	MALIGNANT NEOPLASM OF NASAL CAVITIES
160.2	MALIGNANT NEOPLASM OF MAXILLARY SINUS
160.3	MALIGNANT NEOPLASM OF ETHMOIDAL SINUS
160.4	MALIGNANT NEOPLASM OF FRONTAL SINUS
160.5	MALIGNANT NEOPLASM OF SPHENOIDAL SINUS
160.8	MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES
160.9	MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED
161.0 - 161.9	MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED
172.0 - 172.3	MALIGNANT MELANOMA OF SKIN OF LIP - MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
173.0 - 173.3	OTHER MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
173.4 - 173.8*	OTHER MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK - OTHER MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN
184.0 - 184.9	MALIGNANT NEOPLASM OF VAGINA - MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED
187.1 - 187.9	MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED
232.0 - 232.4	CARCINOMA IN SITU OF SKIN OF LIP - CARCINOMA IN SITU OF SCALP AND SKIN OF NECK
233.30	CARCINOMA IN SITU, UNSPECIFIED FEMALE GENITAL ORGAN
233.31	CARCINOMA IN SITU, VAGINA
233.32	CARCINOMA IN SITU, VULVA
233.39	CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN
233.5	CARCINOMA IN SITU OF PENIS
233.6	CARCINOMA IN SITU OF OTHER AND UNSPECIFIED MALE GENITAL ORGANS
* A code from the range 173.4-173.8 must be submitted if Mohs Microgrpahic Surgery was performed for one of the diagnoses listed under “Other Skin Lesions”. Mohs is typically not covered for these diagnosis codes. However certain unusual or complicated lesions on the broad surfaces of the body will occasionally meet the specifications of the policy but these will require specific justification in the medical records. If the medical record supports the service in accordance with the policy, it must be identified through the use of the term “*Complex lesion” in the remarks field. Medical records may be requested at that point.

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

1. The surgeon's documentation in the patient's medical record should support the medical necessity of this procedure.

2. 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.

3. Documentation maintained in the patient's medical record must be made available to Medicare upon request.

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

Other FI and Carrier Contractor’s policy on Mohs Micrographic Surgery including Trailblazer, First Coast, BC Kansas, Cigna, and Empire NJ.

American Academy of Dermatology Guidelines: "Guidelines of Care for Mohs' Micrographic Surgery."

Northeast Dermatology Associates: “Mohs Micrographic Surgery”. http://www.nedermatology.com/services/mohs/

Habif: Clinical Dermatology, 3rd ed., “Mohs Micrographic Surgery”

Carucci, John MD. Dermatologic Clinics. Vol. 2. No.4. October 2002. Mohs’ Micrographic Surgery for the treatment of Melanoma”.

Spencer, James MD. Journal of the American Academy of Dermatology. Vol. 44. No. 6. June 2001. “Sebaceous Carcinoma of the Eyelid Treated with Mohs Micrographic Surgery”.

Huether, Michael MD. Journal of the American Academy of Dermatology. Vol. 44. No.4. April 2001. “Mohs Micrographic Surgery for the Treatment of Spindle Cell Tumors of the Skin”.

Menaker, Gregg MD. Journal of the American Academy of Dermatology. Vol. 44. No. 5. May 2001. “Rapid HMB-45 Staining in Mohs Micrographic Surgery for Melanoma in situ and Invasive Melanoma”.

Berlin, Joshua MD. Journal of the American Academy of Dermatology. Vol. 46. No. 4, April 2002. “The Significance of Tumor Persistence after Incomplete Excision of Basal Cell Carcinoma”.

Advisory Committee Meeting Notes

Public Open Meeting to discuss the draft policy was held 06/05/2003.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

05/02/2003

End Date of Comment Period

06/15/2003

Start Date of Notice Period

08/14/2003

Revision History Number

L13225a

Revision History Explanation

This version is to correct a typographical error in the list of ICD-9 codes that support medical necessity, where 173.4 was omitted in the range 173.4-173.8.

This LCD was converted from an LMRP on 12/8/2005

11/18/2006 - CPT/HCPCS code 17304 was deleted from group 1
11/18/2006 - CPT/HCPCS code 17305 was deleted from group 1
11/18/2006 - CPT/HCPCS code 17306 was deleted from group 1
11/18/2006 - CPT/HCPCS code 17307 was deleted from group 1
11/18/2006 - CPT/HCPCS code 17310 was deleted from group 1

01/08/2007 - CPT/HCPCS code 17311 was added to group 1
01/08/2007 - CPT/HCPCS code 17312 was added to group 1
01/08/2007 - CPT/HCPCS code 17313 was added to group 1
01/08/2007 - CPT/HCPCS code 17314 was added to group 1
01/08/2007 - CPT/HCPCS code 17315 was added to group 1

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

10/04/2007 - Frequently Asked Questions restored to Appendices.

Reason for Change

ICD9 Addition/Deletion

Last Reviewed On Date

10/04/2007

Related Documents

Article(s)
A37952 - Mohs Micrographic Surgery (MMS)

LCD Attachments

FAQ (10,131 bytes)

Other Versions

Updated on 01/08/2007 with effective dates 12/09/2005 - N/A

Updated on 09/01/2006 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 09/30/2003 - 12/08/2005

Updated on 09/30/2003 with effective dates 09/30/2003 - N/A

Updated on 08/12/2003 with effective dates 09/28/2003 - N/A