Mohs Micrographic Surgery

LCD Information Document Information Source LCD ID N/A LCD ID L35702 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 10/23/2025 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. 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. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description Correcting typographical errors. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be 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, Section 30, Physician ServicesCMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 120, Cosmetic SurgeryCMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12 Section 40-40.6, Surgeons and Global SurgeryCMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 60, Payment for Pathology ServicesCMS 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 Indications, Limitations, and/or Medical Necessity Coverage Indications, Limitations, and/or Medical NecessityAs defined by the American Medical Association Current Procedural Terminology (American MedicalAssociation, Chicago, IL), Mohs Micrographic Surgery (MMS) is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It is a combination of surgical excision and surgical pathology that requires a single physician to act in 2 integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic (hematoxylin-eosin or toluidine blue) examination. Thus, a tissue block in MMS is defined as an individual tissue piece embedded in a mounting medium for sectioning. (American Medical Association. Mohs Micrographic Surgery. CPT Assistant 2006;16:1-7)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). Mohs surgery is usually an outpatient procedure done under local anesthesia (with or without sedation).The majority of simple skin cancers can be managed by simple excision or destruction techniques. The medical records should clearly document that Mohs surgery was chosen because of the complexity (e.g. poorly defined clinical borders, possible deep invasion, prior irradiation), size or location (e.g. maximum conservation of tumor-free tissue is important). Indications:After careful review Medicare Jurisdictions E and F have adopted coverage for Mohs Micrographic Surgery in accordance with the 2012 Appropriate Use Criteria (AUC) for Mohs Micrographic Surgery as published in the Journal of the American Academy of Dermatology Volume 67, Issue 4, pp 531-550, October 2012. These criteria were compiled based on collaboration of the American Academy of Dermatology, the American College of Mohs Surgery, the American Society of Dermatologic Surgery Association and the American Society for Mohs surgery based on evidence based medicine, clinical practice experience and expert judgment. Clinical settings that are supported by the criteria as denoted by the CPT® codes and ICD-10-CM codes listed in the Billing and Coding Article will be considered for coverage when properly performed and the indications, procedure and findings/results clearly and legibly documented within the beneficiary’s clinical record. Clinical settings noted to be inappropriate by the criteria and not otherwise covered in this LCD will be denied and should NOT be billed to Medicare as MMS. The majority of simple skin cancers can be managed by simple excision or destruction techniques. The medical records should clearly show that MMS was chosen because of the complexity (e.g. poorly defined clinical borders, possible deep invasion, prior irradiation), size or location (e.g. maximum conservation of tumor-free tissue is important). Definitions: 1. Area H: Mask areas of the face (central face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermillion], chin, ear and periauricular skin/sulci, temple), genitalia (including perineal and perianal areas), hands, feet, nail units, ankles, nipples/areola. 2. Area M: Cheeks, forehead, scalp, neck, jawline, pretibial surface. 3. Area L: Trunk and extremities (excluding pretibial surfaces, hands, feet, nail units and ankles). 4. Immunocompromised: a patient with HIV/AIDS, organ transplant, hematologic malignancy or pharmacologic suppression. 5. Genetic Syndromes: basal cell nevus syndrome, xeroderma pigmentosa, or other syndromes at high risk for skin cancer. 6. Healthy: no immunosuppression, no prior radiation therapy to affected area, no chronic infections and no genetic syndromes that predispose to skin cancer. 7. Prior Radiated Skin: patient has previously received therapeutic radiation in this area of the body. 8. Aggressive features: a. For Basal Cell Carcinoma i. Morpheaform, fibrosing, sclerosing ii. Infiltrating iii. Perineural iv. Metatypical/keratotic v. Micronodular b. For Squamous Cell Carcinoma i. Sclerosing ii. Basosquamous excluding keratotic BCC iii. Small cell iv. Poorly or undifferentiated, i.e. high degree of polymorphism, high mitotic rate and/or low degree of keratinization v. Perineural or perivascular vi. Spindle cell vii. Pagetoid viii. Infiltrating ix. Keratoacanthoma (KA) type: central facial x. Single Cell xi. Clear Cell xii. Lymphoepithelial xiii. Sarcomatoid xiv. Breslow depth below 2mm or greater xv. Clark level IV or greater 9. Tissue Block: A block is the plate that tissue is placed upon, coated with embedding medium, frozen, and then placed into the microtome for cutting. Thus, a block is a plate with tissue and mounting medium on it. How many tissue pieces go onto the plate (block) does not matter. The technician, with possible input from the physician, decides how many tissue pieces from a given excision stage would fit on one tissue plate (block). For example, a specimen may be butterflied and put on one block (tissue plate), or the same specimen could be bisected and both tissue pieces put on one plate (block). It is still one block. Another example: one may take a subsequent Mohs excision stage as three separate, non-contiguous pieces (specimens). Each of the tissue pieces is considered as a separate tissue specimen; however, depending upon their size and the technician's proficiency, all three pieces could be placed upon one plate (one block), or two pieces on one plate and one on another plate (2 blocks), or each of the three tissue pieces (specimens) could be placed on individual plates (3 blocks). The block is the billing unit, not the tissue piece. Indications:Medicare will consider reimbursement for MMS for the following indications and anatomic locations:I. Basal Cell Carcinoma A. Recurrent BCC of any size or unexpected positive margin on recent excision (healthy or immunocompromised or genetic syndrome(s)) Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A