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 - Average fee payment - $650 - $670
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 - Average fee payment - $380 - $420
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) Average fee payment - $70 - $100
Coding and Billing Guidelines
General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
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.
The National Correct Coding Initiative does not permit payment for the biopsy and the Mohs' surgery on the same lesion, in the same operative session, on the same date of service. It is NOT appropriate to report the 59 modifier (distinct procedural service) when the biopsy and Mohs' surgery is performed on the same lesion, in the same operative session, on the same date of service. The -59 modifier should be reported when a biopsy or excision of lesion is performed in situations other than stated above.
The use of CPT codes 17311-17315 is reserved for the surgeon who removes the lesion and prepares and interprets the pathology slides. The surgical pathology codes 88300-88309 and 88331-88332 and 88342 are part of the Mohs surgery and are bundled into 17311-17315. The surgeon should not append Modifier 59 to these pathology codes unless they pertain to a separate biopsy/excision that does not involve Mohs surgery.
Report the appropriate Mohs surgery code for the body location surgery performed effected, with include any applicable surgery modifiers and the appropriate quantities for the specimens mapped in the days/units field. The quantity should be entered into the days/units field as "00010" for the first stage code and the appropriate number for the additional stages. Report CPT code 17312 for additional stages with first stage code 17311. Report CPT code 17314 for additional stages with first stage codes 17313. All the surgical procedure performed in the same operative session, including repairs should be reported on the same claim.
Do not report multiple instances of 17312 on separate claim lines. These should be totaled and entered as a single item with appropriate units of service greater than one.
Do not report multiple instances of 17314 on separate claim lines. These should be totaled and entered as a single item with appropriate units of service greater than one.
For each additional (separate) lesion treated with Mohs surgery on the same day, bill each first stage as a 17311 or 17313 as appropriate, on a separate claim line with a -59 modifier. Separately identify the additional stages for these lesions by billing the 17312 or 17314 on separate claim lines with a -59 modifier, and the appropriate units of service for these lesions.
CPT code 17315 may be used to report each block after the first 5 blocks for any single stage (17315 is used as an add-on code to 17311, 17312, 17313 or 17314). Please note that this code refers to the number of blocks, not number of slides.
If Mohs on a single site cannot be completed on the same day because the patient could not tolerate further surgery and the additional stages were competed the following day, you must start with the primary code (CPT code 17311) on day two. Computer edits will reject claims where a secondary code (e.g., CPT code 17312) is billed without the primary code (e.g., CPT code 17311) also appearing on same date of service, same claim.
For claims submitted to the carrier or Part B MAC:
Report the -59 modifier on the same line as the biopsy procedure code and the pathology procedure codes: 11100, 11101, and 88331. Do not report modifier -59 on the same detail line as the Mohs surgical procedure.
A Clinical Laboratory Improvement Act (CLIA) certification number is required on all claims submitted for Mohs surgery billed with any of the following CPT codes, 17311-17315. The CLIA number should be submitted in item 23 of the CMS 1500 claim form or the electronic equivalent.
Claims for Mohs surgery services are payable under Medicare Part B in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgery center (24), independent clinic (49), federally qualified health center (50), state or local public health clinic (71) and rural health clinic (72).
Note: The facility fees for the listed procedure codes are not reimbursable with place of service 24, ambulatory surgery center (ASC) although physician fees are reimbursable.
Medicare will consider reimbursement for MMS for current accepted diagnoses and indications 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 MMS 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 MMS is planned to be done. To allow separate payment for a biopsy and pathology on the same day as MMS, the 59 modifier is appropriate. Modifier 59 is also appropriate when a separate skin lesion, other than the lesion for which MMS is performed, is biopsied on the same day that the MMS is performed.
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 MMS surgeon using reasonable effort. The clinical record must clearly show this situation existed.
All coverage criteria must be met before this service can be reimbursed by Medicare.
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.
- 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.
- 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.
- 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:
- 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).
- 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.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
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.
12X, 13X, 18X, 71X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.
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.
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Mohs, 1 stage, h/n/hf/g
Mohs addl stage
Mohs, 1 stage, t/a/l
Mohs, addl stage, t/a/l
Mohs surg, addl block
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 17311, 17312, 17313, 17314 and 17315:
Malignant neoplasm of lip
Malignant neoplasm of lip
Malignant neoplasm, nasal cavities
Malignant neoplasm, maxillary sinus
Malignant neoplasm, frontal sinus
Malignant neoplasm of larynx
Malignant neoplasm of larynx
Malignant neoplasm of connective and other soft tissue
Malignant neoplasm of skin
Other malignant neoplasm of scalp and skin of neck
Other malignant neoplasm of skin of trunk except scotum
Other malignant neoplasm of skin of upper limb including shoulder
Other malignant neoplasm of skin of lower limb including hip
Malignant neoplasm, other specified sites of skin
*Note: If MS is performed for one of the skin diagnoses listed under the “Other Skin Lesions” section, the claim must be submitted with ICD-9-CM code 173.8. Documentation must be maintained in the medical record which references that particular lesion by name or description, and supports the medical necessity of its removal by MMS.
Malignant neoplasm of vulva unspecified site
Malignant neoplasm of prepuce
Malignant neoplasm of glans penis
Malignant neoplasm of penis part unspecified
Malignant neoplasm of scrotum
Malignant neoplasm of male genital organ site unspecified
- Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
- 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 MMS technique, in which the physician acts in two integrated and distinct capacities: surgeon and pathologist (e.g., should show that true MMS 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:
- The biopsy was performed on a lesion other than the lesion on which the MMS was performed.
- 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.
- If a recent (within 60 days) biopsy of the same lesion on which MMS was performed had been done, the results of that biopsy were unobtainable by the MMS surgeon using reasonable effort.
- At this time, all laboratory tests covered under CLIA are edited at the CLIA certificate level. The previously mentioned MMS 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) will not be permitted to bill for these tests.
- When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.
Applicable codes: 17311, 17312, 17313, 17314, 17315
BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.