Coverage Policy Manual
Policy #: 1997141
Category: Surgery
Initiated: June 1993
Last Review: May 2018
  Mohs' Micrographic Surgery

Description: Mohs' microscopic surgery is a precise tissue-sparing surgical technique used in the removal and treatment of selected malignant neoplasms of the skin.  This surgery requires a single physician to act in two distinct roles:  surgeon and pathologist.  The procedure is done in stages with successive stages being used to remove more extensive tumors as needed.

The physician performing Mohs' Micrographic Surgery (MMS) must be trained and 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 for the treatment of the particular lesion.

Policy/
Coverage:
Effective, September 1998
Mohs' Micrographic Surgery (MMS) meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:
    • Basal cell, squamous cell or basosquamous 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); lips, cutaneous and vermilion; eyelids; auricular helix and canal.
    • Basal cell, squamous cell or basosquamous carcinomas that have one or more of the following features:  recurrent; aggressive pathology in the area of hands and feet, genitalia, nail/unit periungual; large size (2.0 cm or greater); positive margins on recent excision; poorly defined borders; in the very young (less than 40 years age); radiation-induced; in patients with proven difficulty with skin cancers or who are immunocompromised; basal cell nevus syndrome; in an old scar (e.g., a Marjolin's ulcer); associated with xeroderma pigmentosum; perineural invasion on biopsy; deeply infiltrating lesion or difficulty estimating depth of lesion.
    • Other skin lesions:  acantholytic squamous carcinoma; angiosarcoma of the skin; keratoacanthoma, recurrent; 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 Queyrat; oral and central facial, paranasal sinus neoplasm; apocrine carcinoma of the skin; malignant melanoma (facial, auricular, genital, digital) when anatomical  or technical difficulties do not allow conventional excision with appropriate margins.
 
If MMS is being submitted for one of the skin diagnoses listed under "Other Skin Lesions" above, the claim should be submitted with diagnosis code 173.8 and documentation in the medical record must reference that particular lesion by name or description and support the medical necessity of its removal by MMS.
 
The necessity of MMS is determined by several factors, the most important being the nature of the lesion that requires the procedure and this requires a skin biopsy.  Rarely the biopsy may need to be done on the same day as the MMS.  In order to obtain separate payment for the initial biopsy and pathology on the same day as MMS use of the -59 modifier would be appropriate.
 
Closure of the wound created by the Mohs' surgery will be reimbursed by the following guidelines:
    • Simple repair is included in the Mohs' surgery and is not separately reimbursed;
    • Intermediate repair (layered closure of one or more of the deeper layers of subcutaneous tissue and superficial fascia, in addition to the skin, dermal and epidermal, closure), requires operative note;
    • Complex repair, defined as complicated wounds requiring reconstructive surgery and would include subcuticular closure, use of drains, galeal scoring and scalp release, and soft tissue debulking  (wide undermining of tissue to allow closure does not constitute complex repair), requires operative note.  A photograph of the open wound should be available if requested.
    • Adjacent tissue transfer, defined as excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement (e.g.,  Z-plasty, W- plasty, and V-Y plasty, rotation flap, advancement flap, double pedicle flap). When applied in repairing laceration, the procedures listed must be developed by the surgeon to accomplish the repair.  This type closure requires an operative note.  A photograph of the open wound should be available if requested.
    • Flaps and grafts require operative notes and a photograph of the open wound.
    • Large defect closure may be submitted for review using the -22 modifier with the appropriate CPT closure code.

Rationale:
2009 Update
A search of the MEDLINE database and review of the NCCN guidelines did not reveal any studies or changes in guidelines that would prompt a change in the coverage statement.
 
2012 Update
A search of the MEDLINE database and review of the NCCN guidelines did not reveal any studies or changes in guidelines that would prompt a change in the coverage statement.
 
2014 Update
A literature search conducted using the MEDLINE conducted through March 2014 did not reveal any new findings from randomized controlled trials that would prompt a change in the coverage statement.
 
2015 Update
A literature search conducted through April 2015 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Basal cell carcinoma (BCC) is the most common form of cancer among Caucasians and its incidence continues to rise. Surgical excision (SE) is considered standard treatment, though randomised trials with long-term follow-up are rare. van Loo and colleagues report the long-term results of a randomised trial comparing surgical excision with Mohs' micrographic surgery (MMS) for facial BCC (van Loo, 2014); 408 facial, high risk (diameter at least 1cm, H-zone location or aggressive histological subtype) primary BCCs (pBCCs) and 204 facial recurrent BCCs (rBCCs) were randomly allocated to treatment with either SE or MMS between 5th October 1999 and 27th February 2002. The primary outcome was recurrence of carcinoma. A modified intention to treat analysis was performed. For primary BCC, the 10-year cumulative probabilities of recurrence were 4.4% after MMS and 12.2% after SE (Log-rank test χ(2) 2.704, p=0.100). For recurrent BCC, cumulative 10-year recurrence probabilities were 3.9% and 13.5% for MMS and SE, respectively (Log-rank χ(2) 5.166, p=0.023). A substantial proportion of recurrences occurred after more than 5years post-treatment: 56% for pBCC and 14% for rBCC. Fewer recurrences occurred after treatment of high risk facial BCC with MMS compared to treatment with SE. The proportion of recurrences occurring more than 5years post-treatment was especially high for pBCC, stressing the need for long-term follow-up in patients with high risk facial pBCC.
 
2016 Update
A literature search conducted through March 2016 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted using the MEDLINE database did not reveal any new literature that would prompt a change in the coverage statement.
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2018. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
17311Mohs 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
17312Mohs 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)
17313Mohs 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
17314Mohs 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)
17315Mohs 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)

References: Clark D.(1993) Cutaneous micrographic surgery. Otolaryng Clin N Am 1993; 26:185-201.

Drake LA, Dinehart SM, Goltz RW, et al.(1993) Guidelines of care for Malignant Melanoma. Am Acad Derm Guidelines 1993.

Drake LA, Dinehart SM, Goltz RW, et al.(1993) Guidelines of care for Mohs’ Micrographic Surgery. Am Acad Derm Guidelines 1993.

Dzubow LM.(1994) Mohs surgery. Lancet 1994; 343:433-444.

van Loo E, Mosterd K, Krekels GA et al.(2014) Surgical excision versus Mohs' micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with 10 year follow-up. Eur J Cancer. 2014 Nov;50(17):3011-20. doi: 10.1016/j.ejca.2014.08.018


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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