LCD L35494: Mohs Micrographic Surgery

As defined by the American Medical Association Current Procedural Terminology (American Medical Association, 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 requires the integration of an individual functioning in 2 separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician or other qualified health care professional 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 examination.

Mohs micrographic surgery is a 2-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).

MMS requires specialized equipment, tissue lab personnel and capabilities not generally present in hospital or freestanding pathology departments.

Qualifications of the physician and office/facility team:

While MOHS surgery is a technical method of tissue handling and processing, the training and expertise of the surgeon greatly impacts the clinical outcome. MMS is reserved for the surgeon who removes the lesion, prepares and interprets the pathology slides coincident with the resection procedure. Therefore, the physician performing the MMS must be trained and highly skilled in MMS techniques and pathology identification. The qualifications of the performing physician must be verifiable if requested by the Contractor.

Providers of MOHS surgery are limited to physicians (i.e., MD/DO) as follows:

• A Licensed Physician, enrolled as a Medicare Provider, who has completed Residency training in Dermatology or general/subspecialty surgery AND has completed additional medical training in MOHS surgery. This additional training and expertise must be verifiable. Verification of this training should be available if requested. Examples of verification are letter/certificate confirming fellowship program (program certified by a nationally recognized organization); residency program with letter confirming adequate MMS training (program certified by a nationally recognized organization); credible post-graduate training course/program covering MOHS micrographic surgery technique and pathology identification; credible preceptorship with demonstrated case experience and expertise (See Sections 1861 [s] [2] and 1862 [a] [140 of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.).

Appropriate Settings:

• The qualified physician must provide services in the appropriate setting for the patient's medical need and condition. Success requires good tissue handling, good surgical technique, and standard of care tissue processing and staining technique. The MOHS surgery facility must meet standards of care as most are not affiliated with hospital delivery systems. A typical facility consists of procedure rooms suitable for dermatological surgery located in close proximity to a fully equipped MOHS laboratory. The necessary equipment for MOHS cases of all complexities is available per standards of care. The MOHS laboratory typically has standard of care equipment such as cryostats, staining facilities (manual and/or automated) for standard staining of MOHS section. There is access to appropriate immunohistochemical staining for selected MOHS cases. The setting must include a MOHS histolaboratory technician who will be either dedicated or one of a small team of biomedical staff who regularly cut MOHS sections and do sufficient numbers per week to maintain a high technical expertise in preparing MOHS sections.

This LCD addresses the reasonable and necessary threshold for coverage based on 3 requirements;

• Qualifications of the physician and office/facility team;

• Characteristics of the lesion pre-procedure;

• Documentation of the Medical Necessity for the MOHS micrographic technique and associated plans for the repair. See Documentation Requirements in associated A57477 Billing and Coding Article: Mohs Micrographic Surgery.

Indications:

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, was carefully reviewed. 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.

The majority of simple 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 (e.g., poorly defined clinical borders, possible deep invasion, or prior irradiation), size or location (e.g. maximum conservation of tumor-free tissue is important).

Clinical settings that are supported by the criteria as denoted by the CPT codes and diagnosis codes listed in the associated article Billing and Coding: Mohs Micrographic Surgery will be considered for coverage when properly performed and the indications, procedures and findings/results are clearly and legibly documented within the beneficiary’s clinical record. Clinical settings noted to be inappropriate by the criteria and not otherwise covered in the LCD will be denied and should NOT be billed to Medicare as MMS.

Definitions:

• 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.

• Area M: Cheeks, forehead, scalp, neck, jawline, pretibial surface.

• Area L: trunk and extremities (excluding pretibial surfaces, hands, feet, nail units and ankles).

• Immunocompromised: a patient with HIV/AIDS, organ transplant, hematologic malignancy or pharmacologic suppression.

• Genetic Syndromes: basal cell nevus syndrome, xeroderma pigmentosa, or other syndromes at high risk for skin cancer.

• Healthy: no immunosuppression, no prior radiation therapy to affected area, no chronic infections and no genetic syndromes that predispose to skin cancer.

• Prior Radiated Skin: patient has previously received therapeutic radiation in this area of the body.

• Aggressive features:

• For Basal Cell Carcinoma

• Morpheaform, fibrosing, sclerosing

• Infiltrating

• Perineural

• Metatypical/keratotic

• Micronodular

• For Squamous Cell Carcinoma

• Sclerosing

• Basosquamous excluding keratotic BCC

• Small Cell

• Poorly or undifferentiated, i.e. high degree of polymorphism, high mitotic rate and/or low degree of keratinization

• Perineural or perivascular

• Spindle Cell

• Pagetoid

• Infiltrating

• Keratoacanthoma (KA) type: central facial

• Single Cell

• Clear Cell

• Lymphoepithelial

• Sarcomatoid

• Breslow depth below 2mm or greater

• Clark level IV or greater

Medicare will consider reimbursement for MMS for the following indications and anatomic locations:

• Basal Cell Carcinoma

• Recurrent BCC of any size or unexpected positive margin on recent excision (healthy or immunocompromised or genetic syndrome(s))

• Aggressive Pathology

• Areas H, M and/or L

• Nodular Pathology

• Areas H, M and/or L

• Superficial Pathology

• Areas H and M only

• No coverage for area L

• Primary Aggressive

• Size ≤ 0.5 cm

• Areas H and M

• Area L would rarely be medically necessary

• Size ≥ 0.6 cm

• Areas H, M and L

• Primary Nodular BCC (healthy patient)

• Size ≤ 0.5 – 1 cm

• Areas H and M only

• No coverage for area L

• Size 1.1 – 2 cm

• Areas H and M

• Area L would rarely be medically necessary

• Size ≥ 2 cm

• Areas H, M and L

• Primary Nodular BCC (immunocompromised patient)

• Size ≤ 0.5 cm

• Areas H and M only

• No coverage for area L

• Size 0.6 – 1 cm

• Areas H and M

• Area L would rarely be medically necessary

• Size ≥ 1.1 cm

• Areas H, M and L

• Primary Superficial BCC (healthy patient)

• Size ≤ 0.5 cm

• Area H

• Area M would rarely be medically necessary

• No coverage for area L

• Size ≥ 0.6 cm

• Areas H and M

• No coverage for area L

N/A