Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27503

Moh's Micrographic Surgery

L27503

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.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Moh’s 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.

Indications

1. Medicare will consider reimbursement for MMS if all of the following are met:

• The lesion diagnosis and indication are listed in this policy.
• The physician performing the MMS is trained and highly skilled in MMS techniques and pathology identification.
• The physician’s documentation in the patient's medical record indicates that the diagnosis is appropriate for MMS and that MMS is the most appropriate choice for the treatment of the particular lesion.

2. Lesion biopsy:

In order to determine the exact nature of the lesion(s) to be removed, a biopsy of the skin lesion is needed. Occasionally, that biopsy may be done on the same day that the MMS is scheduled. In order to allow separate payment to the Moh’s surgeon for a biopsy and pathology on the same day as MMS, the -59 modifier is appropriate. The -59 modifier is also appropriate when a submitting a claim for biopsy of a distinctly separate skin lesion that is done on the same day that the MMS is performed.

Payment for another biopsy to the Moh’s surgeon will not be made if a biopsy of the lesion had been done by a physician other than the Moh’s surgeon within 60 days prior to the scheduled MMS. An exception exists when a biopsy has been performed by someone other than the Moh’s surgeon within that period and the biopsy results could not be obtained by the MMS surgeon using reasonable effort. The clinical record must clearly show that this situation existed.

3. Current accepted diagnoses and indications for Mohs' Micrographic Surgery are:

• Basal cell carcinomas, squamous cell carcinomas, or basalosquamous cell carcinomas in an anatomic locations where they are prone to recur:
  
  • Other skin lesions
    
  • Adenocystic carcinoma of the skin
  • Adenoid type of squamous cell carcinoma
  • Angiosarcoma of the skin
  • Apocrine carcinoma of the skin
  • Atypical fibroxanthoma
  • Bowen's disease (squamous cell carcinoma in situ)
  • Bowenoid papulosis
  • Dermatofibrosarcoma protuberans
  • Erythroplasia of Queryrat
  • Extramammary Paget's disease
  • Keratoacanthoma
  • Leiomyosarcoma or other spindle cell neoplasms of the skin
  • Malignant fibrous histiocytoma
  • Malignant melanomas*
  • Merkel cell carcinoma
  • Microcystic adnexal carcinoma
  • Oral and central facial, paranasal sinus neoplasm
  • Sebaceous gland carcinoma
  • Squamous cell carcinoma, rapid growth
  • Squamous cell carcinoma, long standing duration
  • Verrucous carcinoma
    
    *Malignant melanomas in any area are difficult to determine margins in frozen sections, as is done with MMS. Only in exceptional circumstances should MMS be performed for such lesions. It should be carefully documented in the medical records why MMS was medically necessary.
    
  • Laryngeal carcinomas

4. CPT codes 88301-88306, 88331, 88332, and 88342

5. If the preparation and interpretation of the slides of tissue taken during the MMS are performed by someone other than the surgeon or his or her employee, then MMS surgery may not be billed.

Limitations

Claims may be denied when the above coverage criteria are not met.

Claims will be denied when Medicare determines that the services were not medically reasonable and necessary, or that the services were determined to fall under one of the Medicare "Exclusions", e.g., cosmetic surgery.

Lab Services, Outpatient Hospital Services, Surgical Services

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27503

07/31/2008

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