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Mohs Definition Mohs Coding and Reimbursement You do the excision and you interpret the slides Alexander Miller, M.D. -- You are both surgeon and pathologist November 9, 2018 Anything else by CPT definition is not Mohs. Anything else by Medicare definition is not Mohs.

-- Doing otherwise and billing the procedure as Mohs is interpreted by Medicare as fraud

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Corollary: or “Slow Mohs”, by definition, is not Mohs . SE1318 Delineates performance and documentation requirements Guidance To Reduce Mohs Surgery Reimbursement Issues Coding for “Slow Mohs”: Provider Types Affected • Surgeon codes for the excision with the final maximum This MLN Matters® Special Edition Article is intended for physicians and hospitals submitting excision diameter determining malignant excision code claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (MACs)) for providing Mohs Micrographic Surgical (MMS) services to (11600-11646) selection Medicare beneficiaries. • Pathologist selects appropriate histopathology code(s) What You Need to Know Medicare will only reimburse for MMS services when the Mohs surgeon acts as both surgeon and pathologist. You may not bill Medicare for these procedures if preparation or interpretation of pathology slides is performed by a physician other than the Mohs surgeon.

Distribute Mohs Codes Coding Essentials for Mohs Each Mohs stage includes: • staining with a “routine” stain: hematoxylin and eosin (H&E), toluidine • Mohs CPT codes: 17311 – 17315 blue • Repair CPT codes: • Processing of tissue into up to 5 tissue blocks – Intermediate: 12031 – 12057 17311 First stage: head, neck, hands, feet, genitalia; any location involving – Complex: 13100 – 13153 muscle, cartilage, bone, tendon, major nerves, or vessels • Adjacent tissue rearrangement (flaps): CPT 14000 – 14302Not and select others 17312 Each additional stage after the first stage • Grafts and specialized flaps: CPT 15000 series 17313 First stage: trunk, arms, legs • Modifiers and when to use them 17314 Each additional stage after the first stage Do 5 17315 Each additional tissue block over 5 blocks per any stage 6

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Definition of Terms One Tissue Block • Tissue block: One or more pieces of tissue embedded on a single frozen section specimen disk.

• Routine stains: H&E, toluidine blue (one) Specimen • Stage=Level=Layer bisected • Surgeon and pathologist: one and the same person

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More than 5 Blocks of Tissue Produced Mohs Surgery Documentation: LCD in Any Stage Noridian JE Mohsor Local Coverage Determination (LCD) for California, • Code 17315 Nevada, Hawaii and Pacific Islands: Documentations Requirements “The surgeon must describe the of the specimens taken in the first stage. That • Add-on code, used once for every block of tissue beyond description should include depth of invasion, pathological pattern, cell morphology, and, if five, per stage present, perineural invasion or presence of scar tissue. For subsequent stages, the surgeon • The tissue block is the unit of service that determines the use may note that the pattern and morphology of the tumor, if still seen, is as described for the of 17315 first stage, or, if differences are found, note the changes. There is no need to repeat the detailed description documented for the first stage, presuming that the description would fit – Number of individual tissue pieces that a specimen is cut into does not matter the tumor found on subsequent stages.” – Number of tissue pieces on one block does not matter “When the documentation does not meet the criteria for the service rendered or the – Number of slides made does not matter documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.”

Distribute Mohs Surgery Documentation: MLN 2013 CMS Medicare Learning Network Matters (MLN Matters®) article titled “Guidance to Reduce Mohs Surgery Reimbursement Issues”: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1318.pdf Your documentation in the patient's medical record should support the medical necessity of this procedure and of the number and locations of the specimens taken. The operative notes and pathology “Additionally, you should be aware of Mohs Medicare coverage limitations: 1) Only documentation should clearly show that the procedure was performed using accepted MMS technique, physicians (MD/DO) may perform MMS; 2) The physician performing MMS must be in which you acted in two integrated, but distinct, capacities as surgeon and pathologist. The notes specifically trained and highly skilled in MMS techniques and pathologic identification; should also contain the location, number, and size of the lesion(s), the number of stages performed, and and 3) As mentioned above, if the surgeon performing the excision using MMS the number of specimensNot per stage. does not personally provide the histologic evaluation of the specimen(s), the CPT codes for MMS cannot be used, rather the codes (11600-11646) for the You must describe the histology of the specimens taken in the first stage. That description should standard excision of malignant lesions should be chosen.” include depth of invasion, pathological pattern, cell morphology, and, if present, perineural invasion or presence of scar tissue. For subsequent stages, you may note that the pattern and morphology of the tumor (if still seen) is as described for the first stage; or, if differences are found, note the changes. Translation: RN’s, PA’s, LVN’s, MA’s may not do Mohs surgery, including the There is no need to repeat the detailed description documented for the first stage, presuming that the excisions of layers of tissue. Dodescription would fit the tumor found on subsequent stages.

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What else do you have to know? Local Coverage Determinations (LCDs)  What are they?  Where do you find them?  Why are they important?  How should you use them?

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LCD’s: What are they? Local Coverage Determinations: Where to find?  Your Medicareor contractor’s website • Coverage documents generated by the Medicare Administrative Contractor (Noridian for Western US)  Don’t know your contractor? Do a search.  • Why? https://www.cms.gov/Medicare/Medicare- Contracting/Medicare-Administrative- – Because there is high utilization (high volume/dollar services) Contractors/Downloads/MACs-by-State- – To assure patient access to care April-2015.pdf – Because a service is being frequently denied – To standardize criteria for documentation and coverage: Western U.S.: Noridian, JE & JF uniform LCDs

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Distribute LCDs: Why important? Typical LCD Structure

 Covered ICD-10 codes  Coverage Guidance  Coverage criteria Coverage Indications, Limitations, and/or Medical  Documentation Necessity criteria  Pertinent CPT codes  Indications: Medicare will consider reimbursement for Not MMS for the following indications and anatomic locations: • If it’s not there, it’s not covered.  Limitations: • Inadequate documentation = claim rejection upon audit Only physicians (MD/DO) may perform Mohs micrographic surgery… Do

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Typical LCD Structure: How to Use MLN: Mohs Surgery Documentation Operative Report Essentials  Coding Information  Who did the Mohs surgery: physician CPT/HCPCS Codes  Physician was both surgeon and pathologist Group 1 Codes: 17311, 17312, etc.  Why was Mohs surgery chosen?  Tumor complexity (poorly defined clinical  ICD-10 Codes that Support Medical Necessity borders, possible deep invasion, prior irradiation) ICD-10 Codes  Tumor size  Tumor location (conservation of tumor-free  Associated Information tissue) Documentation requirements  Mohs surgery is the most appropriate treatment choice: medical necessity

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MLN: Mohs Site,Tissue Processing and Noridian LCD, effective October, 2015

Histology Documentation “The majority of simple skin cancers can be managed by simple excision or destruction techniques. The medicalor records should clearly show that MMS was chosen because of AK  Site documentation the complexity (e.g. poorly defined clinical borders, possible deep invasion, prior AZ  Location  Number of lesions irradiation), size or location (e.g. maximum conservation of tumor-free tissue is CA  Size of each lesion (preoperative photo is optional, but is helpful) important).” HI  Processing ID • LCD closely follows and incorporates the AAD Appropriate Use Criteria for Mohs  Number of stages MT  Number of specimens per stage (distinct, non-contiguous tissue pieces excised in a stage) Surgery  Histology • Defines tissue block ND  First stage: • Allows for legitimate billing of pathology codes (CPT 88302 – 88305) on a Mohs patient NV  Depth of invasion when tissue other than that submitted for Mohs processing is examined OR  Pathological pattern  Cell morphology • Medical record must show that one and the same physician acted as the surgeon and SD  Perineural invasion or scar tissue, if present pathologist UT  Subsequent stages • Medical necessity for the Mohs surgery must be documented WA  Note differences between first stage characteristics • Must document location, number and size of the lesion(s), the number of stages WY  If same, say that it is the same performed, and the number of specimens per stage.

Distribute Mohs L CDs: Histology documentation First Coast Mohs LCD descriptive requirements: same as MLN • First stage • Radically different approach from those of Noridian and WPS – Depth of invasion • “Providers of Mohs surgery are limited to physicians (i.e., MD/DO) as follows: – Pathological pattern • Enrolled in Medicare and a licensed physician who has completed Residency training in – Cell morphology 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 – Perineural invasion or scar tissue presence should be available if requested during a pre or post payment medical review. Examples of • Subsequent stages verification are letter/certificate confirming fellowship program (program certified by a nationally recognized organization); residency program with letter confirming adequate MMS training – NoteNot if tumor pattern and morphology is same as in the first stage (program certified by a nationally recognized organization); credible post-graduate training – Or, describe the differences from the first stage course/program covering Mohs micrographic surgery technique and pathology identification; credible preceptorship with demonstrated case experience and expertise.” – No need to repeat the detailed first stage documentation, if it is the same • “…the surgeon must address why the lesion will not be (was not) managed by excision or destruction technique.” All of the above documentation requirements have already been specified Do by CMS in a MedLearn Matters article, 2013

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Mohs AUC Mohs Continued on a Second Day

From the American Academy of Dermatology On the second day of Mohs, start the billing series with a first stage code, 17311 or 17313, regardless of how many stages were done the Download the new Mohs surgery AUC app! previous day. There are many considerations when determining whether to use Mohs surgery for the treatment of . With the AAD’s new Mohs Surgery Appropriate Use Criteria (AUC) app, you can easily “If MMS on a single site cannot be completed on the same day because the patient and systematically determine when Mohs surgery is most appropriate for your patients from your could not tolerate further surgery and the additional stages were completed the mobile Apple device. following day, you must start with the primary code (CPT code 17311) on day two. Highlights of the free app include: •Decision support on the appropriateness of Mohs surgery for 270 unique scenarios. Computer edits will reject claims where a secondary code (e.g., CPT code 17312) is •Guided navigation through tumor and patient characteristics. •Color-coded body maps for high-, medium-, and low-risk areas. billed without the primary code (e.g., CPT code 17311) also appearing on same date •Supplemental clinical algorithms. of service, and the same claim.” •Quick reference guide that can be shared with referring physicians and patients. Download the app to your iPhone, iPod, or iPad today! Source: MLN Matters “Guidance to Reduce Mohs Surgery Reimbursement Issues” http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- Mohs AUC rates appropriateness for Mohs surgery; it does not imply that Mohs is the only MLN/MLNMattersArticles/Downloads/SE1318.pdf appropriate treatment for a given lesion. --Howard Steinman insight Duplicate

Mohs Continued on a Second Day Diagnostic Biopsy on Day of Mohs On the second day of Mohs, start the billing series with a first stage code, 17311 . No biopsy hasor been done of tumor prior to Mohs surgery. or 17313, regardless of how many stages were done the previous day. . You confirm the presence of a Mohs qualifying tumor with a diagnostic frozen section biopsy and interpretation done preoperatively, on the day of Example: Mohs surgical excision on face, 6 total stages, surgery. completed on two separate days . Your Mohs technician makes the diagnostic frozen section slide and you interpret it and generate a frozen section pathology report. First day, four stages: Is this OK to do? Yes. Code 17311, 17312 x 3 Code: Continued on subsequent day, two stages: • 11100.59, biopsy Code 17311, 17312 • 88331.59, frozen section pathology • The Mohs surgery is coded without a modifier No modifier needed (Mohs has a 0 day global)

Two Separate MohsDistribute done Biopsy of Unrelated Lesion done on one patient, Same day on day of Mohs Surgery • Code: . Two stages of Mohs on nose . Same day notice a lesion suspicious for BCC on the left cheek, so you biopsy it and – First site: use routine Mohs coding send specimen for routine histopathology – Second site: append .59 modifier to all codes You Code: – In “notes” section of electronic billing, specify the two separate sites that were treated 17311: Mohs surgery, first stage Not 17312: Mohs surgery, second stage 11100.76 or 11100 .59.76 for the biopsy

If using the above modifier results in a claim rejection from Medicare, add Why the .76? As of July of 2013 CMS has instructed Medicare contractors to reject claims coded with a .59 modifier .76 “Repeat Procedure or Service by Same Physician or Other modifier for “repeat” services. Instead, a .76 modifier is to be used. Qualified Health Care Professional” to the second Mohs site codes Since the above is done on the same day as Mohs, and on the same general area, it may be Do construed as a repeat service.

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Initial E/M visit determines need for Coding for Special Stains Mohs, and Mohs done on same day • Basic Mohs codes include staining with routine stains: H&E, May you bill for an E&M visit, 99202 or 99203, in addition to the Mohs surgery? toluidine blue NCCI directive: • Additional, non-routine histochemical stain: “If an E/M is performed on the same date of service as a major surgical procedure for – 88314.59, reported once per block the purpose of deciding whether to perform this surgical procedure, the E/M service is separately reportable with modifier 57.” • Immunoperoxidase stain (immunohistochemistry) – 88342.59, reported once per specimen; initial single antibody Code: stain (CPT® 2018) . 17311, 17312…: routine Mohs codes . 99202.57 or 99203.57 for a new patient evaluation, if a flap or graft repair is done on the same day as the Mohs surgery (90 day global) . If only the Mohs surgery is done (0 day global), 99202.25 or 99203.25* or no E/M code Duplicate Immunohistochemistry Codes Howor is “Specimen” defined? 88342 Immunohistochemistry or immunocytochemistry, per CPT® 2018 Definition: Specimen specimen, initial single antibody stain procedure “A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” 88341 each additional single antibody stain procedure (List separately in addition to code for primary procedure) The above definition precedes the 88300 – 88309 histopathology code series. However, the definition is applied to all other pathology codes that include the word 88344 each multiplex antibody stain procedure specimen in their descriptors.

(Do not use more than one unit of 88341, 88342, or 88344 for the same separately identifiable antibody per specimen)

Distribute Examples of Specimen Immunohistochemistry (IHC): Mohs

• One large Mohs stage excised as one piece, NCCI Policy Manual for 2018, chapter 10, page X-23:

quadrisected, each processed separately as four “If a single immunohistochemical/immunocytochemistry stain procedure for one or blocks and each block stained with IHC = one more antibodies is performed on multiple blocks from a surgical specimen, multiple slides from a cytologic specimen, or multiple slides from a hematologic specimen, only specimen = one 88342 one unit of service shall be reported for each separate specimen.” • Two Notseparate, discontiguous margins pieces of tissue excised, each processed separately and 12 = One specimen stained with IHC = two specimens = 88342x2 34 Do

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Correct Coding Example: Mohs surgery, 2 stages Two stages of Mohs, , cheek o First stage: one tissue layer, quadrisected, each piece placed upon a block Slides from each block are stained with: o Second stage: two separate tissues excised, identified, and processed individually . H & E as two separate blocks . Melan-A

12 12 Correct answer: Slides from each block are stained with: . H & E 17311 – Mohs surgery, first stage 4 3 4 3 88342.59 – Immunohistochemistry, . Melan-A one specimen, one stain

Duplicate Answer: Mohs surgery, 2 stages orCoding Examples • 3 stage excision, nose • 7 stage excision, cheek – five Slides from each block are stained with: . H & E – 17311 stages done on one day, 2 stages on . Melan-A – 17312 X 2 the next day First stage: – First day: 17311 1 17311 – Mohs surgery, first stage • Same day 2 stage excision, chest 17312 X 4 12 88342.59 – IHC, one specimen, one stain – 17313.59 Second stage: – 17314.59 – Second: 17311 17312 – Mohs surgery, first stage 4 3 2 17312 88342 – IHC, specimen 1 88342 – IHC, specimen 2 In “notes”, specify the two distinct treated In “notes”, specify that surgery was locations continued on the same site

Mohs andDistribute Repairs Modifiers: Detailed descriptions in . When done on the same day, repairs are billed without any modifier codes Appendix A of CPT

. When a repair is done on any day following Mohs, bill without any modifier codes (Mohs has 0 day global period) • .59: distinct procedural service • .76: Repeat Procedure or Service by Same Physician or Other . Allow the insurer to reduce the payment for Mohs and repair done on the Qualified Health Care Professional same day based upon the multiple surgical procedure reduction rule – do • .25: significant, separately identifiable E/M service on same day as the not reduceNot the charge yourself procedure • .57: E/M service resulting in a decision to perform a surgery with a 90 day global surgical period; E/M done day of or day before the surgery • .24: unrelated E/M service done in postoperative global period Do 41 42

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Clinical examples of each modifier Q: Mohs surgery tissue staining use • .59, .76: two Mohs surgeries, same day First stage of Mohs, nose. • .25: patient has an unrelated condition evaluated/treated on Several slides are cut from one block of tissue. Two slides are same day as Mohs stained with H & E and the third is stained with toluidine blue. • .57: referred patient presents for a Mohs surgical consultation, examination and evaluation day before Mohs surgery with a flap reconstruction is done You code as which of the below choices? • .24: patient evaluated/treated for a drug rash 5 days after A. 17311 – one stage of Mohs Mohs surgery with complex repair B. 17311x2 – two stages of Mohs (If Mohs surgery only without reconstruction was done, C. 17311 and 88314 for special stain then no modifier needed)

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Q: Answer Q: Mohs and subsequent office visit You excise a BCCor from the temple with 2 stages of Mohs and leave to heal A. 17311 secondarily. 5 days later, at follow-up, patient presents with a generalized rash. You diagnose a drug eruption and initiate therapy. CPT®: “(Do not report 88314 in conjunction with 17311-17315 for routine frozen section stain (eg, Upon the patient’s return you code the following: A. Nothing, as this is during the global follow-up period hematoxylin and eosin, toluidine blue) performed B. 99213 for the evaluation during Mohs surgery” C. 99213.24 D. 99213.25 Report 88314.59 for special histochemical stains done in addition to H&E or toluidine blue 46

Distribute Q: You excise a basal cell carcinoma from the cheek with one Q: Answer stage of Mohs surgery and do a 7 cm complex repair. The global surgical follow-up period for the above procedure is: B. Code 99213 for evaluation and management, and no modifier is needed A. 0 days B. 10 days Why is that? C. 90 days Mohs surgery has a 0 day global follow-up period D. does not matter Not What is the global surgical package? That means: any services provided and billed for subsequent to It is a period of time that includes all necessary services the surgery are not part of a 0 day global surgical package, are normally furnished by a surgeon before, during, and after a procedure. Unrelated services or services furnished during billable, and do not require a modifier the package time period beyond those included in the package require a modifier for payment consideration. Do 47 48

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Q: Answer (Global Package) Global Surgical Follow-up Periods 0 Days: Minor 10 Days: Minor 90 Days: Major C: 10 days Procedure Procedure Procedure Flaps Simple surgical follow-up period concept: Biopsy (11100…) Destruction Grafts (17000 - 17286) 90 days: flaps and grafts Shave removal Tissue Expanders 10 days: destructions, excisions, repairs (11300 – 11313 Excisions 0 days: , Mohs surgery (11400 – 11646) Destruction of Debridement Vascular (11000, 11011-42) Repairs (12001 – Useful reference: Proliferative Lesion 13153) http://www.cms.gov/Outreach-and-Education/Medicare- Mohs (17106 – 08) Learning-Network- (17311-17315) MLN/MLNProducts/downloads/GloballSurgery- Dermabrasion, ICN907166.pdf 49 Chemical Peel Duplicate

90 day global follow-up period procedures include: CMS Survey on Postoperative - the day prior to surgery, Visits - the day of surgery and or - 90 days post surgery, starting the count on day 1 after surgery “You have been selected by the Centers for Medicare & Medicaid Services to report information on post-operative visits…” • Complex repairs • Report on 5 patients

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