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 two 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 two-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 three requirements;

  1. Qualifications of the physician and office/facility team;
  2. Characteristics of the lesion pre-procedure;
  3. 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:**

  1. **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.
  2. **Area M:**   Cheeks, forehead, scalp, neck, jawline, pretibial surface.
  3. **Area L:** trunk and extremities (excluding pretibial surfaces, hands, feet, nail units and ankles).
  4. **Immunocompromised:** a patient with HIV/AIDS, organ transplant, hematologic malignancy or pharmacologic suppression.
  5. **Genetic Syndromes:** basal cell nevus syndrome, xeroderma pigmentosa, or other syndromes at high risk for skin cancer.
  6. **Healthy:** no immunosuppression, no prior radiation therapy to affected area, no chronic infections and no genetic syndromes that predispose to skin cancer.
  7. **Prior Radiated Skin:** patient has previously received therapeutic radiation in this area of the body.
  8. **Aggressive features:**
    1. For Basal Cell Carcinoma 
      1. Morpheaform, fibrosing, sclerosing
      2. Infiltrating
      3. Perineural
      4. Metatypical/keratotic
      5. Micronodular
    2. For Squamous Cell Carcinoma 
      1. Sclerosing
      2. Basosquamous excluding keratotic BCC
      3. Small Cell
      4. Poorly or undifferentiated, i.e. high degree of polymorphism, high mitotic rate and/or low degree of keratinization
      5. Perineural or perivascular
      6. Spindle Cell
      7. Pagetoid
      8. Infiltrating
      9. Keratoacanthoma (KA) type: central facial
      10. Single Cell
      11. Clear Cell
      12. Lymphoepithelial
      13. Sarcomatoid
      14. Breslow depth below 2mm or greater
      15. Clark level IV or greater

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

  1. **Basal Cell Carcinoma**
    1. Recurrent BCC of any size or unexpected positive margin on recent excision (healthy or immunocompromised or genetic syndrome(s)) 
      1. Aggressive Pathology 
        1. Areas H, M and/or L
      2. Nodular Pathology 
        1. Areas H, M and/or L
      3. Superficial Pathology 
        1. Areas H and M only
        2. No coverage for area L
    2. Primary Aggressive 
      1. Size  0.5 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      2. Size  0.6 cm 
        1. Areas H, M and L
    3. Primary Nodular BCC (healthy patient) 
      1. Size  0.5 - 1 cm 
        1. Areas H and M only
        2. No coverage for area L
      2. Size 1.1 - 2 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary 
      3. Size  2 cm 
        1. Areas H, M and L
    4. Primary Nodular BCC (immunocompromised patient) 
      1. Size  0.5 cm 
        1. Areas H and M only
        2. No coverage for area L
      2. Size 0.6 - 1 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      3. Size  1.1 cm 
        1. Areas H, M and L
    5. Primary Superficial BCC (healthy patient) 
      1. Size  0.5 cm 
        1. Area H
        2. Area M would rarely be medically necessary
        3. No coverage for area L
      2. Size  0.6 cm 
        1. Areas H and M
        2. No coverage for area L
    6. Primary Superficial BCC (immunocompromised patient) 
      1. Size  1.0 cm 
        1. Areas H and M
        2. No coverage for area L
      2. Size > 1.0 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
    7. Primary BCC with no mention of sub-type 
      1. Size  0.5 - 1 cm 
        1. Areas H and M only
        2. No coverage for area L
      2. Size 1.1 - 2 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      3. Size 2 cm 
        1. Areas H, M and L
    8. Primary BCC with sub-types of adenoid, cystic, adamantoid, or fibroepithelioma of Pinkus 
      1. Size  0.5 - 1 cm 
        1. Areas H and M only
        2. No coverage for area L
      2. Size 1.1 - 2 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      3. Size  2 cm 
        1. Areas H, M and L
  2. **Squamous Cell Carcinoma**
    1. Recurrent SCC of any size or unexpected positive margin on recent excision 
      1. Aggressive Pathology 
        1. Areas H, M and L
      2. Verrucous Pathology 
        1. Area H
      3. KA-type SCC (Not central facial) 
        1. Areas H, M and L
      4. In situ/Bowen 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      5. AK with focal SCC in situ; Bowenoid AK; SCC in situ, AK type 
        1. Not covered
      6. Without aggressive histologic feature, < 2 mm depth without other defining features, Clark level  III 
        1. Areas H, M and L
    2. Primary aggressive SCC (healthy patients) 
      1. Size - all 
        1. Areas H, M and L
    3. Primary aggressive SCC (immunocompromised patients) 
      1. Size - all 
        1. Areas H, M and L
    4. Primary SCC without aggressive histologic features, < 2 mm depth without other defining features, Clark level  III (healthy patients) 
      1. Size  1.0 cm 
        1. Areas H and M
        2. No coverage for area L
      2. Size 1.1 - 2 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      3. Size > 2 cm 
        1. Areas H, M and L
    5. Primary SCC without aggressive histologic features, < 2 mm depth without other defining features, Clark level  III (immunocompromised patients) 
      1. Size  1.0 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      2. Size  1.1 cm 
        1. Areas H, M and L
    6. Primary verrucous SCC (healthy or immunocompromised patients) 
      1. All sizes 
        1. Area H only
        2. No coverage for areas M and L
    7. Primary SCC KA type, not central facial (healthy patients) 
      1. Size  1.0 cm 
        1. Areas H and M
        2. No coverage for area L
      2. Size  1.1 cm 
        1. Areas H, M and L
    8. Primary SCC KA type, not central facial (immunocompromised patients) 
      1. Size  0.5 cm 
        1. Areas H and M. Area L would rarely be medically necessary
      2. Size > 0.6 cm 
        1. Areas H, M and L
    9. Primary in situ SCC/Bowen disease (healthy patients) 
      1. Size  1.0 cm 
        1. Areas H and M
        2. No coverage for area L
      2. Size 1.1 - 2 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      3. Size > 2 cm 
        1. Areas H, M and L
    10. Primary in situ SCC/Bowen disease (immunocompromised patients) 
      1. Size  0.5 cm 
        1. Areas H and M
        2. No coverage for area L
      2. Size 0.6 - 1 cm 
        1. Areas H and M
        2. Area L would rarely be medically necessary
      3. Size  1.1 cm 
        1. Areas H, M and L
    11. Primary AK with focal SCC in situ; Bowenoid AK; SCC in situ, AK type (healthy or immunocompromised patients) 
      1. Any size 
        1. Not covered
  3. **Basal or Squamous Cell Carcinoma**
    1. Primary BCC or SCC regardless of sub-type, size or depth arising in: 
      1. Prior irradiated skin,
      2. Traumatic scar,
      3. Area of osteomyelitis,
      4. Area of chronic inflammation/ulceration, or
      5. Patients with genetic syndromes predisposing to skin cancer 
        1. Areas H, M and L
  4. **Lentigo Maligna and melanoma in situ**
    1. Primary lentigo maligna (healthy or immunocompromised patients) 
      1. Areas H and M
      2. Area L would rarely be medically necessary
    2. Locally recurrent lentigo maligna (healthy or immunocompromised patients) 
      1. Areas H, M and L
    3. Primary melanoma in situ; non-lentigo maligna (healthy or immunocompromised patients) 
      1. Areas H and M
      2. Area L would rarely be medically necessary
    4. Locally recurrent melanoma in situ; non-lentigo maligna (healthy or immunocompromised patients) 
      1. Areas H, M and L
  5. **Other less common skin cancers**
    1. Adenocystic carcinoma 
      1. Areas H, M and L
    2. Adnexal carcinoma 
      1. Areas H, M and L
    3. Apocrine/eccrine carcinoma 
      1. Areas H, M and L
    4. Angiosarcoma 
      1. Areas H, M and L would rarely be medically necessary
    5. Atypical fibroxanthoma 
      1. Areas H, M and L
    6. Bowenoid papulosis 
      1. Not covered
    7. Dermatofibrosarcoma protuberans 
      1. Areas H, M and L
    8. Desmoplastic trichoepithelioma 
      1. Areas H and M would rarely be medically necessary
      2. Area L not covered
    9. Extramammary Paget Disease 
      1. Areas H, M and L
    10. Leiomyosarcoma 
      1. Areas H, M and L
    11. Malignant fibrous histiocytoma 
      1. Areas H, M and L
    12. Merkel Cell Carcinoma 
      1. Areas H and M
      2. Area L would rarely be medically necessary
    13. Microcystic Adnexal Carcinoma 
      1. Areas H, M and L
    14. Mucinous Carcinoma 
      1. Areas H, M and L
    15. Sebaceous Carcinoma 
      1. Areas H, M and L
    16. Rare Biopsy proven malignancies not otherwise specified 
      1. Areas H, M and L would rarely be medically necessary

**Limitations:**

If a surgeon performs an excision using Mohs surgical techniques but does not
personally provide the histologic evaluation of the specimen(s), the procedure
codes for MMS included in the associated Billing and Coding Article may not be
used. Standard excision codes should be chosen for such services.  
  
Medicare is aware that a biopsy of the skin lesion for which Mohs surgery is
planned may be 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 the Mohs surgery is planned. In order to allow
separate payment for a biopsy and pathology on the same day as Mohs surgery,
the -59 modifier is appropriate. The -59 modifier is also appropriate when a
separate skin lesion, other than the lesion for which Mohs surgery is
performed, is biopsied on the same day that the Mohs surgery is performed.

Procedures that exceed the medical need are not reasonable and necessary (not
a Medicare covered service), therefore, documentation (pre-procedure E/M note
and/or post-procedure operative notes) must address (a) why the lesion will
not be (was not) managed by standard excision or destruction technique and
(when applicable) (b) why (when utilized or referred to a plastic surgeon)
procedures for complex repair, adjacent tissue transfer or rearrangement,
flap, or graft codes are employed. Also, the options for care (both the
primary procedure options and repair options) must be discussed with the
patient and clearly noted in the pre-procedure (or post procedure as
appropriate) documentation.

If a prior biopsy of the site undergoing Mohs surgery has been previously
performed within the last 60 days, the surgeon should make a reasonable effort
to obtain those results rather than repeating the biopsy.