Ask Glenn
Ask Glenn: Answers to Your Mohs Coding Questions
Many ACMS members have questions about proper coding and billing for Mohs surgery. This reinforces a need for ongoing education to ensure the College meets its goal of integrity and ethics in all aspects of Mohs practice. Glenn Goldman, MD, FACMS, answers these coding and billing questions at askglenn@mohscollege.org. Many responses are included here for the benefit of all members.
Q: A local dermatologist was doing Mohs and in the middle of his cases he didn't feel right so called an ambulance and sent the patients over to me to finish. One patient he had taken the first stage and his tech had processed it but I read the slide which was positive so I did another stage which was clear then did intermediate closure. On the second patient he had taken the first stage then read the slide and marked his map, I rechecked the slide which was positive and took another stage. I then closed the site.
A: I believe that these are complex cases. The appropriate way to code would be to document very carefully what you are doing and why, and then do the following:
- Patient 1: Bill initial stage of Mohs surgery (the one you did) and linear intermediate closure: 17311, 12XXX closure. When you start a case individually you must start at 17311 – for you it is a first stage. 17312 cannot/should not be billed independently.
- Patient 2: Bill stage one of Mohs surgery and linear intermediate closure. Same applies: 17311, 12XXX closure.
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Q: Do you use the 20000 series codes for lipoma excisions instead of the 11400 series since it is a soft tissue tumor and not a neoplasm of the skin? For example, for excision of submuscular lipoma on the forehead, would 21011/21012 be appropriate? I also understand these codes already include intermediate repair and a 90-day global period.
A: Lipoma is in fact a subcutaneous tumor. The code for a subgaleal lipoma is 21013 for less than 2 cm and 21014 for larger than 2 cm. The repair is included.
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Q: We are having a billing issue after performing Mohs and repairing the site. In this example, a defect on the forehead was repaired. The repair extended to the eyebrow. This changes the repair location to code 14061, instead of 14041. Our EMR chart note lists the repair location as the forehead, but we billed eyebrow (CPT 14061). UHC HMO plans are asking for all of our chart notes and not paying for the repair since our chart note does not state the repair included the eyebrow. We have not had any luck requesting that our EMR add verbiage to the note stating the repair ended at the eyebrow. Can you offer any guidance? Thanks.
A: The repair may have extended to the brow but the repair was on the forehead, as was the defect. As such, a forehead code would be used.
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Q: A woman had a subcutaneous nodule on her cheek; I thought it was an epidermoid cyst so I made an incision and could not find any obvious cyst and removed what appeared to be some dark adipose tissue then did an intermediate closure. Pathology came back as Merkel Cell Carcinoma. Would you code that as a biopsy or an excision? Thanks.
A: An incisional biopsy such as this would be coded as a biopsy.
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Q: I’m being told recently by our coders that I can’t code an E&M visit when I do same day Mohs + flap/graft. I knew you couldn’t do it for minor procedures but thought the decision to perform the flap/graft allowed you to code for an E&M. Can you clarify? Thank you.
A: Unless your LCD for your Medicare carrier says otherwise (as some do) you can bill for E/M with a flap, graft, or other 90-day global procedure. That is CPT.
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Q: My local Medicare carrier is denying or requesting repayment for immuno codes used during Mohs, mentioning that the immuno codes are bundled with the Mohs codes. I can’t see how this could possibly be correct. Could you please comment? Thanks very much.
A: The immune codes are entirely separate from the ACMS. Have your DERMCAC contact your Medicare Carrier Representative. This issue has occurred elsewhere and has been forwarded to the ACMS/AAD/ASMS/ASDS.
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Q: We have been having constant issues with VC incorrectly applying MSRR when paying our claims. They incorrectly reduce the procedures and add-on codes. Do you have any reference in print that I can submit to them when I try to stand my ground. Thank you.
A: It is best to approach the AAD on issues such as this. This is a common problem with insurers, and it often requires a case by case discussion with the insurer. Some insurers do not follow standard rules, however, and they are not always required by law to follow CPT.