CurrentUnitedHealthcarePolicy 2025R9044A

Mohs Micrographic Surgery (CMS 1500) reimbursement

Reimbursement rules for reporting Mohs micrographic surgery services on CMS 1500 forms for UnitedHealthcare Medicare Advantage plans, applying to network physicians and other qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyMohs Micrographic Surgery (CMS 1500) reimbursement

Policy CodePolicy 2025R9044A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not report separate pathology codes when the surgeon performs both Mohs surgery and the pathology; bill the appropriate Mohs CPT codes instead.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

17311-17315Primary Mohs procedure codes referenced

CMS 1500Form this policy governs

Multiple procedure reduction exceptionMPPR exception

Inclusive pathologyInclusive pathology

MD/DO onlyPhysician requirement

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Mohs Reimbursement Criteria

Mohs reimbursement criteria

Reimbursement rules and scenarios for Mohs surgery and associated pathology/excision services.

Mohs CPT codes (17311-17315) represent combined surgical excision and histopathologic examination services and should not be reported with separate pathology codes when the surgeon performs both roles.

Exceptions — separate reporting allowed when ALL of the following apply:

The pathology services for the Mohs specimen are performed and billed by a different provider than the surgeon (i.e., a separate pathologist).
The surgeon bills an appropriate excision or biopsy code (for example CPT 11600-11646 or 11102-11107) rather than Mohs codes when the pathology is reported separately.

Separate reporting for distinct procedures/sites

A diagnostic biopsy or excision is performed on a separate lesion or site during the same session as Mohs and the tissue is examined by a pathologist (other than the Mohs surgeon). In this case the surgeon may report the appropriate excision/biopsy code and the pathologist may report the appropriate histopathology codes (e.g., CPT 88302-88309, 88331, 88332).
If the surgeon performs the biopsy or excision on a separate lesion and also examines the specimen, the biopsy/excision and associated pathology may be reported when appropriate modifiers (for example 59, XS, or XU) are used to indicate distinct procedural circumstances.

Pathology codes billed by the Mohs surgeon for the same date of service and same site as Mohs will be denied as included unless records document the pathology was related to a biopsy or excision performed distinctly separate from the Mohs tumor site.

Repairs, grafts, and flaps performed in addition to Mohs are separately reportable. Multiple procedure payment reductions may apply when the same provider performs multiple procedures; reductions will not be applied when repair is performed by a provider of a different specialty within the same group practice.

Mohs should be performed only when a single physician functions in two distinct capacities (surgeon and pathologist). If either role is delegated to another physician or qualified health care professional who reports services separately, Mohs CPT codes should not be reported and will be denied; the appropriate excision/biopsy and histopathology codes should be used instead.

Procedure and Pathology Coding

Primary Mohs CPT codesCPTCovered

17311	Mohs micrographic technique, first stage, including removal of all gross tumor; without repair
17312	Mohs micrographic technique, second stage
17313	Mohs micrographic technique, third stage
17314	Mohs micrographic technique, fourth stage
17315	Mohs micrographic technique, fifth and subsequent stages

Same-date-of-service pathology by same provider — billing guidance

Same-date pathology billed by Mohs surgeonPathology codes billed by the Mohs surgeon for the same date of service and same site are considered inclusive to the Mohs procedure and will be denied unless documentation shows the pathology was for a separate biopsy or excision distinct from the Mohs site.

Included pathology and excision codesMohs CPT codes include skin biopsy and excision services (CPT 11102-11107, 11600-11646, 17260-17286) and pathology services (CPT 88300-88309, 88329-88332). These codes should not be reported separately when billed by the Mohs surgeon on the same date and site.

When separate reporting is appropriateIf a diagnostic biopsy (e.g., CPT 11102-11107) or frozen section pathology (e.g., CPT 88331) is performed prior to Mohs and is a distinct, separately identifiable service, it may be reported separately when appended with an appropriate modifier (e.g., 59, -X{SU}, or 58) to distinguish the diagnostic/ staged procedure from the definitive Mohs surgery.

Provider Responsibilities and Policy Updates

Documentation Required

Policy updates and provider responsibility

UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with changes in CMS policy and other national coding guidelines; providers are responsible for keeping current with CMS and local carrier updates and for submitting accurate claims. Enrollee benefit design, legislative mandates, provider contracts, and other factors may supplement, modify, or supersede this policy and can affect reimbursement for services described herein.

Keep current with CMS and local carrier policy changes and billing requirements; sign up for CMS or local carrier distributions as needed.
Verify specific enrollee benefit coverage (call the number on the member ID card) because benefit specifics may alter reimbursement.
Ensure submission of accurate CMS 1500 claims; UnitedHealthcare may interpret or apply the policy with reasonable discretion and system-specific variations may occur.

Key Definitions

Histopathology

DefinitionThe branch of histology that includes the microscopic examination and study of diseased tissue.

ContextReferenced in Modifiers section as the discipline applicable to examination of Mohs specimens.

RelevanceHistopathology services are considered inclusive to Mohs when performed by the Mohs surgeon, and separate billing may be denied.

Mohs Micrographic Surgery

DefinitionA technique for removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins; includes both surgical excision and histopathologic examination performed by the same physician.

ProcessPerformed as staged tumor removal with immediate microscopic evaluation of margins; additional excision is performed until margins are clear.

Provider rolesRequires an individual provider to function in two distinct capacities (surgeon and pathologist); if either role is delegated and billed separately by another provider, Mohs CPT codes should not be reported.

Coding implicationMohs CPT codes (17311-17315) include associated biopsy/excision and pathology services; separate reporting of those services by the same physician is inappropriate.