CurrentUnitedHealthcarePolicy N/A

Mohs Micrographic Surgery — Reimbursement and Billing Guidelines

Guidelines for reporting and reimbursement of Mohs Micrographic Surgery (MMS) for UnitedHealthcare Community Plan Medicaid products, including coding, billing, and payment interactions for surgeons and pathologists.

Policy Summary

PayerUnitedHealthcare

PolicyMohs Micrographic Surgery — Reimbursement and Billing Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not report Mohs CPT codes 17311-17315 when surgical or pathology responsibilities are delegated and reported separately; report appropriate excision/biopsy or pathology codes instead.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

17311-17315Mohs procedure codes addressed

CMS-1500 / UB04Claim forms covered

MedicaidProduct applicability

MPPR exceptionMPPR exception

MD/DO onlyProvider requirement

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Mohs Coverage and Billing Criteria

Mohs coverage criteria

Covered when the following billing and provider qualifications are met:

Mohs CPT codes 17311-17315 include both the surgical excision and the immediate pathology examination and should be reported only when a single physician performs both the surgical and pathology components of the service.

The physician reporting Mohs must be a physician (MD/DO) specifically trained in Mohs technique with documentation in the operative note and pathology showing the physician performed both surgical and pathology services; Mohs CPT codes reported by non-MD/DO provider specialties will be denied.

If either the surgical or pathology responsibilities are delegated to another physician or other qualified health care professional who reports those services separately, do not report Mohs CPT codes 17311-17315; instead the surgeon should report the appropriate excision or biopsy code (e.g., CPT 11600-11646 or 11102-11107) and the pathologist may report the appropriate histopathology codes (e.g., CPT 88302-88309, 88331, 88332).

Pathology codes submitted by the same Mohs surgeon for the same date of service will be denied as included unless documentation demonstrates the pathology was related to a distinct biopsy or excision separate from the Mohs tumor site.

Exception for separate lesion: When a biopsy or excision is performed on a separate lesion in the same session and the tissue is examined by a different pathologist (or reported with modifier 59/XS/XU for a distinct lesion), UnitedHealthcare will allow the surgeon's excision/biopsy code and the pathologist's histopathology code.

Claims are subject to other UnitedHealthcare reimbursement policies (for example, CCI editing and Laboratory Services) and applicable regulatory, contract, and benefit design provisions.

Multiple procedure payment reductions (MPPR) will not be applied between physicians of different specialties within the same medical group when one physician performs Mohs (17311-17315) and another physician of a different specialty in the same group performs wound repair on the same date; MPPR still applies when the same provider performs multiple procedures on the same date.

Procedure and Alternate Coding

Mohs procedure codesCPTCovered

17311	Mohs micrographic technique; first stage, up to 5 tissue blocks
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

Alternate excision/ pathology codesCPTCovered

11600-11646	Excision codes (when Mohs not reported or when tissue excision/pathology are separate)
11102-11107	Biopsy codes (alternate reporting)
88302-88309	Level II-VIII surgical pathology, gross and microscopic examination
88331	Immunohistochemistry, per specimen
88332	Morphometric analysis

Billing Constraints and Provider Responsibilities

Billing Rule

Billing Constraints for Mohs Services

Mohs is a two-step process requiring a single provider to function in two distinct capacities: surgeon (staged excision) and pathologist (immediate histologic evaluation of margins). If either responsibility is delegated to another physician or qualified health care professional who reports the services separately, do NOT report Mohs CPT codes 17311-17315.

Do not report Mohs CPT codes 17311-17315 when surgical or pathology responsibilities are delegated and reported separately.
Mohs CPT codes 17311-17315 include the pathology component; if another provider separately reports Mohs pathology services for the same date of service, Mohs codes will be denied.
If the surgeon delegates pathology and another provider bills for pathology separately, the surgeon should instead bill the appropriate excision or biopsy code (e.g., CPT 11600-11646, 11102-11107, or 11641 as applicable).
Pathology examination of the specimen is inclusive to Mohs and should not be separately reported by the Mohs surgeon; separate pathology codes by the same provider for the same Mohs site will be denied unless documentation shows the pathology was for a distinct biopsy or excision.
When a separate lesion is excised or biopsied in the same session and that tissue is sent to an outside pathologist (different provider performs pathology), the surgeon may bill the appropriate excision/biopsy code for that separate site and the pathologist may bill appropriate histopathology codes (e.g., CPT 88302-88309, 88331, 88332).

Terms and Provider Qualifications

Mohs Micrographic Surgery

DefinitionMohs Micrographic Surgery (Mohs, MMS): a precise, tissue-sparing, microscopically controlled surgical technique for removal of complex or ill-defined skin cancer that removes the tumor in stages with immediate histologic examination of 100% of surgical margins until margins are clear.

ProcessTwo-step process: staged tumor removal followed by immediate histologic evaluation of margins; additional excision and evaluation performed until margins are clear.

GoalAchieve highest possible cure rates while minimizing wound size and distortion at critical anatomic sites (e.g., eyes, ears, nose, lips).

ComponentsIntegration of two distinct provider capacities: the surgeon and the pathologist; pathology examination of specimens is an inclusive component of the Mohs procedure.

Provider qualification (MD/DO) and coding notes