Subject: Mohs Micrographic Surgery

Transcription

1 Original Effective Date: 05/15/02 Reviewed: 10/31/17 Revised: 10/01/18 Subject: Mhs Micrgraphic Surgery THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION. Psitin Statement Billing/Cding Reimbursement Prgram Exceptins Definitins Related Guidelines Other References Updates DESCRIPTION: Mhs micrgraphic surgery is a micrscpically cntrlled tissue-sparing surgical prcedure used fr the remval f cmplex r ill-defined cancerus neplasms f the skin and histlgic examinatin f the surgical margins. Mhs surgery uses precise measurements f tumr margins t remve cancerus cells and leave healthy tissue intact. The prcedure is perfrmed in successive stages t remve extensive tumrs, as needed. Mhs surgery is primarily used t treat basal and squamus cell carcinmas, but can be used t treat less cmmn tumrs including but nt limited t melanma. In perfrming Mhs micrgraphic surgery, the physician functins in tw separate, but distinct capacities: as the surgen and the pathlgist. If either part f the prcedure is delegated t anther physician wh reprts his service separately (i.e., pathlgy delegated t anther physician), the surgery shuld nt be reprted as Mhs. POSITION STATEMENT: NOTE: Mhs micrgraphic surgery requires the physician t functin in tw separate, but distinct capacities: as the surgen and the pathlgist. If either part f the prcedure is delegated t anther physician wh reprts his/her service separately (i.e., pathlgy delegated t anther physician), the prcedure shuld nt be reprted as Mhs micrgraphic surgery. Mhs micrgraphic surgery meets the definitin f medical necessity when perfrmed fr ONE f the fllwing indicatins:

2 A) Basal cell carcinmas, squamus cell carcinmas, basalsquamus/bassquamus cell carcinmas in the fllwing anatmic lcatins: Mask areas f face (central face, eyelids-including inner/uter canthi, eyebrws, nse, lips-cutaneus/mucsal/vermillin, chin, ear and periauricular skin /sulci, temple) Cheeks, frehead, scalp, neck, jawline, pretibial surface Hands, feet, nail units Ankles Genitalia (including perineal and perianal) Nipples/arela. B) Basal cell carcinmas, squamus cell carcinmas, r basalsquamus/bassquamus cell carcinmas, regardless f subtype, size, r depth, in: Prir radiated skin Traumatic scar Area f stemyelitis Area f chrnic inflammatin/ulceratin Members with genetic syndrmes. C) The fllwing recurrent skin cancers: Recurrent aggressive basal cell carcinmas (BCC) Ndular BCC Superficial (except n trunk and extremities ) BCC f any size r unexpected psitive margin n recent excisin Recurrent aggressive squamus cell carcinmas (SCC) Verrucus SCC KA-type SCC (nt central facial) In situ/bwen SCC f any size r unexpected psitive margin n recent excisin. D) Lentig maligna, melanma in situ, nn-lentig maligna primary r lcally recurrent. E) Less cmmn skin cancers including: Adencystic carcinma Adnexal carcinma Angisarcma Apcrine/eccrine carcinma Atypical Fibrxanthma Dermatfibrsarcma prtuberans Extramammary Paget s Disease

3 Leimysarcma Malignant fibrus histicytma/undifferentiated plemrphic sarcma Merkel cell carcinma Micrcystic adnexal carcinma Mucinus carcinma Sebaceus carcinma. Mhs Micrgraphic Surgery des nt meet the definitin f medical necessity fr all ther indicatins and including but nt limited t: Bth recurrent and primary actinic keratsis (AK) with fcal SCC in situ; Bwenid AK; SCC in situ (AK type) f any size in all areas in healthy r immuncmprmised members Basal cell carcinma (BCC) lcated n trunk and extremities (excluding pretibial surface, hands,feet, nail units, and ankles) including: Recurrent superficial BCC (healthy r immuncmprmised members, r members with genetic syndrmes) f any size Primary superficial BCC (healthy r immuncmprmised members) f any size Primary ndular BCC (healthy members) 2 cm Primary ndular BCC (immuncmprmised members) 1 cm. Squamus cell carcinma (SCC) lcated n trunk and extremities (excluding pretibial surface,hands, feet, nail units, and ankles) including: Primary SCC; withut aggressive histlgic features, < 2 mm depth withut ther defining features, Clark level III (healthy members) 2 cm Primary SCC keratacanthma (KA) type; nt central facial (healthy members) 1 cm Primary in situ SCC/Bwen disease (healthy members) 2 cm Primary in situ SCC/Bwen disease (immuncmprmised members) 1 cm. Desmplastic trichepithelima lcated n trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles) Bwenid papulsis. BILLING/CODING INFORMATION: CPT Cding: Mhs micrgraphic technique, including remval f all grss tumr, surgical excisin f tissue specimens, mapping, clr cding f specimens, micrscpic examinatin f specimens by the surgen and histpathlgy preparatin including rutine stain(s) (e.g., hematxylin and esin, tluidine blue), head, neck, hands, feet, genitalia r any lcatin with surgery directly invlving muscle,

4 cartilage, bne, tendn, majr nerves r vessels; first stage, up t 5 tissue blcks Mhs micrgraphic technique, including remval f all grss tumr, surgical excisin f tissue specimens, mapping, clr cding f specimens, micrscpic examinatin f specimens by the surgen, and histpathlgic preparatin including rutine stain(s) (eg, hematxylin and esin, tluidine blue), head, neck, hands, feet, genitalia, r any lcatin with surgery directly invlving muscle, cartilage, bne, tendn, majr nerves, r vessels; each additinal stage after the first stage, up t 5 tissue blcks (List separately in additin t cde fr primary prcedure) Mhs micrgraphic technique, including remval f all grss tumr, surgical excisin f tissue specimens, mapping, clr cding f specimens, micrscpic examinatin f specimens by the surgen and histpathlgy preparatin including rutine stain(s) (e.g., hematxylin and esin, tluidine blue), f the trunk, arms, r legs; first stage, up t 5 tissue blcks Mhs micrgraphic technique, including remval f all grss tumr, surgical excisin f tissue specimens, mapping, clr cding f specimens, micrscpic examinatin f specimens by the surgen, and histpathlgic preparatin including rutine stain(s) (eg, hematxylin and esin, tluidine blue), f the trunk, arms, r legs; each additinal stage after the first stage, up t 5 tissue blcks (List separately in additin t cde fr primary prcedure) Mhs micrgraphic technique, including remval f all grss tumr, surgical excisin f tissue specimens, mapping, clr cding f specimens, micrscpic examinatin f specimens by the surgen and histpathlgy preparatin including rutine stain(s) (e.g., hematxylin and esin, tluidine blue), each additinal blck after the first 5 tissue blcks, any stage (List separately in additin t cde fr primary prcedure) ICD-10 Diagnsis Cdes That Supprt Medical Necessity: C00.0 C00.9 Malignant neplasm f lip C21.1 Malignant neplasm f anal canal C30.0 Malignant neplasm f nasal cavity C31.0 Malignant neplasm f maxillary sinus

5 C31.2 Malignant neplasm f frntal sinus C43.0 C43.8 Malignant melanma f lip C44.01 C44.09 Malignant neplasm f skin f lip C C Malignant neplasm f skin f eyelid C C Malignant neplasm f skin f ear and external auricular canal C C Malignant neplasm f skin f ther and unspecified parts f face C44.41 C44.49 Malignant neplasm f skin f scalp and neck C C Malignant neplasm f skin f ther part f trunk C C Malignant neplasm f skin f left upper limb, including shulder C C Malignant neplasm f skin f left lwer limb, including hip C44.81 C44.89 Malignant neplasm f verlapping sites f skin C4A.0 C4A.9 Merkel cell carcinma C C Malignant neplasm f nipple and arela, female C C Malignant neplasm f nipple and arela, male C51.0 C51.1 Malignant neplasm f vulva C52 C60.1, C60.2 Malignant neplasm f vagina Malignant neplasm f penis C63.2 Malignant neplasm f scrtum D03.0 D03.8 Melanma in situ D04.0 D04.8 Carcinma in situ f skin

6 D07.4 Carcinma in situ f penis REIMBURSEMENT INFORMATION: Mhs micrgraphic surgery requires the physician t functin in tw separate, but distinct capacities: as the surgen and the pathlgist. If either part f the prcedure is delegated t anther physician wh reprts his/her service separately (i.e., pathlgy delegated t anther physician), the prcedure shuld nt be reprted as Mhs micrgraphic surgery. LOINC Cdes: Dcumentatin Table LOINC Cdes LOINC Time Frame Mdifier Cde LOINC Time Frame Mdifier Cdes Narrative Physician histry and physical Attending physician visit ntes Pathlgy Reprts Sectins Pathlgy Study Reprts Physician perative reprt Include all data f the selected type that represents bservatins made six mnths r fewer befre starting date f service fr the claim Include all data f the selected type that represents bservatins made six mnths r fewer befre starting date f service fr the claim Include all data f the selected type that represents bservatins made six mnths r fewer befre starting date f service fr the claim Include all data f the selected type that represents bservatins made six mnths r fewer befre starting date f service fr the claim Include all data f the selected type that represents bservatins made six mnths r fewer befre starting date f service fr the claim

7 Treatment plan Include all data f the selected type that represents bservatins made six mnths r fewer befre starting date f service fr the claim PROGRAM EXCEPTIONS: Federal Emplyee Prgram (FEP): Fllw FEP guidelines. State Accunt Organizatin (SAO): Fllw SAO guidelines. Medicare Advantage prducts: The fllwing Lcal Cverage Determinatin (LCD) was reviewed n the last guideline reviewed date: Mhs Micrgraphic Surgery (MMS) (L33689) lcated at fcs.cm. DEFINITIONS: Basal Cell Carcinma: Cancer that begins in the lwer part f the epidermis (the uter layer f the skin). It may appear as a small white r flesh-clred bump that grws slwly and may bleed. Basal cell carcinmas are usually fund n areas f the bdy expsed t the sun. Basal cell carcinmas rarely metastasize (spread) t ther parts f the bdy. They are the mst cmmn frm f skin cancer. Als called basal cell cancer. Basalsquamus Cell Carcinma: basal cell with squamus differentiatin. Melanma: A frm f cancer that begins in melancytes (cells that make the pigment melanin). It may begin in a mle (skin melanma), but can als begin in ther pigmented tissues, such as in the eye r in the intestines. Squamus Cell Carcinma: Cancer that begins in squamus cells. Squamus cells are thin, flat cells that lk like fish scales, and are fund in the tissue that frms the surface f the skin, the lining f the hllw rgans f the bdy, and the lining f the respiratry and digestive tracts. Mst cancers f the anus, cervix, head and neck, and vagina are squamus cell carcinmas. RELATED GUIDELINES: Nne applicable. OTHER: Nne applicable. REFERENCES: 1. American Academy f Dermatlgy, Guidelines f Care fr the Management f Primary Cutaneus Melanma, 2011, accessed at aad.rg 06/23/14.

8 2. American Cllege f Mhs Surgery, Abut Mhs Micrgraphic Surgery-Effectiveness, accessed at mhscllege.rg 06/23/ ClinicalTrials.gv, Checking Wether the m-ala Cream Culd Mark Crrectly the Brders f BCC s Tumrs, spnsred by Assuta Hspital Systems, accessed 12/16/ ClinicalTrials.gv, Effect f the Subcnscius n Mhs Micrgraphic Surgery, spnsred by Nrthwestern University, accessed 12/16/ ClinicalTrials.gv, Mhs Versus Traditinal Surgery, Basal Cell Carcinmas (BCC) (BACHIMO), spnsred by Hspital Ambrise Pare, accessed 12/16/ ClinicalTrials.gv, Safety and Efficacy f Oral Midazlam fr Periperative Anxiety Relief f Patients Underging Mhs Micrgraphic Surgery, spnsred by May Clinic, accessed 12/16/ Cnnlly SM, Baker DR, et al, AAD/ACMS/ASDSA/ASMS 2012 apprpriate use criteria fr Mhs micrgraphic surgery: a reprt f the American Academy f Dermatlgy, American Cllege f Mhs Surgery, American Sciety fr Dermatlgic Surgery Assciatin, and the American Sciety fr Mhs Surgery. J Am Acad Dermatl Oct;67(4): Di: /j.jaad First Cast Service Optins, Inc.(FCSO), LCD fr Mhs Micrgraphic Surgery (MMS), L33689; accessed at fcs.cm. 9. Lee KY, Rh MR, Chung WG, Chung KY, Cmparisn f Mhs Micrgraphic Surgery and Wide Excisin fr Extramammary Paget s Disease: Krean Experience, Dermatl Surg. 11/ Msterd K, Krekels GA, Nieman FH, et al, Surgical Excisin Versus Mhs Micrgraphic Surgery fr Primary and Recurrent Basal-Cell Carcinma f the Face: A Prspective Randmized cntrlled Trial with 5-Years Fllw-Up, Lancet Oncl Dec; 9(12): Natinal Cancer Institute (NCI). NCI Dictinary f Cancer Terms; accessed at cancer.gv 10/04/ Natinal Cancer Institute, Skin Cancer Treatment, updated 07/11/17, accessed at cancer.gv. 13. Natinal Cmprehensive Cancer Netwrk (NCCN). NCCN clinical practice guidelines in nclgy: Basal Cell Skin Cancer Versin accessed at nccn.rg. 14. Natinal Cmprehensive Cancer Netwrk (NCCN). NCCN clinical practice guidelines in nclgy: Melanma Versin accessed at nccn.rg. 15. Natinal Cmprehensive Cancer Netwrk (NCCN). NCCN clinical practice guidelines in nclgy: Squamus Cell Skin Cancer Versin accessed at nccn.rg. COMMITTEE APPROVAL: This Medical Cverage Guideline (MCG) was apprved by the Flrida Blue Medical Plicy & Cverage Cmmittee n 10/31/17. GUIDELINE UPDATE INFORMATION: 09/11/00 New Medical Cverage Guideline. 04/25/02 Reviewed, refrmatted, and revised t include applicable diagnsis cdes. 01/01/ CPT Update. 06/15/04 Scheduled review and revisin t guideline; cnsisting f updated references. 01/01/ HCPCS update: added 17311, 17312, 17313, 17314, and 17315; deleted 17304, 17305, 17306, 17307, and 17310; Medicare exceptins added. 02/15/09 Status changed frm archived t active psitin statements, reimbursement sectin,

9 cding sectin and references updated. 02/15/10 Annual review: psitin statements maintained and references updated. 10/15/10 Revisin; related ICD-10 cdes added. 09/15/11 Revisin; frmatting changes. 10/01/11 Scheduled review; psitin statements maintained, ICD-9 cdes updated, references updated and frmatting changes. 11/15/12 Annual review; psitin statements maintained, cding and references updated; frmatting changes. 10/15/13 Annual review; psitin statements maintained; reimbursement infrmatin and references updated. 01/01/14 Annual HCPCS update. Added cde /15/14 Annual review; psitin statements maintained; cding sectin and references updated. 10/01/15 Revisin; ICD9 and ICD10 cding sectins updated. 11/01/15 Revisin: ICD-9 Cdes deleted. 10/01/16 Revisin; frmatting changes. 11/15/17 Review; psitin statements, descriptin, cding, and references updated. 02/01/18 Revisin; psitin statement sectin updated. 10/01/18 ICD-10 cding update; deleted cdes C & C