88304
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.21
Facility
$41.08
Non-Facility
$41.08
Documentation Required
- Medical records must document that MMS was chosen because of lesion complexity, size, and/or location and why other approaches were not medically necessary or reasonable.
- Operative notes and pathology documentation must show MMS was performed using accepted Mohs technique with the same physician performing both surgical and pathology services, and must include lesion location, number, size, number of stages performed, and number of specimens per stage.
- The Mohs surgeon must document the histology of first-stage specimens including depth of invasion, pathological pattern, cell morphology, and presence or absence of perineural invasion or scar tissue.
- For subsequent stages, documentation may reference the first-stage description for pattern and morphology or note differences found; repeating the full detailed description is unnecessary if the first-stage description still applies.
Key Coverage Criteria
- Mohs Micrographic Surgery (MMS) is covered for removal of complex or ill-defined skin cancer when 100% of the surgical margins are histologically examined and the same physician performs both the surgical excision and the histologic evaluation.
- MMS is covered when lesion complexity, size, or location make other approaches not medically necessary or reasonable, and documentation explains why alternative simple excision or destruction techniques are inappropriate.
- Separate payment is allowed for a nonroutine histochemical stain on frozen tissue during MMS when CPT 88314 is reported with modifier -59.
- Both MMS and subsequent formalin-fixed histopathology are covered when tissue distinct from the tissue examined during MMS is submitted for additional pathology and the clinical record clearly documents the reason the submitted tissue is separate (e.g., additional margin or unrelated specimen).
- Recurrent basal cell carcinoma (any size) or unexpected positive margin on recent excision (healthy, immunocompromised, or genetic syndrome) with aggressive histology is covered for Areas H, M, and L.
- Recurrent basal cell carcinoma with nodular pathology (any size) is covered for Areas H, M, and L.
4 Active Policies
A56514 — Billing and Coding: Mohs Micrographic Surgery
L35702 — Mohs Micrographic Surgery
A56515 — Billing and Coding: Mohs Micrographic Surgery
L35704 — Mohs Micrographic Surgery
Related Codes
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