Documenting and Coding for Mohs Surgery

Mohs surgery is the most effective method for treating and removing skin cancer. But for your billing team, documenting and coding for Mohs surgery can be challenging. There are only a few codes used, but knowing when and how to use them requires a certain level of knowledge.

Is your team choosing the correct Mohs CPT codes? As part of the procedure, both surgery and a histopathologic examination are included. When it comes to documenting and coding for Mohs surgery, both components are required to bill properly. Here’s some information to help:

When you’re coding for Mohs, look into the code range set of 17311-17315, according to AMA (American Medical Association) CPT 2020 Professional Book.1 The first step in choosing a CPT code for Mohs is verifying three key components: anatomic site, stage and tissue block. These three components will guide you in selecting the right CPT code.

Here are the 17311-17315 lay descriptions: 

17311

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon and histopathologic preparation, including routine stain(s) (for example, hematoxylin and eosin, toluidine blue), head neck, hands, feet, genitalia or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to five tissue blocks.1

+17312

Each additional stage after the first stage, up to five tissue blocks (list separately in addition to code for primary procedure). Use 17312 in conjunction with 17311.1

17313

Mohs microscopic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon and histopathologic preparation, including routine stains(s) (for example, hematoxylin and eosin, toluidine blue) of the trunk, arms or legs; first stage up to five tissue blocks.1

+17414

Each additional stage after the first stage, up to five tissue blocks (list separately in addition to code for primary procedure). Use 17314 in conjunction with 17313.1

+17315

Mohs microscopic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon and histopathologic preparation, including routine stain(s) (for example, hematoxylin and eosin, toluidine blue), each additional block after the first five tissue blocks, any stage (list separately in addition to code for primary procedure). Use 17315 in conjunction with 17311-17314.1

Also, be mindful of your anatomic site and how many stages and tissue blocks have been performed for each procedure, as these will impact which CPT code you will need to charge in order to ensure correct coding initiatives.

Need additional support with documentation and coding? We’re always a phone call or click away to help. Schedule a consultation with one of our practice management experts today!

Source:
1American Medical Association. 2020 CPTâ Professional Edition. 2019. Print.

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