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Code This!

Scenario Week of August 16, 2013:
View Current Scenario

Assign the correct ICD-9-CM and ICD-10-CM diagnosis codes and PCS and CPT 2013 procedure codes for the following coding scenario.

PRE-OP DIAGNOSIS: Biopsy proven basal cell carcinoma nasal dorsum, skin

POST-OP DIAGNOSIS: Basal cell carcinoma nasal dorsum, skin

PRE-OP SIZE: 1.5 x 1.9 cm

POST-OP SIZE: 2.2 x 2.5 cm

INDICATION: Patient with biopsy confirmed basal cell carcinoma of the skin of the dorsum of the nose for Mohs micrographic surgical excision due to the tumor location in an area with high incidence of recurrence and with poorly defined borders.

PROCEDURE: Mohs micrographic surgery for basal cell carcinoma of the nose. Two-stage procedure: 1st stage = 4 tissue blocks; 2nd stage = 6 tissue blocks

DESCRIPTION OF PROCEDURE: The surgical site was injected with plain Marcaine 0.5% solution for local anesthesia and prepped and draped in sterile fashion. Prior to each stage the surgical site was tested for anesthesia and re-anesthetized as needed and again prepped and draped in a sterile fashion.

The clinically visible tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With the first stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs technique. The wound was dressed and the patient returned to the waiting room.

A map was prepared to correspond to the area of skin which was excised. The tissue was prepared for the cryostat and sectioned into four tissue blocks. Each section was coded, cut, and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. The areas noted to be positive were mapped for excision in the second stage.

The patient was returned to the operating room and re-anesthetized and prepped and draped in sterile fashion.

The positive areas identified in the mapping from the previous stage were removed with the Mohs technique and re-processed for analysis. During the second stage excision six tissue blocks were prepared.

No tumor was identified after the final stage of surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, it was decided that the best closure option for the size and location of the defect was referral to plastic surgery for nasal reconstruction using a median forehead flap for optimal functional and cosmetic results.

Assign the appropriate ICD-9-CM and ICD-10-CM diagnosis codes and PCS and CPT 2013 procedure codes.


CODING ANSWERS:

ICD-9-CM Diagnosis Code
173.31 Basal cell carcinoma of skin of other and unspecified parts of face

CPT Procedure Codes
17311 Mohs micrographic technique, first stage, up to 5 tissue blocks
17312 each additional stage, after the first, up to 5 tissue blocks
17315 each additional block after the first 5 tissue blocks, any stage

ICD-9-CM Procedure Code
86.24 Chemosurgery of skin

ICD-10-CM Diagnosis Code
C44.311 Basal cell carcinoma of skin of nose

ICD-10-PCS Code
0HB1XZZ Excision of Face Skin, External Approach

Rationale

CPT2013 Procedure Codes

Medicare Recovery Auditors have found an error in Mohs billing submissions according to MLN Matters SE1318. The error is in regard to billing codes 17311–17315 when the surgical pathology components are performed and billed by a different practitioner other than the surgeon.

The surgeon performed a Mohs procedure, a highly specialized technique for accurately examining 100 percent of the margin and allowing complete complex skin cancer resection with very narrow margins, resulting in smaller operative wounds and lower chance of recurrence.

The CPT codes for Mohs procedure are only assigned when the surgeon acts as both the surgeon and the pathologist, due to the precision and controlled surgical technique and evaluation of the specimen required. Mohs surgeons are dermatologists who have received additional training to become experts in Mohs micrographic surgery, and are members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO). This official national organization maintains the high level of training and quality of care of this subspecialty. The close proximity of a histology laboratory designated by a current Clinical Laboratory Improvement Amendments (CLIA) number is now a necessary part of the claim when reporting Mohs micrographic surgery codes to the Centers for Medicare and Medicaid Services (CMS). Thus, these CPT codes will be subject to CLIA edits.

For the first stage of this procedure of excision of the basal cell carcinoma of the nose, with four tissue blocks, the appropriate CPT code is 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) (eg, 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 5 tissue blocks.

For the second stage procedure with six tissue blocks, two codes are required. First is assigned CPT 17312, 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) (eg, 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; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure).

A second code is required because code 17312 covers only up to 5 tissue blocks. Therefore, additional CPT 17315, 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) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure), is also assigned.

The use of CPT codes 17311–17315 is reserved for the surgeon who removes the lesion and prepares and interprets the pathology slides. The surgical pathology codes 88300–88309, 88331–88332, and 88342 are part of the Mohs surgery and are bundled into 17311–17315. The surgeon should not append modifier 59 to these pathology codes unless they pertain to a separate biopsy/excision that does not involve Mohs surgery.

ICD-9-CM

The diagnostic term basal cell carcinoma of the skin of the nose may be indexed in the ICD-9-CM alphabetic index as follows: Carcinoma, basal cell, (see also Neoplasm, skin, malignant) 173.91. Review of the tabular listing for code 173.91 shows that this is an unspecified code, but there are more specific codes in this category. Category 173.3, Other and unspecified malignant neoplasm of other and unspecified parts of face, has an inclusion term for Nose, external, and has a subcategory for basal cell carcinoma, 173.31.

Alternatively, go to the Neoplasm table under Neoplasm, skin, nose, external, see also Neoplasm, skin, face. Neoplasm, skin, face, basal cell, 173.31.

The ICD-9-CM procedure code can be directly indexed under the term Mohs operation (chemosurgical excision of skin) 86.24. Review of the tabular description of code 86.24 shows that category 86.2 is Excision or destruction of lesion or tissue of skin and subcutaneous tissue, and code 86.24 is entitled Chemosurgery of skin.

ICD-10-CM

The diagnostic term basal cell carcinoma of the skin of the nose may be indexed in the ICD-10-CM alphabetic index as follows: Carcinoma, basal cell, (see also Neoplasm, skin, malignant) C44.91. Review of the tabular listing for code C44.91 shows that this is an unspecified code with more site specific codes in category C44. Subcategory C44.3 is specific to skin of other and unspecified parts of face, with the category further broken down into specific types of malignant neoplasms and sites. Review of this subdivision indicates code C44.311 is the most specific code assignment for basal cell carcinoma of the skin of the nose.

Alternatively, go to the Neoplasm table under Neoplasm, skin, nose, C44.301 and refer to the tabular listing for this code. The tabular description of code C44.301 indicates this is a code for an unspecified neoplasm of the skin of the nose, so refer to the subcategory C44.3, and there is a specific code for basal cell carcinoma of the skin of the nose, C44.311.

ICD-10-PCS

Review of the operative report indicates the objective of the procedure was to excise a skin lesion from the dorsum of the nose. The operative report specifies the excision was skin. Official Coding Guidelines: B3. Root Operation indicates that the ICD-10-PCS definition of the root operation “excision” is “Cutting out or off, without replacement, a portion of a body part.” The explanation provided is that excision involves the act of “cutting with either a sharp instrument or other methods such as a hot knife or laser.”

Index: Excision, Skin, Face which leads to 0HB1XZ. This is in table 0HB and indicates the body part character 1 face, X External approach for the skin, device character Z for no device, and seventh qualifier character Z is assigned as the entire lesion was excised. The appropriate code assignment is therefore 0HB1XZZ.

The table 0HB could be accessed directly rather than using the index, as the use of the index is not required in ICD-10-PCS, but the PCS tables should always be consulted to find the most appropriate valid code.

 
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