Otolaryngology Coding Alert

Although a dermatologist or plastic surgeon typically performs Mohs micrographic surgery, an otolaryngologist may be called in to repair the surgical wound.
 
Mohs surgery is a precise technique for treating skin cancers, such as basal cell and squamous cell carcinomas. It has become widely available in the last few years and reportedly has the highest cure rate of any skin cancer treatment. Because Mohs surgery eliminates virtually all malignant cells with minimal damage to the surrounding skin, the technique is used most often for malignancies on the face and in cosmetically sensitive areas. Mohs may also be used to remove skin cancers with ill-defined clinical margins and recurrent skin cancers.
 
"The surgery is better for patients because they lose less skin," says Pam Biffle, CPC, CCS-P, director of Medical coding for Concentra, a large occupational healthcare group in Addison, Texas. "This isn't at all like an excision with wide margins. If the pathology comes back positive, they take out another specimen until there is no further sign of the cancer. Based on what is seen, the surgeon can determine if it is necessary to remove another layer." Even though the original procedure is unusual and the cancer, as well as the wound, is likely to be irregularly shaped, the same repair codes apply to Mohs reconstruction as for any other closure, Biffle says.
 
Because Mohs surgery is more sensitive cosmetically, many patients who have the procedure require only simple closure. Sometimes, however, closing the wound may require intermediate (layered) or complex closure (13000 series), adjacent-tissue transfer (14000 series), or flaps and/or grafts (15000 series).

Repairing the Wound

The surgeon may apply a dressing after a Mohs procedure and send the patient to the otolaryngologist, who may determine the wound should be left open to heal on its own or perform one of many closures (simple, intermediate and complex repairs; adjacent tissue transfers; more extensive flaps; and, in extreme cases, grafts). Biffle notes that the nature and size of the wound, which can vary considerably because the malignancies tend to be irregularly shaped, are the determining factors. If an intermediate or complex repair is performed, the size of the defect must be documented to select the correct code. The same applies to tissue transfer and grafts.
 
Most of these repair codes also vary by location, but repairs by otolaryngologists are most likely to be on the face and/or neck. For example, Mohs surgery for a basal cell carcinoma of the cheek leaves an 8.5-sq cm defect. The repair is coded 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less). For defects larger than 10 sq cm, 14041 ( defect 10.1 sq cm to 30.0 sq cm) should also be reported.
 
Note: The depth of the wound (i.e., superficial, deep or subfascial) must also be known to code many repairs correctly.

Medical Versus Cosmetic

Mohs reconstructions are sometimes denied on first submission because the carrier incorrectly classifies the closure as cosmetic. Even when a cancer diagnosis is used in association with the reconstruction, some payers deny any claim with reconstructive flaps as cosmetic the first time around.
 
As a result, it may be necessary to reinforce the noncosmetic nature of the reconstruction, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's Editorial Panel and Executive Committee. This may involve clearly documenting the cancer itself, as well as the original Mohs surgery. Even so, you may have to appeal. In such cases, photographs of the defect may help demonstrate to the carrier why the reconstruction is medically necessary surgery and not a cosmetic procedure.

Complex Repair

Deep defects can require that repairs be performed in two or more stages. If a complex repair, adjacent tissue transfer, flap or graft procedure is performed, any subsequent procedures fall within the first procedure's 90-day (for adjacent-tissue transfers, flaps and grafts) or 10-day (for complex and intermediate repairs) global period. Therefore, some carriers may require that modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) be appended to the code that describes the subsequent repair.
 
For example, if a tubed pedicle is performed with a complete transfer (15574, Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet; or 15576, eyelids, nose, ears, lips, or intraoral), modifier -58 should be appended to 15620 (Delay of flap or sectioning of flap [division and inset]; at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet) or 15630 ( at eyelids, nose, ears, or lips).

Two Different Surgeons

Some carriers include the reconstruction in the global period of the original micrographic surgery even when different surgeons (from different practices) performed the two services. Although no modifier should be required in such situations, Eisenberg says, if the carrier continues to inappropriately deny reconstruction claims for this reason, it may be necessary to append modifier -59 (Distinct procedural service) if the reconstruction was performed on the same day, or modifier -58 if the reconstruction was performed later. In the unlikely event that the Mohs surgeon and the otolaryngologist are in the same practice, modifier -58 should be appended to the reconstruction code. Eisenberg notes that when Mohs reconstruction is scheduled well in advance, there is ample time to contact the carrier and determine its particular billing requirements. "Technically, there is no reason to append a modifier because different physicians from different practices performed the two procedures. But private carriers may have their own policies, which should be obtained in writing, if possible, before the reconstruction is performed," he says.

Multiple Grafts and Donor Sites

Mohs reconstruction may require that grafts be harvested from two separate donor sites (from both upper eyelids for a graft on the nasal tip, for example) or that more than one graft be performed to repair the defect. To correctly code these situations, the operative report should clearly state the type of repair. Multiple adjacent-tissue transfers to repair a defect may be confused with pedicle or other flaps. However, only one tissue transfer code may be reported, based only on the size of the defect.
 
If a graft is performed, the procedure notes should state whether it was a split- or full-thickness graft. Both of these grafts are coded by total area of the graft and not by the defect or by the number of grafts performed. For example, if a split-thickness graft totaling 40 sq cm is performed, 15120 (Split graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children [except 15050]) is reported once. Harvesting of the graft is included in split- and full-thickness graft codes and cannot be billed separately regardless of the number of donor sites. In addition, any repairs to donor sites that require skin flaps or grafts may be reported separately.
 
Note: Some graft codes include "direct" or "primary" closure of the donor site. Flaps and grafts, however, are considered more extensive procedures than these closures and may be reported separately.