Reporting Mohs micrographic surgery with a simple repair
Derm Coding Consult
By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Coding & Reimbursement, February 1, 2022
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The Integumentary System, Repair (Closure) guidelines were recently revised. Before 2022, the coding guidelines stated that simple repair included local anesthesia and chemical or electrocauterization of wounds not closed. The American Medical Association CPT Editorial Board (AMA CPT®) indicated that this statement was often misinterpreted to mean that simple repair codes may be reported when chemical or electrocauterization is used in place of sutures.
The revisions now include guidance that chemical cauterization, electrocauterization, or wound closure using adhesive strips as the sole repair material does not constitute a simple repair. When used alone in the repair of a wound, chemical cauterization, electrocauterization, and adhesive strips are included in the appropriate evaluation and management (E/M) code.
The 2022 guideline now reads as follows:
Simple repair is used when the wound is superficial (e.g., involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures) and requires simple one-layer closure. Hemostasis and local or topical anesthesia, when performed, are not reported separately.
Reporting simple repair after Mohs micrographic surgery (MMS)
Most dermatologic surgical procedures indicate that a simple repair, when performed, is included in the procedure and not separately reported. However, this is not the case for MMS guidelines.
CPT code 17311-17315 - 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) (e.g., hematoxylin and eosin, toluidine blue) describes the MMS procedure as described in the RVS Update Committee (RUC) Database. The code values for MMS do not include work involved in closing the surgical defect. As such, if a repair is performed to close the surgical defect, the appropriate CPT code(s) can be reported separately, including the appropriate simple repair code (12001-12018), when performed.
In alignment with the code value, the AMA CPT Assistant coding guidance states that some wounds after MMS are allowed to heal spontaneously by secondary intention without reconstruction of the wound. However, if surgical repair is necessary, then the repair codes (simple, intermediate, complex, flaps, or grafts) should be reported separately.
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The AMA further states that simple repair is used when the wound is superficial (e.g., involving primarily epidermis, dermis, or subcutaneous tissues without significant involvement of deeper structures) and requires simple one-layer closure. Hemostasis and local or topical anesthesia, when performed, are not reported separately.
The simple repair codes are used to designate wound closure utilizing sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Closure of a wound with adhesive strips alone does not qualify as a simple repair.
Mohs with simple repair documentation requirements
Like any repair procedure, clear, detailed, and concise documentation is essential to accurately describe the type and size of the repair performed.
First, document how many layers are involved in and/or closed to complete the repair. This information will help define the type of repair performed as either simple, intermediate, or complex.
Then, identify and document the anatomic location and the final length (in centimeters), whether curved, angular, or stellate, of the line of closure. This is important because accuracy in code selection is dependent on the CPT code descriptor which is classified according to anatomic location and size of the repair.
Below are some examples to further help understand the revisions.
Example 1
A 73-year-old male patient presents with a poorly defined infiltrating basal cell carcinoma on the preauricular cheek. Following one stage of Mohs tissue excision the defect measuring 1.1 cm by 0.8 cm was repaired linearly. Cones of skin bordering the superior and inferior edges of the defect were excised, the skin was sutured shut with buried absorbable sutures, followed with surgical tape stripping of the surface skin. The line of closure measured 2.7 cm in length.
The encounter is reported as follows:
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) (e.g., 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 |
12013 |
Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.6 cm to 5.0 cm |
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Example 2
A 75-year-old female patient presents with a right dorsal hand infiltrating basal cell carcinoma excised with one stage of Mohs surgery. The longitudinally elongated 1.5 by 1.0 cm oval Mohs defect was fashioned into a fusiform shape via excisions of triangular cones of skin bordering the proximal and distal edges of the surgical defect. Following a minimal undermining the skin edges were sutured shut with absorbable buried sutures and the surface skin was taped with surgical tape strips over tincture of Mastisol. The total line of closure measured 2.8 cm.
This encounter is reported as follows:
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) (e.g., 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 |
12002 |
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.6 cm to 7.5 cm |
For more information on the new and revised guidelines, review the Academy’s Coding and Billing Manual as well as the Academy’s Principles of Documentation in Dermatology.
Read more information on reporting repair services in Derm Coding Consult, and in the AADA Coding Resource Center.
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