Documenting Mohs Surgery

Question:

What should be documented in my note to support billing for Mohs surgery?

Answer:

This is a great question. To support Mohs surgery, comprehensive documentation should include several key components:

Pre-operative Documentation:

• Detailed pathology report confirming the skin cancer diagnosis (basal cell carcinoma, squamous cell carcinoma, etc.)

• Clinical photography showing the lesion's size, location, and characteristics

• Patient history including previous treatments, recurrences, or incomplete excisions

• Documentation of high-risk features (location on face/genitals, size >2cm on trunk/extremities or >1cm on face, aggressive histologic subtypes, perineural invasion)

• Medical necessity justification explaining why Mohs is preferred over standard excision

Operative Documentation:

• Detailed operative report describing the procedure, number of stages required, and final defect size

• Stage-by-stage documentation with tissue mapping and frozen section results

• Real-time photographs of each stage and the final defect

• Pathology reports for each Mohs stage confirming margin status

• Documentation of any complications or unusual findings

Post-operative Documentation:

• Reconstruction plan and methods used for wound closure

• Post-operative care instructions and follow-up schedule

• Final pathology confirming complete tumor removal

• Patient education materials provided

Insurance and Administrative:

• Prior authorization if required by the insurance plan

• Appropriate CPT codes (17311-17315 for Mohs surgery stages, plus reconstruction codes)

• Documentation supporting medical necessity, particularly for lesions that might be considered for standard excision

This thorough documentation ensures proper patient care, supports insurance reimbursement, and provides a complete medical record for future reference.

*This response is based on the best information available as of 8/28/25.

Two Procedures on the Same Day

Question:

If a patient develops a complication from a surgical procedure during the global period and needs to return to the OR for treatment, will the second procedure require a modifier and if so, which modifier? We are debating whether it would be a modifier 58 for staged procedure, or 78 for an unplanned return to the OR.

Answer:

Modifiers 58 is appended to a subsequent procedure if it is staged or more extensive than the original procedure. Modifier 78 is for an unplanned return to the OR, typically a complication. Therefore, in the scenario you describe, a modifier 78 for an unplanned return for a complication would be the appropriate modifier.

*This response is based on the best information available as of 8/28/25.

Measuring an ED&C

Question:

How are measurements determined for electrodessication and curettage (ED&C) procedures for destruction of malignant lesions CPT codes 17260-17286? Is it the lesion only or the lesion after curettage?

Answer:

Great question—this detail can make a big difference in accurate coding. For CPT codes 17260–17286, which describe destruction of malignant skin lesions (including methods like electrodessication and curettage), the measurement is based on the lesion diameter prior to the procedure, not the size of the wound or defect after curettage.

Here’s what’s key:

• Measure the lesion itself before any destruction technique is applied.

• Do not measure the post-procedure defect or area of tissue removed.

• The method of destruction (e.g., ED&C, cryosurgery, laser) does not affect code selection—only anatomic location and lesion size matter.

*This response is based on the best information available as of 8/14/25.

Multiple Angioplasties

Question:

I’m new at coding, just out of vascular residency, and I have a question about reimbursement for a Medicare patient. If I do three angioplasties in the right leg, 37220 iliac, 37224 femoral-popliteal, and 37228 tibial, is 37228 paid at 100 percent and 37220 and 37224 paid at 50 percent?

Answer:

Per Medicare reimbursement policy that is correct. The 37228 tibial angioplasty pays the highest, so it is paid at 100%. The other 2 are each reduced by 50% for payment. This is the same anytime more than a single stand-alone CPT code is billed together. This is based on Medicare's multiple procedure payment reduction (MPPR) rule. Private payors typically follow this same payment policy but may vary, so check your payor policies.

*This response is based on the best information available as of 8/14/25.

How Do You Bill for H&P?

Question:

The hospital requires our surgeons to perform and document an H & P prior to the patient having an elective gall bladder surgery. Sometimes it’s done in the office before the surgery and sometimes it’s done on the same day as the procedure. If this H & P is documented, can the E/M be billed? And does it make a difference if it’s done a week before the surgery?

Answer:

A pre-operative H & P, regardless of when it occurs, is included in the global surgical package and is not separately billable. CPT clarified this in 2009 in a CPT Assistant comment, see below:

“If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.” (Source CPT May 2009)

*This response is based on the best information available as of 8/14/25.

Intraoperative Nerve Stimulation

Question:

We are having difficulty locating a code. One of our hand surgeons is performing therapeutic nerve stimulation intraoperatively for regeneration of nerve. Is this reportable, and if yes, what is the code?

Answer:

Great question and thank you for asking us!

Two new Category III CPT codes have been introduced: 0882T and 0883T. These codes became effective on July 1, 2024, and are included in the 2025 CPT manual.

• 0882T – Intraoperative therapeutic electrical stimulation of a peripheral nerve to promote nerve regeneration, including lead placement and removal, upper extremity, minimum of 10 minutes; initial nerve

• 0883T – Intraoperative therapeutic electrical stimulation of a peripheral nerve to promote nerve regeneration, including lead placement and removal, upper extremity, minimum of 10 minutes; each additional nerve

Key points to note about these Category III codes:

• They are specific to the upper extremity

• Require a minimum of 10 minutes of stimulation

• Are add-on codes and must be reported in conjunction with a primary procedure

*This response is based on the best information available as of 8/14/25.