Mohs surgery uses five CPT codes (17311–17315): location determines the primary code (head/hands/genitalia vs. trunk/extremities), stages are add-on codes, and 17315 covers additional tissue blocks beyond the first 5 in any given stage (counted per stage, not cumulative).
Biopsy coding follows a strict hierarchy: incisional > punch > tangential. Only one primary code is billed per day; additional specimens use add-on codes.
Complex repair (2020 criteria) requires layered closure plus at least one additional element: exposed bone/cartilage/tendon, wound edge debridement, extensive undermining, free margin involvement, or retention sutures.
CMS documentation for Mohs must specifically justify why Mohs was chosen over excision — stating 'meets AUC' alone is insufficient.
Flap area includes both primary and secondary defects; interpolation flap coding is determined by the recipient site, not the donor site.
Overview
Procedural coding in dermatologic surgery translates surgical decision-making into standardized documentation for reimbursement, quality tracking, and regulatory compliance. The Current Procedural Terminology (CPT) system, maintained by the American Medical Association, assigns five-digit numeric codes to each procedure. For Mohs surgeons, mastering these codes is essential — not only for fair compensation but also to withstand audits and satisfy CMS documentation requirements. This article organizes the coding framework into logical procedural categories: biopsies, destruction, excision, Mohs surgery, wound repair, flaps, grafts, and the modifiers that govern multi-procedure billing. Regulatory topics (CLIA, OSHA, incident-to billing) are included because they directly affect daily Mohs practice.
Skin Biopsy Codes
The 2019 CPT update replaced the legacy biopsy codes (11100/11101) with six technique-specific codes. The primary distinction is the biopsy method: tangential (shave/scoop/saucerize/curette), punch, or incisional. The clinical intent of a biopsy is diagnosis — not removal or treatment. Each technique has a primary code and an add-on code for additional specimens.
Tangential Biopsy (11102 / 11103)
Tangential or shave biopsy (11102 for the first lesion, 11103 add-on for each additional) encompasses any horizontal slicing technique: shave, scoop, saucerize, or curette biopsy. The goal is tissue sampling for diagnosis, not definitive removal. Four tangential biopsies are coded as 11102 plus 11103 × 3 units.
Punch Biopsy (11104 / 11105)
Punch biopsy (11104 primary, 11105 add-on) uses a cylindrical punch instrument. Simple suture closure of the punch defect is included in the code — do not bill a separate repair. The goal remains diagnosis.
Incisional Biopsy (11106 / 11107)
Incisional biopsy (11106 primary, 11107 add-on) involves a vertical excision technique that reaches subcutaneous tissue. CPT has confirmed that this code requires a true vertical technique penetrating below the dermis, not simply a tangential biopsy that incidentally reaches fat. Simple closure is included.
Billing Multiple Biopsy Types
When multiple biopsy techniques are performed on the same day, only one primary code is billed. The hierarchy is: incisional (11106) > punch (11104) > tangential (11102). Additional biopsies of any type use the corresponding add-on code. Example: one punch, two tangential, and one incisional biopsy → code 11106 + 11105 + 11103 × 2.
Site-Specific Biopsy Codes
Certain anatomical locations have dedicated biopsy codes that supersede the general skin biopsy codes. These must be used when the biopsy involves the specified site.
Site
CPT Code
Eyelid margin
67810
External ear
69100
Lip
40490
Penis
54100
Vulva (first)
56605
Vulva (add-on)
56606
Vestibule of mouth
40808
Intranasal
30100
Nail unit
11755
Tongue (anterior 2/3)
41100
Tongue (posterior 1/3)
41105
Floor of mouth
41108
Destruction Codes
Destruction codes cover ablation of lesions by any method (cryotherapy, electrodesiccation, curettage, laser, chemical). They are organized by lesion type: premalignant (actinic keratoses), benign, and malignant. All destruction codes carry a 10-day global period.
Premalignant Lesion Destruction (17000–17004)
These codes apply exclusively to actinic keratoses (ICD-10: L57.0). Code 17000 covers the first lesion; 17003 is the add-on for each additional lesion up to 14 total. For 15 or more lesions, use 17004 alone (it replaces both 17000 and 17003). Ten-day global period applies.
Benign Lesion Destruction (17110–17111)
Destruction of benign lesions (seborrheic keratoses, warts — not skin tags or cutaneous vascular proliferations): 17110 covers up to 14 lesions, 17111 covers 15 or more. Ten-day global period.
Malignant Lesion Destruction (17260–17286)
Destruction of malignant lesions (typically curettage of skin cancer) is coded by anatomical region and size. Three location groups exist: trunk/extremities (17260–17266), scalp/neck/hands/feet/genitals (17270–17276), and face/ears/eyelids/nose/lips (17280–17286). Size is based on the first-pass curetted diameter. The code includes preoperative assessment, preparation, anesthesia, and postoperative care.
Excision Codes
Excision codes are divided into benign (11400–11446) and malignant (11600–11646) categories. Both require full-thickness excision through the dermis into subcutaneous tissue. Excision size is defined as the greatest clinical dimension of the lesion plus the surgical margin. Simple (one-layer) repair is bundled into the excision code; intermediate or complex repair is billed separately.
Excision vs. Shave Removal
The distinction is purely about depth. Excision penetrates the full thickness of the dermis into subcutaneous tissue. Shave removal (11300–11313) uses a transverse/horizontal incision that does not penetrate through the full dermis. Whether the lesion is completely excised histologically is irrelevant to code selection — only the depth of tissue removal determines whether to use excision or shave codes.
Coding Excisions by Size and Location
Excision codes are selected based on excised specimen size (lesion + margins) and anatomical location. Three location groups apply to both benign and malignant excisions: trunk/arms/legs, scalp/neck/hands/feet/genitals, and face/eyelids/ears/nose/lips/mucous membrane.
Size (lesion + margin)
Benign (trunk)
Malignant (trunk)
Malignant (face)
≤ 0.5 cm
11400
11600
11640
0.6–1.0 cm
11401
11601
11641
1.1–2.0 cm
11402
11602
11642
2.1–3.0 cm
11403
11603
11643
3.1–4.0 cm
11404
11604
11644
> 4.0 cm
11406
11606
11646
Subcutaneous Soft Tissue Tumor Excision
Lesions confined to the subcutaneous tissue below the skin but above the deep fascia use musculoskeletal excision codes (21011/21012 for face/scalp, 21555/21552 for neck, etc.). Code selection is based on location and clinical tumor size plus margin. These carry a 90-day postoperative period. Note: epidermal cysts that push into the subcutis are still coded as integumentary excisions (114XX), not soft tissue excisions.
Mohs Surgery Codes (17311–17315)
Mohs micrographic surgery has five dedicated CPT codes. These codes encompass the surgeon's dual role as both surgeon (excision, mapping) and pathologist (histologic preparation and interpretation). The codes include removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding, microscopic examination by the operating surgeon, and histopathologic preparation including routine stains (H&E, toluidine blue).
Code Definitions
The five Mohs CPT codes are organized by anatomical location and stage progression.
CPT Code
Description
17311
First stage, head/neck/hands/feet/genitalia or any site involving muscle/cartilage/bone/tendon/major nerves/vessels — up to 5 tissue blocks
17312
Each additional stage after 17311 — up to 5 tissue blocks
17313
First stage, trunk/arms/legs — up to 5 tissue blocks
17314
Each additional stage after 17313 — up to 5 tissue blocks
17315
Each additional tissue block beyond the first 5 blocks in any given stage (counted per stage, not cumulative across the case; debulk specimen not included)
CMS Documentation Requirements
CMS guidance on Mohs surgery documentation specifies four mandatory elements in the operative note: (1) Clear justification for choosing Mohs over simple excision or destruction, including tumor complexity, size, location, or tissue conservation needs — simply stating that a tumor meets Mohs AUC is insufficient. (2) Evidence that the procedure followed accepted Mohs technique with the surgeon acting in two integrated but distinct capacities (surgeon and pathologist). (3) Location, number, and size of lesion(s), number of stages, and number of specimens per stage. (4) Histologic description of first-stage specimens including depth of invasion, pathological pattern, cell morphology, and perineural invasion or scar tissue if present. For subsequent stages, differences from the first-stage description should be noted; the full description need not be repeated if the findings are unchanged.
Wound Repair Codes
CPT defines three tiers of wound repair: simple (included in excision codes), intermediate, and complex. Accurate classification directly affects reimbursement and audit risk. Repairs are coded by the total length of closure within a given anatomical group and can be summed across multiple wounds in the same group.
Simple Repair (12001–12021)
Simple repair covers superficial wounds involving epidermis, dermis, or subcutaneous tissue without significant deeper structure involvement. It is a single-layer closure. Normal wound debridement and single-layer suturing are included. Simple closure is always bundled into excision codes and should not be billed separately.
Intermediate Repair (12031–12057)
Intermediate repair requires layered closure of one or more deeper layers of subcutaneous tissue and superficial (non-muscle) fascia. Per the 2020 update, it includes limited undermining, defined as undermining distance less than the maximum defect width (measured perpendicular to the closure line) along at least one entire edge. A single-layer closure of a heavily contaminated wound requiring extensive cleaning also qualifies. Intermediate repair is billed in addition to excision codes, based on total length summed within a body region.
Complex Repair (13100–13153)
Complex repair (updated 2020) requires meeting intermediate repair criteria (layered closure) plus at least one additional element: (1) exposure of bone, cartilage, tendon, or named neurovascular structure; (2) debridement of wound edges (traumatic lacerations, avulsions); (3) extensive undermining — distance equal to or greater than the maximum defect width along at least one entire edge; (4) involvement of free margins (helical rim, vermilion border, or nostril rim); or (5) placement of retention sutures.
Flap Codes (Adjacent Tissue Transfer)
Adjacent tissue transfer (ATT) codes 14000–14302 cover local tissue rearrangement to repair a defect. By CPT definition, a flap requires the physician to make additional incisions beyond those needed for excision to develop a flap. Alterations of standing cone placement (curvilinear closures, M-plasties) do not constitute flaps.
Flap Size Calculation
Since 2004, ATT codes are selected based on the combined size of the primary defect (excision site) plus the secondary defect (tissue created by flap design). Both defects are measured together to determine the correct code. Excision coding is bundled into the flap code for non-Mohs excisions. For Mohs surgery, the Mohs codes are billed separately from the reconstruction.
Flap Codes by Location and Size
ATT codes are organized by anatomical location and defect area.
In 2012, CPT revised the island pedicle flap code (15740) to require identification and dissection of a named axial blood vessel. Under this definition, most dermatologic island pedicle flaps are random-pattern advancement flaps and should be coded using the 140XX ATT series, not 15740.
Interpolation Flap Coding
Interpolation (two-stage) flap coding is determined by the recipient site, not the donor site. A cheek-to-nose interpolation flap is coded from the nose. The secondary take-down procedure is also coded based on the recipient site. The paramedian forehead flap has its own dedicated code: 15731 (formation) and 15630-58 (pedicle division and inset at the nose).
Ear cartilage graft to nose or ear (if concurrent)
21235
No modifier -59 needed with 15576
Pedicle division and inset (eyelids, nose, ears, lips)
15630-58
Modifier -58 because both stages have 90-day globals
Paramedian forehead flap
15731
Axial pattern forehead flap
Forehead flap pedicle division at nose
15630-58
Graft Codes
Skin graft codes cover repair of a wound with tissue from a separate donor site. The excision or Mohs procedure is billed separately. Repair of the donor site is included in the graft code.
Split-Thickness Skin Grafts (15100–15121)
STSG codes are organized by location: trunk/arms/legs (15100/15101) and face/scalp/eyelids/mouth/neck/ears/orbits/genitalia/hands/feet/digits (15120/15121). The primary code covers the first 100 cm² (or 1% body area in infants/children); the add-on covers each additional 100 cm².
Full-Thickness Skin Grafts (15200–15261)
FTSG codes (15200–15261) are organized by location and size. For two skin grafts in the same anatomical area, the primary code is billed only once; the add-on code is used for increased size. Do not use the code for graft bed preparation separately — it is included.
Cartilage Grafts
Three cartilage graft codes apply to Mohs reconstruction: 21235 (ear cartilage to nose or ear, includes graft harvest), 20912 (septal cartilage, any purpose), and 21230 (rib cartilage to face/chin/nose/ear).
Surgical Modifiers
Modifiers are two-digit codes appended to CPT codes to clarify circumstances when multiple procedures are performed. Mastery of modifiers is essential for the MDS board exam and for compliant billing.
Modifier -25
Indicates a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day as a procedure. The modifier is appended to the E/M code. The E/M must be unrelated to the decision to perform surgery and above and beyond the usual pre- and postoperative work. CMS considers the decision to perform a minor procedure (0–10 day global) as included in the procedure payment and not separately reportable. A new-patient encounter alone does not justify modifier -25. AMA/CPT does not require a different diagnosis to support -25.
Modifier -51
Indicates multiple procedures on the same day of service. Medicare and most insurers do not recommend reporting -51 on claims; their processing software appends it automatically in the correct position.
Modifier -59
Distinct procedural service — identifies procedures performed on the same day that are not normally reported together but are appropriate under the circumstances. This modifier overrides NCCI bundling edits. Documentation must support a different session, procedure, different site, separate incision, separate lesion, or separate injury. The modifier is placed on the Column 2 (bundled) code per NCCI edit tables.
Modifier -76
Repeat procedure or service by the same physician on the same day. Used for procedure codes that cannot be quantity-billed and must instead be reported as separate line items.
Modifiers During the Global Period
Several modifiers handle procedures or services that occur within the postoperative global period of a prior procedure.
Modifier
Definition
Clinical Example
-24
Unrelated E/M service during the postoperative period
Patient returns 4 weeks after graft repair with contact dermatitis unrelated to the surgical site (code E/M with -24)
-58
Staged or related procedure during the postoperative period — planned, more extensive, or therapy following surgery
Interpolation flap pedicle division 3 weeks after initial stage (15630-58)
-78
Unplanned return to operating room for a related procedure during the postoperative period
Abscess requiring surgical drainage 1 week after lipoma excision
-79
Unrelated procedure during the postoperative period
Cryotherapy of actinic keratosis on the forehead 7 days after BCC excision on the arm (17000-79)
Regulatory Requirements
Mohs surgeons must comply with multiple regulatory frameworks that govern laboratory operations, workplace safety, and billing practices.
CLIA (Clinical Laboratory Improvement Amendments)
CMS regulates all non-research laboratory testing through CLIA. Each Mohs laboratory must hold its own CLIA certification, and Mohs surgery is classified as high-complexity testing. Five certificate types exist: Certificate of Waiver (CoW), Certificate for Provider-Performed Microscopy (PPM), Certificate of Registration (CoR — temporary, valid up to 2 years while awaiting survey), Certificate of Compliance (CoC — granted after on-site survey, surveyed every 2 years), and Certificate of Accreditation (CoA — from a CMS-approved non-profit accreditation organization, inspected every 2 years). State notification within 30 days is required for changes in lab ownership, lab director, or technical supervisor. Proficiency testing is mandatory for moderate and high-complexity testing.
OSHA (Occupational Safety and Health Administration)
All healthcare settings require an OSHA compliance plan. Key elements include: an Exposure Control Plan outlining measures to minimize employee exposure to blood and other potentially infectious materials (OPIM); universal precautions and engineering controls (sharps disposal, hand hygiene); personal protective equipment; housekeeping and decontamination procedures; and annual documentation of safer medical device evaluation with input from non-managerial healthcare workers.
JCAHO National Patient Safety Goals
Office-based surgery settings should adhere to JCAHO patient safety goals: use at least two patient identifiers (name and date of birth); label all medications not in original containers in the procedure area; follow CDC/WHO hand hygiene guidelines with measurable improvement goals; verify correct surgery on the correct patient at the correct site with appropriate marking and a surgical pause/timeout before the procedure.
Incident-to Billing
Non-physician providers (NPPs: nurse practitioners, physician assistants) may bill Medicare independently at 85% of the fee schedule. Incident-to billing (ITB) allows NPPs to bill at 100% under the supervising physician's name, subject to strict requirements: (1) the physician must initiate patient care and establish the diagnosis and plan of care; (2) the physician must be physically present in the office suite (direct supervision); (3) ITB cannot be used at the first visit or when a change in plan of care occurs; (4) both the physician and NPP must be employed by the same billing entity; (5) services must be the type usually performed in the office setting as part of normal treatment. NPPs cannot bill Medicare for Mohs surgery codes under any circumstances.
Appropriate Use Criteria for Mohs Surgery
The AAD, ACMS, ASDSA, and ASMS jointly published appropriate use criteria (AUC) for Mohs surgery in 2012 using the RAND/UCLA methodology. The expert panel rated 270 clinical scenarios: 200 (74%) were deemed appropriate for Mohs, 24 (9%) uncertain, and 46 (17%) inappropriate. Among 69 BCC scenarios, 53 were appropriate; among 143 SCC scenarios, 102 were appropriate; among 12 lentigo maligna/melanoma in situ scenarios, 10 were appropriate; and among 46 rare cutaneous malignancy scenarios, 35 were appropriate. The AUC are not treatment guidelines — they do not determine the correct treatment, do not establish that one treatment is superior, and do not create medicolegal obligation. If a tumor meets criteria for more than one scenario, the scenario with the highest rating should be used. Cost, age, and cosmesis may inform clinical decisions but are not factored into the AUC ratings.
Body Site and Patient Risk Definitions
The AUC define three anatomical zones and five patient risk categories. Area H (high risk): mask areas of the face (central face, eyelids, canthi, eyebrows, nose, lips, chin, ear, periauricular skin, temple), genitalia (perineal, perianal), hands, feet, nail units, ankles, nipples/areola. Area M (medium risk): cheeks, forehead, scalp, neck, jawline, pretibial surface. Area L (low risk): trunk and extremities excluding pretibial surface, hands, feet, nail units, and ankles. Patient risk categories include healthy patients and immunocompromised patients (HIV, hematologic malignancy, organ transplant, pharmacologic immunosuppression). Tumors arising in prior irradiated skin, traumatic scars, sites of osteomyelitis, chronically inflamed or ulcerated skin, or in patients with genetic cancer predisposition syndromes are rated appropriate for Mohs in all scenarios regardless of subtype, size, or patient status.
Key AUC Scenarios by Tumor Type
Several AUC scenarios are commonly tested and clinically important. Understanding the boundary between appropriate, uncertain, and inappropriate ratings prevents both undertreatment and overutilization.
Scenario
AUC Rating
Key Detail
AK with focal SCCIS on pathology
Inappropriate
All scenarios and locations — AK is not SCCIS
Primary sBCC <0.5 cm, Area M, healthy
Uncertain
Threshold below which Mohs is not clearly justified
Recurrent sBCC, Area L
Inappropriate
All scenarios inappropriate in low-risk zone
Primary nBCC <1 cm, Area L, healthy
Inappropriate
Must exceed 2 cm in Area L to be appropriate
Primary aggressive BCC <0.5 cm, Area L
Inappropriate
Only scenario where aggressive BCC is not appropriate
Primary SCCIS <1 cm, Area L, healthy
Inappropriate
Uncertain at 1–2 cm; appropriate above 2 cm
Primary SCCIS <0.5 cm, Area L, immunocompromised
Inappropriate
Uncertain at 0.5–1 cm
Invasive SCC (no aggressive features) <1 cm, Area L, healthy
Inappropriate
Uncertain for immunocompromised in same scenario
KA <1 cm, Area L, healthy
Inappropriate
All other KA scenarios appropriate; 0.5–1 cm appropriate in immunocompromised
Primary MIS/LM, Area L (not recurrent)
Uncertain
All other MIS/LM scenarios appropriate
Bowenoid papulosis
Inappropriate
All scenarios
Desmoplastic trichoepithelioma, Area L
Inappropriate
Uncertain in Areas H and M
Angiosarcoma
Uncertain
All scenarios
Merkel cell carcinoma, Area L
Uncertain
Appropriate in Areas H and M
Photodynamic Therapy Codes
Three CPT codes apply to photodynamic therapy (PDT) in dermatology, distinguished by the level of physician involvement.
CPT Code
wRVU
Description
96567
0
PDT delivery without direct physician involvement
96573
0.48
PDT with direct physician involvement (provider applies medication and activates light source)
96574
1.01
PDT with physician-performed debridement by curettage or abrasion, with direct involvement in PDT delivery
Quick Reference: Common Coding Scenarios
The following table summarizes coding for frequently encountered Mohs surgery day scenarios.
[1]Connolly SM, Baker DR, Coldiron BM, et al.AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery. J Am Acad Dermatol. 2012. doi:10.1016/j.jaad.2012.06.009PMID: 22959232
[2]Aggarwal P, Neltner SA, Fleischer AB.Risk Factors That Are Associated With Outliers in Mohs Micrographic Surgery in the National Medicare Population, 2018. Dermatol Surg. 2022. doi:10.1097/DSS.0000000000003349PMID: 34923533