Dr. Ted Rosen discusses a recent paper with specific guidance on avoiding audits and reimbursement denials for Mohs micrographic surgery.
Reducing Mohs Micrographic Surgery Reimbursement Issues
By Ted Rosen, MD, FAAD
Editor-in-Chief
Payers, including Medicare, suspect that Mohs micrographic surgery (MMS) is overused in clinical practice to increase compensation. Furthermore, denying payment for “inappropriate” use of MMS helps payers in their efforts to conserve funds.
In a recently published article,1 Howard W. Rogers, MD, PhD, observes that when reviewing many of his colleagues’ Mohs notes, he finds that they often fail to meet requirements set out in Medicare’s updated guidance to reduce MMS reimbursement issues (release date October 2020). Dr. Rogers also notes that in addition to Medicare Administrative Contractors (MACs), the standards set forth by Medicare have been adopted by Medicare Advantage plans and private insurers.
Stating that accuracy of MMS documentation and compliance with Medicare and insurer requirements will keep Mohs surgeons “out of hot water with auditors,” Dr. Rogers reviews the guidance statements and provides suggestions for helping Mohs surgeons “audit proof” their notes.
First, the patient’s medical record must contain clear documentation showing that MMS was not just an appropriate treatment modality but was THE most appropriate treatment in the specific case. To fulfill that requirement, the record should contain information showing why other modalities, like standard excision or destruction, were not employed.
Explaining further, Dr. Rogers says that he finds that most surgeons’ Mohs notes include a statement that the skin cancer treated is appropriate based on the Mohs appropriate use criteria or the appropriate use criteria score. To establish that MMS was the most appropriate treatment, the record should show that the procedure was chosen because of the tumor’s complexity, size, or location.
Medicare’s guidance also notes that MMS should only be performed by a physician (MD/DO) who is specifically trained and highly skilled in MMS techniques and pathologic identification and who is preparing and reading the pathology slides resulting from the procedure. To establish that the procedure meets the definition of the Current Procedural Terminology codes for MMS, the operative notes and pathology documentation in the patient’s medical record must show that the performing physician acted in two distinct but integrated capacities: surgeon and pathologist, Dr. Rogers writes.
Dr. Rogers interprets this requirement as meaning that the surgeon should include a statement that details the number of tissue blocks examined in each stage of the procedure.
Since the Mohs surgeon is also functioning as the pathologist, detailed histologic findings from the Mohs slides must be recorded. The description should include cell morphology, pathological pattern, depth of tissue invasion, and if found, presence of scar tissue or of perineural invasion. In addition, the Mohs operative report must include information on “the number of specimens per stage.”
Dr. Rogers suggests using a template-based system to translate typical pathologic findings to populate the Mohs note with a histologic description.
The revised guidance also clarifies stage one documentation. It states, “If tumor is visualized on stage one, you must describe the histology of the specimens taken.” The corollary to this requirement is that if no tumor is visualized in the first stage of the procedure, then description of the histology is not possible or necessary.
Dr. Rogers describes this update as “the most notable improvement in the 2020 MMS reimbursement requirements” considering that, in the past, some auditors denied payment for one-stage MMS procedures because documentation did not contain a description of the tumor histology.
Dr. Rogers also notes that there is variability in wording and requirements of MMS coverage polices and local coverage determinations from different Medicare carriers and private insurers. Therefore, he encourages Mohs surgeons to refer to the local coverage determinations of their local MAC and coverage policies of private insurers to ensure any unique requirements are met.
Reference:
1. Rogers HW. Audit Proof Your Mohs Note. Cutis. 2022 Aug;110(2):73-74. doi: 10.12788/cutis.0589. PMID: 36219633.