Therefore, Mohs surgeons contacted by Dermatology Times say they will avoid such procedures in all but the highest-risk cases, creating inconveniences for patients and higher healthcare costs.
The Centers for Medicare and Medicaid Services (CMS) first proposed the change in July 2007. A public comment period closed Aug. 30.
Despite objections from the American College of Mohs Surgery (ACMS), American Academy of Dermatology (AAD) and other organizations, on Nov. 27, CMS published this decision as a final ruling in the Federal Register, effective Jan. 1, 2008.
Without the exemption — in place since 1992 — David G. Brodland, M.D., says that if a Mohs surgeon removes a skin cancer and, subsequently, reconstructs the wound with a skin graft the same day, "The lesser-reimbursed of the two procedures will be reimbursed half of what it would have been reimbursed had it been done alone.
"The problem is that the Mohs codes have been very carefully valued, and their valuation has been very carefully broken down into various parts," with pathology alone (cutting, staining, tissue mapping and microscope work) representing more than half the codes' value, says Dr. Brodland, ACMS president.
When one factors in the costs of technicians and equipment, being reimbursed 50 percent for the second Mohs doesn't cover the cost of doing the procedure, according to valuations that have been accepted by the American Medical Association (AMA)'s Specialty Society Relative Value Scale Update Committee (RUC), he says.
"It doesn't take a genius to realize that if we operate at a deficit, before long, the lights go out," Dr. Brodland says.
Brett Coldiron, M.D., estimates that the change could cut a typical Mohs surgeon's gross income by 20 percent to 30 percent.
"I'm still going to treat my transplant patients who have two or three sites (at a loss), and other immunocompromised patients, because I don't want their cancers to spread. But I'm not going to treat the rest of them with multiple sites at a loss. And I don't believe that I should be expected to," says Dr. Coldiron, AAD Health Care Finance Committee chair.
CMS decided to eliminate the Mohs exemption in response to a fivefold increase in utilization of Mohs codes during the past decade, Dr. Coldiron says.
However, he says, "We think that the increase occurred because there's an epidemic of skin cancer, and the fact that it's taken many years to get enough people trained to do Mohs." Additionally, RVUs have increased because CMS finally corrected for true practice expense costs, he says.
However, when Dermatology Times asked CMS why it nixed the exemption, a spokeswoman replied, "Except in unusual circumstances, CMS follows the lead of the American Medical Association with regard to coding and modifiers for services, as set out in the 2008 CPT."
The CPT Editorial Panel removed the Mohs codes from the exemption list to accommodate a recommendation by the RUC, according to an AMA statement.
"The recommendation resulted from the RUC's recent five-year evaluation, a process that relies heavily on surveys executed by the medical specialty societies," the statement continues.
Dr. Coldiron counters, "The AAD and the Mohs College did a detailed survey which supported the existing values very well. There was nothing in the survey to suggest eliminating the multiple-surgery exemption. In fact, quite the opposite."
The survey found that 80 percent of a typical Mohs procedure represents intra-service time on an individual tumor, time which cannot overlap other tumors and, therefore, provides no opportunities for savings, he says.