Five billing hints for Mohs, repairs in 2010

April 1, 2010

Recent changes to how dermatologists charge for Mohs and subsequent repairs have diminished reimbursement for those procedures. But some dermatologists are taking more of a financial hit than necessary because of simple, correctable mistakes, according to Inga C. Ellzey, M.P.A., R.H.I.A., C.D.C., president and chief executive officer, Inga Ellzey Practice Group, Casselberry, Fla.

Recent changes to how dermatologists charge for Mohs and subsequent repairs have diminished reimbursement for those procedures. But some dermatologists are taking more of a financial hit than necessary because of simple, correctable mistakes, according to Inga C. Ellzey, M.P.A., R.H.I.A., C.D.C., president and chief executive officer, Inga Ellzey Practice Group, Casselberry, Fla.

“The big change came in 2008, when Mohs became subject to the Multiple Procedure Reduction Rule,” Ms. Ellzey says.

Today, Mohs codes 17311, and 17313 fall under the Multiple Procedure Reduction Rule, in which the government pays 100 percent of the highest value procedure but only 50 percent of the lowest value procedure. The rule applies to subsequent surgical procedures to Mohs performed during the same operative session by the same physician.

“… a surgeon might do Mohs and a flap. The flap is the highest paid service. It would be paid at 100 percent and the first stage of Mohs would be cut in half,” Ms. Ellzey says. “So, that was a huge hit, with an average write-off of about $300 per case of Mohs.”

Mohs surgeons were also impacted when Medicare did away with the consultation code.

“So, dermatologists have seen their revenue whittle away quite a bit,” she says. “The question is: What can they do to enhance their revenue?”

Five tips for maximizing Mohs reimbursement

Hint 1: Seeing a patient for the first time? Charge for an office visit. Use the office visit code that applies to the level of care.

“If a patient was sent to you from an outside entity, from outside your practice, and the patient has never been seen before by you or a colleague, you are going to charge a new patient,” Ms. Ellzey says. “If that patient was seen before by you or your group, then you will charge an established patient visit.”

Hint 2: Know the medical necessity criteria for Mohs. Most carriers follow Medicare’s national Mohs policy, which defines the groups of patients who are candidates for Mohs. Most states and carriers reimburse according to the national policy, Ms. Ellzey says.

Dermatologists should know this policy, as well as other policies for Mohs reimbursement for their contracted carriers.

An especially tricky area is the code conversion to 173.8, Ms. Ellzey says.

“When you use a 173.8, that tells us you have a site that is not on the face but in your documentation you have shown a medical necessity based on the policy. This is the biggest reason that people do not get paid for Mohs: they do not know about the conversion to 173.8,” she says. “Another example is that you would think a malignant melanoma is covered, but the ICD-9 codes for malignant melanoma are not on the list of covered diagnoses. So, you have to convert the 172 code to 173.8.”

Hint 3: Make sure your documentation supports the codes you use in billing.

Hint 4: If you think a skin cancer is aggressive and cut more than five blocks, make sure you are paid for each additional block.

“Sometimes dermatologists are not aware of the fact that they can get paid for each additional stage, if they cut more than five; so, in the first stage, what if you cut it into 13 blocks? You can bill for eight extra blocks, and it is $100 a block,” Ms. Ellzey says.

Hint 5: Start with a primary code for delayed Mohs that goes into another day but is on the same site.

“If the patient still has cancer but has been on the table for three hours and the doctor says, ‘OK we are going to stop for today and you can come back tomorrow.’ You would think that if you have already done four stages; the next day would start (with a code for) stage five,” Ms. Ellzey says.

But, in reality, doctors have to do all the preparation of a new procedure and, therefore, should code for a stage one.

Ms. Ellzey, whose dermatology-specific billing service companies serve more than 125 providers in 31 states, says these are easy-to-miss, standard procedures that help dermatologists to receive optimal pay for Mohs and repairs.