Hitting where it hurts: Medicare policy change affects Mohs surgeons' bottom line

May 1, 2009

Mohs surgeons are experiencing a drastic reduction in reimbursement due to a change in Medicare policy, and further cuts may be coming. The task for dermatologists who perform Mohs surgery is to face the fact of reduced reimbursements and work with the American College of Mohs Surgery (ACMS) to reverse these measure

Key Points

National report - Mohs surgeons are experiencing a drastic reduction in reimbursement due to a change in Medicare policy. The gap can be 23 percent or more, depending on how many procedures are performed on the same day.

In separate interviews, an expert in billing for dermatologic procedures and a Mohs surgeon discussed the implications of these changes for practices that offer Mohs surgery.

Lost exemptions

"Four CPT (Current Practice Terminology) codes are used for the Mohs stages, 17311, 17312, 17313 and 17314. Other codes are used for the various repairs used to close the defect. The codes are also now separated by anatomical site.

"Before 2008, if the Mohs surgeon did both the Mohs and the repair, both procedures were paid at 100 percent, because Mohs was exempt from the Multiple Surgery Reduction Rule," she says, noting that for years, dermatologic surgeons who did not perform Mohs surgery have been performing procedures that were not exempt, such as excision and repair.

"Now, Mohs surgery is subject to this rule, and so, the most costly procedure is reimbursed at 100 percent, and the others are paid at 50 percent," Ms. Ellzey tells Dermatology Times.

For example, the national average for 17311 - Mohs surgery on the central face - is $616, and for a complex repair - code 13132 - the national average is $513.

Prior to 2008, the reimbursement would have been $1,139. Now, the complex repair would be reimbursed at $256, for a total reimbursement of $872, or $267 less than before.

If the wound is closed with an adjacent tissue transfer code - 14060 - the national average reimbursement is $696.

So, the reimbursement prior to 2008 would have been 100 percent for both procedures - $616 for the Mohs and $696 for the repair for a total of $1,312; now, the reimbursement would be 100 percent for the repair, or $696, and $308 for the Mohs, for a total of $1,004 ($308 less than before).

Two same-day procedures

"It gets worse if the doctor does two Mohs surgery procedures on the patient on the same day," Ms. Ellzey says. "Then, the surgeon takes 50 percent reductions on three of the four procedures."

The American College of Mohs Surgery (ACMS) is lobbying to reverse the ruling, according to Ms. Ellzey.

"This development has really hit Mohs surgeons hard," she says. "I saw an average loss of $300 per surgical site."

Among the 100 practices for which she bills, 50 have Mohs surgeons.

National Mohs policy

Another issue for Mohs surgeons is the Medicare National Mohs Policy.

This policy stipulates that "not every skin cancer that comes to the attention of Mohs surgeon should be removed by Mohs surgery," Ms. Ellzey says.

However, the medical director of the Medicare carrier for a given state can interpret this policy; therefore, states' interpretations of the policy can vary widely.

The national policy specifies that the central face is always covered, but that peripheral areas must meet certain criteria.

Lesions are covered if they are at least 1 cm in diameter, recurrent, have ill-defined borders or are morpheic; if the patient is under 40, for example.