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A Review of Mohs Surgery Claims with Incorrect Coding May Reveal Fraud

  • by Cindy Gallee, JD, RHIA, CHC
  • Dec 1, 2014, 09:03 AM

bigstock_man_working_on_computer_late_a_18399773There are a number of ways a dermatology claim for Mohs surgery can be problematic. But even though there had been a focus on this type of surgery in past years by payers and Recovery Audit Contractors (RACs), legal activity against doctors who allegedly have fraudulently billed Mohs surgery claims has again surfaced, indicating that the issue is not yet resolved.1 What this means for payers is that since Mohs surgery is a high volume and high expense procedure, it needs to be carefully reviewed for possible misuse.

According to the American Society for Mohs Surgery (ASMS), “Mohs surgery is a highly effective treatment for certain types of skin cancer.  It is an exacting procedure in which the dermatologist performs both surgical excision of the skin cancer and microscopic examination of the surgical margins to ensure that all skin cancer cells have been removed.” In Mohs surgery, the skin tumor is removed in stages, after which each stage of specimen is evaluated histologically for margins clear of disease.

The CPT codes used to bill for Mohs surgery are 17311-17315 and contain the following descriptions:

17311

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks

17312

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)

17313

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks

17314

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)

17315

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure)

 Mohs surgery coding can be inaccurate in several ways:

  • Mohs surgery codes 17311-17315 include both the procedure and the preparation/interpretation of the pathology slides. It is not correct to report both 17311 and 88305, for example. The surgeon who performs the procedure must also be the one who interprets the pathology. If a surgeon does a Mohs excision, but not the pathology interpretation, CPT codes 11600-11646 would be used.
  • It is standard practice and necessary for a biopsy to be performed prior to the Mohs procedure. However, Medicare and other payers have different rules as to the circumstances when both will be paid in one date of service with modifier -59, such as no previous biopsy on the same lesion within 60 days, no pathology report is available, or when the biopsy and the Mohs procedure are on different sites.
  • The secondary code (CPT 17312) must appear on the same claim and same date of service as the primary code (CPT 17311). If a Mohs procedure of one lesion cannot be completed on one day, the second day’s coding would start again with the primary code.

When payers isolate these Mohs procedure codes, the common inaccuracies described above can become apparent. Also, trending analysis will identify outliers across all of a payer’s claims with these CPT codes or across all of a provider’s Mohs procedure claims.

Payers can rely on Context 4 Healthcare's Fraud, Waste & Abuse solution. The Context4 Healthcare Fraud, Waste and Abuse (FWA) Module of FirstPassTM starts with real-time claims analysis during the adjudication cycle, while you’re still calculating your claim liability. FirstPassTM contains thousands of rules consisting of millions of editing combinations, many of which are designed to identify potential FWA conditions.
 
Additionally, the rules include evaluation of billed charges against our proprietary national Usual, Customary & Reasonable (UCR) fee schedule to find claims with charges out of the national norm for a service. These claims are identified and brought to your attention for follow up and compliance review. As claims are processed, the FirstPassTM FWA Module ensures that claims meet one or more of our potential FWA rules and alerts your processors to the situation so further analysis and investigations can begin.
 
At Context, we analyze billions of claims each year, and as part of this process we frequently find out-of-the-ordinary claim submissions that have potential for FWA activity. Utilization, regulatory, bundling, unbundling, and provider verification edits are some of the edit categories included in the FWA module.

 

1 On November 21, 2014, the U.S government announced it joined a 2011 lawsuit against a Florida doctor for allegedly performing unnecessary Mohs surgeries. See http://www.justice.gov/usao/fls/PressReleases/141121-01.html. Also see http://www.justice.gov/usao/vae/news/2014/08/20140812Bojaghlinr.html where a dermatologist on August 12, 2014 was indicted on 60 counts of health fraud including performing unnecessary and invasive Mohs micrographic surgeries.

Related FWA Briefs Articles: Avoid Overpayment - Review Documentation for Outpatient Therapy Claims; Tips for Payers to Improve Monitoring Hospital Admissions for Fraud

 

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