Ask Glenn
Answers to Your Mohs Coding & Billing Questions
Many ACMS members have questions about proper coding and billing for Mohs surgery. This reinforces a need for ongoing education to ensure the College meets its goal of integrity and ethics in all aspects of Mohs practice. Glenn Goldman, MD, FACMS, answers these coding and billing questions at askglenn@mohscollege.org. Many responses are included here for the benefit of all members.
Q: We have a patient s/p Mohs on the shin with flap repair complicated by dehiscence. Comorbid factors include venous stasis. We are providing wound care as 99024 within the global period. Can you address how one may charge for wound care supplies utilized if applicable? Thanks.
A: The appropriate code is postoperative visit. In general one should not charge for wound care supplies. What is appropriate is to write the patient a prescription for durable medical equipment and have them pick up appropriate supplies to bring with them. If the clinic supplies them, however, I would consider this part of the postop. There are J codes for a variety of supplies, but these often lead to direct patient charges / denials without prior authorization.
Glenn
Q: Hi Glenn,
I recently treated a a recurrent morpheaform BCC. Now that the average stage number is under scrutiny I have been taking much bigger layers but now I find that I have to bill 17315 more. In this case I cleared the tumor in 4 stages. The number of specimens for each stage were 13, 12, 14, and 10 respectively. By my count, if I am not mistaken, this would be 29 units of 17315. I suspect I will have to just eat it as Medicare will probably not reimburse such a high number of 17315s but we spent more than 12 hours on this case. Any suggestions? FYI, I billed it out as 17311, 17312x3, 17315x8, 17315x8 (-76), 17315 x8 (-76), 17315x5 (-76).
A: It is my understanding that you are not able to get around a medically unlikely edit in most cases. The MUE for 17315 is 15, if I am not mistaken. Submitting more than the medically unlikely edit may result in the entire claim being denied. In such a case it is reasonable/appropriate to bill 17311, 17312, 17312, 17312, 17315 X 15. 17315 is billed in aggregate for all stages. IF you wanted to bill for more than 17315 X 15 then you would likely need to do so by paper bill with an explanation of the length of the procedure, etc. I am not sure that is worthwhile. I would generally accept that payment for the Mohs stages and the 17315 that are under the MUE. Looks like a good case, and you helped someone out.
Glenn
Q: Hello Dr. Goldman,
If the Mohs stages are performed in a clinic under one tax ID/business entity and the repair is performed by the same provider in a surgery center under a different tax ID/business entity, does the multiple surgery reduction rule apply since they are different tax IDs? Thank you.
A: I have checked this out with several consultants. The MSR rule still applies
Glenn
Q: Glenn,
I want to be sure I understood correctly something you said at the meeting. If I see a patient in clinic and biopsy a skin cancer and see him back for surgery, if I do a flap for a closure I can't bill and E/M with the flap because I already did the eval at the first visit? I can only bill the E/M if the patient is sent to me from an outside doc? Thanks.
A: IF you have seen a patient prior to surgery and did a biopsy and recommended surgery it is not advisable to bill an E/M on the day of surgery.
Glenn
Q: We have begun having issues with CPT code 88342.
- Humana has denied one claim for lack of documentation. Is there any sample documentation you can send so that we have update our EMR?
- Medicare is denying a claim for using quantity of 6 for the 88342. Is there a way to bill multiples for this code and get Medicare to pay?
Any advice would be greatly appreciated.
A: This is a sample of documentation that we and others use for immunohistochemistry:
Note: MART-1 (Melanoma Antigen Recognized by T-cells) antibody immunostaining was used during Mohs surgery as per standard protocol, in addition to routine processing of all specimens with hematoxylin and eosin. The peripheral margins/edges were processed with the MART-1 stain (*** specimens total). The center was examined with hematoxylin & eosin and MART-1 immunostains. The patient was informed of the procedure and its risk/benefits during the consent for the procedure.
“One or more of the reagents used in immunohistochemical testing in this case may not have been cleared or approved by the U.S. Food and Drug Administration (FDA). The FDA has determined that such clearance or approval is not necessary. These tests are used for clinical purposes. They should not be regarded as investigational or for research. These reagents’ performance characteristics have been determined by Fletcher Allen Health Care. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical laboratory testing.”
For 88342 you can bill ONE time per stage up to three stages. The code has a medically unlikely edit at 3 units – ergo one basically cannot bill more than three units. This is not logical – but it is what it is…
Glenn
Q: Hello Dr. Goldman,
I have a question about the proper coding for a galeal hinge flap, which I sometimes do over exposed bone prior to full thickness grafting on the scalp. In the past I have used CPT 15732 which is for a muscle myocutaneous/fasciocutaneous flap of the head/neck. My billing department is questioning the use of this code, primarily because it is rarely used, and also because of its associated billing rates, which they worry might be a red flag. I have spoken with a few colleagues who also use 15732 in this situation. Regardless, I want to make sure I'm coding correctly, and I am wondering if this is something you have encountered and could advise me with. Thank you very much, in advance, for your time and assistance.
A: It is a good question, as there is no good answer. The code 15732 notes the use of temporalis, masseter, sternomastoid or levator scapulae) on page 87. As such I cannot recommend it for a galeal flap. I think that it is more appropriate to use the cutaneous flap code 14040 or 14041 along with the graft. The superficial fascia is, technically, a part of the integument. It is a tough one to know how to code, but I no longer use the 15732 since the CPT book has been very specific about what needs to be in the flap.
Glenn