Wiki Moh's reimbursement with outside pathology

[rpmbilling]

I have a provider who performed Moh's surgery on a patient (17311 & 17312). While looking through the frozen sections he noticed some odd cells and decided to have a section of tissue put into a permanent section & sent out for further evaluation (like he normally does for a biopsy/excision). Now the insurance (UHC AARP Medicare Complete) is denying the Moh's citing their Moh's Micrographic Surgical policy. I explained that reimbursement on the Moh's surgery requires him to do all surgical and pathology on the specimen. He is pushing back stating special circumstances where he performed the frozen block pathology in the office along with the surgery, but also needed further pathology from an outside lab. Have you ever seen the provider get paid for the Moh's in a "special" situation like this? I've been searching for days and can't find anything that would allow this special circumstance. Thanks so much!

 

[thomas7331]

This is kind of a unique situation - I worked in Mohs coding for about 4 years and never encountered this particular problem. For what it's worth, my thought is that rather than just sending the specimen to pathology, the physician should have requested a pathology consultation for a second opinion. That way, the pathologist might have billed a consultation code, e.g. 80500, which is not a component of the Mohs and would not have run afoul of the UHC policy. But I don't know if it's possible, or ethical, to get this changed after the fact, or if it's really worth the effort for this single case. As it is, the pathologist has billed a code that is integral to the Mohs procedure for a tissue sample that was part of the Mohs procedure itself and the UHC policy clearly states that this will be denied. I think your only argument here - and it's a long shot - is to appeal and just ask UHC for an exception to policy due to an unusual circumstance. My guess is the probably won't agree to it unless your physician's documentation is detailed and persuasive enough to make the case that this second opinion was really necessary.