Mohs Reimbursment

DocAssist

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I am having trouble with Health Net Federal Services reimbursing Mohs procedures when multiple units are billed on one line. Also they are still applying modifier 51 to the first repair procedure. It's obvious their system edits are not correct and they have told me it does not matter what modifier I attach to the procedure their edits will over ride. I am having to do appeals on all these claims. There are no other Dermatoligist in my town that perform Mohs so I am unable to ask anyone if they are also having this issue this same carrier issue. If someone is also experiencing this same problem I would very much like to discuss what avenues you have taken to get the matter resolved. I have run out of ideas at this point but very much welcome new ones.

Thanks for reading this. I look forward to hearing from you.
 

b.cobuzzi

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Can you tell me exactly what codes you are submitting, with what modifiers and units and what the payer are changing them to. Thanks.

Barbara Cobuzzi
 

kevbshields

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Indeed, the second line(s) of many services get a multiple reduction (equivolent to a Mod-51). This can be especially true for many of the payers. With Moh's, I've seen some payers want each line listed individually, as opposed to units. Now, I'm not saying that's correct or what they're wanting, just commenting that the payers sometimes have issues with these. Keep in mind these codes just changed in '07, so some education or encouragement for them to update their system may be in order.

Good luck!
 

thomas7331

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Mohs

Here in NM the Medicare carrier prefers to see multiple Mohs procedures billed on separate lines with modifier 59 added to the additional first layer codes.

They should not be taking multiple procedure reductions on any Mohs codes, and should also not be reducing the first closure codes. The decision to apply multiple procedure reductions to Mohs was reversed by CMS in April 2007 and is documented on their web site. We've found that the commercial carriers have followed the CMS guidelines, and when not, they've been willing to adjust for additional payment when we present the CMS guidelines to them.
 

slpagel

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why are you using Mod 59 with multiple layers of the same lesion?

Also why is it in Dermatology everyone says to use 59; when you do a biopsy then and excision due to diagnosis on the same lesion. I would think 58 would be the better choice since it's the same lesion. I would appreciate your coments since I am quite new to dermatology.
 
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