Part B Insider (Multispecialty) Coding Alert

Letter-writing campaign works, but other carriers may be recalcitrant

If your surgeon is performing  Mohs micrographic surgery (CPT Codes 17304-17310) on patients with lesions on their scalps or necks, you could be in for a nasty shock.
 
At least two carriers stopped covering MMS for scalp and neck lesions as of June 15. Noridian and Palmetto GBA both removed 173.4 (Other malignant neoplasm of skin; scalp and skin of neck) from the list of covered diagnosis for Mohs last summer, and providers who didn't notice the change have suddenly received an avalanche of denials. Noridian has the new policy on its site, but Palmetto didn't publish a new policy.
 
Palmetto just started denying MMS claims with 173.4 as the diagnosis, claiming that the diagnosis didn't support the service, says Jennie Horner with Southern Ohio Medical Center.
 
Noridian agreed to add 173.4 to the list of covered diagnoses for MMS after dermatologists wrote and complained, says Carrie Gaul, office manager for Gaul Dermatology in Spencer, Iowa. Noridian wrote back in a letter that it hadn't been aware this would be a problem for providers, because the policy had been in place in Texas for a while, and nobody complained until it expanded to 10 other states.
 
"People don't realize, even though there's an LMRP, you can still write in and voice your complaints," she says.
 
The carriers are supposed to cover MMS for removal of lesions around the ear, but they left out the scalp and neck code that would support that, Gaul says. Physicians don't always need to perform Mohs on the neck, but if a lesion is poorly defined and the doctor can't decide on the margins, it's hard to do a traditional incision.
 
And if the lesion is over a major bundle of nerves below the earlobe, Mohs is necessary. "If you take a traditional skin excision in that area, you will definitely sacrifice those." Also, it's probably not a great idea to cut into a lesion over the jugular vein. Any "large, invasive or aggressive" lesion in that region will require Mohs, Gaul adds.
 
Gaul says the surgical report should definitely justify the indications for Mohs. Don't bill for Mohs for a superficial small basal cell or squamous cell.