Wiki claims regarding the provider specialty

[Slraheb]

Hi My provider specializes in MOHS surgery and has been for over 10 years, she is board certified, fellowship trained surgeon and dermatologist.
For some reason Unitedhealthcare has been denying and retracting payments regarding MOHS codes 17311-17315 stating "This code is inconsistent with the provider type/speciality". I have sent in reconsiderations, appeals, copies of her group and individual NPI information from the NPPES website, copies of the CPT codes from the AMA CPT coding book, visit notes, path reports, etc. When I call they read this to me:
"Per the American Medical Association (AMA) and CMS, Mohs requires the integration of an individual provider functioning in two separate and distinct capacities: surgeon and pathologist. If either of these responsibilities isdelegated to another physician or other qualified health care professional who reports the services separately, the MohsCPT codes (17311-17315) should not be reported. Therefore, Mohs codes (17311–17315) will be denied if any anotherphysician or other qualified health care professional reports the Mohs pathology services separately..The AMA also indicates that pathology examination of the specimen is an inclusive component of Mohs and should notbe separately reported by the Mohs surgeon. If a separate pathology code is submitted for the same date of service asMohs by the same provider and records do not indicate the pathology was related to a biopsy or excision performed distinctly separate from the Mohs tumor site, the pathology code will be denied as included in the Mohs surgery."
I have explained that she performs both, over and over, it's like it's falling on deaf ears. The patient is not going to another provider on the same day having another MOHS.
Has anyone else come across this? And if so what did you do to fix it?

 

[TThivierge]

Hello Slraheb,
Is provider giving good documentation to support dx code define in area where MOHS treatment located at? Pictures or circle of body area from diagram is not good enough as support. Yes I have seen this as documentation.

Also be specific in dx code used per supported notations from provider. As example D23.30 is for facial area. Are you suing Z dx codes last define past history of patient? Code what you found during the full body skin exam. For example, the patient may have many benign nevi (D22.0-D22.9), skin tags (L91.8), Actinic Keratosis (L57.0), Seborrheic Keratosis (L82.0-L82.1) that you council the patient on and advise monitoring. Check out dx codes of L04, R59, D36, I88.9 and Z12.83, Z85.828 but add chronic conditions if pt suffer with them. Lab test dx codes given same day should match claim for treatment...it is way to support medical necessity. And medical orders should support lab test given. Once the lab result come back use the dx from pathologist doc it discover a bacteria or fungus problem. Maybe this is reason nothing is paid. Also is the provider updating his or her qualifications by payer to do the MOHS? Contact the credentialing department of the payer who denies.

I hope helped you with these suggestions.
Lady T

 

[thomas7331]

Hi My provider specializes in MOHS surgery and has been for over 10 years, she is board certified, fellowship trained surgeon and dermatologist.
For some reason Unitedhealthcare has been denying and retracting payments regarding MOHS codes 17311-17315 stating "This code is inconsistent with the provider type/speciality". I have sent in reconsiderations, appeals, copies of her group and individual NPI information from the NPPES website, copies of the CPT codes from the AMA CPT coding book, visit notes, path reports, etc. When I call they read this to me:
"Per the American Medical Association (AMA) and CMS, Mohs requires the integration of an individual provider functioning in two separate and distinct capacities: surgeon and pathologist. If either of these responsibilities isdelegated to another physician or other qualified health care professional who reports the services separately, the MohsCPT codes (17311-17315) should not be reported. Therefore, Mohs codes (17311–17315) will be denied if any anotherphysician or other qualified health care professional reports the Mohs pathology services separately..The AMA also indicates that pathology examination of the specimen is an inclusive component of Mohs and should notbe separately reported by the Mohs surgeon. If a separate pathology code is submitted for the same date of service asMohs by the same provider and records do not indicate the pathology was related to a biopsy or excision performed distinctly separate from the Mohs tumor site, the pathology code will be denied as included in the Mohs surgery."
I have explained that she performs both, over and over, it's like it's falling on deaf ears. The patient is not going to another provider on the same day having another MOHS.
Has anyone else come across this? And if so what did you do to fix it?

This strikes me as being clearly an error on United's part. It seems to me that one of 3 things is going on here: 1) they're giving you the incorrect denial reason when the claim is actually denied for something else that has nothing to do with specialty (for example a missing or invalid CLIA number on the claim); or 2) they have programmed their system incorrectly to deny Mohs procedures when performed a dermatologist, or 3) they have made an error in credentialing or loading your provider so that the system is not recognizing that your provider is able to perform these. My guess is that 2) is the most likely, and that they will eventually identify the error and fix the problem and go back to adjust the incorrectly denied claims: obviously, any payer that will not pay a dermatologist for Mohs is very quickly going to find that they don't have any Mohs surgeons available for their members in its networks. Has your physician checked with other Mohs surgeons in your area to see if they are experiencing the same thing?

I would stop sending appeals and stop calling the phone reps as the people that handle those are not going to be the right ones to help you - the responses you're getting make it clear that they don't understand the problem. You need to go to your network representative and escalate this and keep going up the chain of command until you get a valid answer as to why your claims are denied and what the fix is going to be. If you network rep is unresponsive, then I would suggest that you have your physician discontinue all Mohs procedures for patients with this insurance (and explain to the patient why you are doing this so they will start contacting their insurance company too), or else start requiring patients to sign a waiver that they'll be responsible for payment. I'd also have the physician send a letter stating that she is terminating the contract. A request to terminate will usually get someone's attention when all else fails, especially when it's from a specialist such as this, which payers absolutely need to make sure they have enough of in their network.