Wiki Mohs and 88331 performed on same DOS

[sinman0531]

Hello all,

I have one provider that I bill for who has a bad habit of billing 88331 as a separate encounter on the same day he does a Mohs surgery. Of course, it’s never paid because the 88331 is inclusive of Mohs.

My question is this: if the provider is using it pre-operatively to confirm malignancy before doing the surgery, should he actually be billing 88305 (and would that pay)?

OR,

Would it be better to bill one of the codes under a different pathologist (we have several at the practice) and bill it as a second opinion?

 

[thomas7331]

The provider is billing correctly if the 88331 was done prior to the Mohs surgery, but a modifier is needed to prevent the code from denying.

There is guidance on this in the CPT book in the section on Mohs: "If a biopsy of a suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report a diagnostic skin biopsy (11102, 11104, 11106) and frozen section pathology (88331) with modifier 59 to distinguish from the subsequent definitive surgical procedure of Mohs surgery."

 

[sinman0531]

The provider is billing correctly if the 88331 was done prior to the Mohs surgery, but a modifier is needed to prevent the code from denying.

There is guidance on this in the CPT book in the section on Mohs: "If a biopsy of a suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report a diagnostic skin biopsy (11102, 11104, 11106) and frozen section pathology (88331) with modifier 59 to distinguish from the subsequent definitive surgical procedure of Mohs surgery."

Yeah, even with modifiers we have never been paid on an 88331 performed by the same surgeon on the same day as a Mohs. Even with notes, they always say it's inclusive of the Mohs procedure itself. That's why I was wondering if we have a separate pathologist perform the consult if that will pay because then they are truly separate services?

 

[thomas7331]

Yeah, even with modifiers we have never been paid on an 88331 performed by the same surgeon on the same day as a Mohs. Even with notes, they always say it's inclusive of the Mohs procedure itself. That's why I was wondering if we have a separate pathologist perform the consult if that will pay because then they are truly separate services?

That really surprises me - I billed these for years and never had an issue with payment when the modifier was correctly used. The NCCI PTP table shows that the modifier is allowed to unbundle this and the guidance is also documented in the current NCCI Policy Manual, Chapter III:

if a suspected skin cancer is biopsied for pathologic diagnosis prior to proceeding to Mohs micrographic surgery, the biopsy (e.g., CPT codes 11102-11107) and frozen section pathology (CPT code 88331) may be reported separately using modifier 59 or -X{SU}, or 58 to distinguish the diagnostic biopsy from the definitive Mohs surgery. Although the "CPT Manual" indicates that modifier 59 should be used, it is also acceptable to use modifier 58 to indicate that the diagnostic skin biopsy and Mohs micrographic surgery were staged or planned procedures.

It's possible your Medicare contractor may want the 58 modifier as indicated above, but either way, they and your Medicare Advantage plans are required to adhere to this policy - if they are not, then they are incorrectly processing your claims and you should escalate this issue.

Your commercial payers may have different policies and may or may not follow NCCI, but if you are contracted with them, then you are generally required to follow their policies as part of your contractual agreement - it's something you might want to discuss with your network representatives.

But if you really cannot get payment for these, I would not recommend trying to bypass your bundling rules by having another physician in your practice bill for the component code - that may get you payment in the short run, but auditors will eventually identify what you are doing and will likely catch up with you. If your providers don't want to absorb the costs of the denials, my own recommendation would be that they send out the biopsy specimens to an outside lab and let that lab's pathologists perform the interpretation and submit the claims themselves.