Wiki Mohs for Muir-Torre Syndrome

[Sarahp941]

I am having back to back patients who my Provider is recommending Mohs for Muir-Torre Syndrome. The patient has never been diagnosed with Muir-Torre Syndrome, but they want to do Mohs as they have a high suspicion of diagnosis. I am not familiar with this diagnosis but after research, I know this is a genetic disorder that relates to internal malignancies in numerous body locations - GI, etc. and Adenomas are a common symptom. The diagnosis is Atypical Sebaceous Adenoma, it is considered benign, not malignant. So how would this qualify for Mohs and not Excision - maybe with deeper margins? I just want to get my facts together before we actually do the surgery, and not deal with it after the fact. Thanks in advance!

 

[thomas7331]

From a coding perspective, you would still need to code the diagnosis and procedure based on what is documented. The decision to perform Mohs vs. excision is up to the provider and would not be coded differently because of patient's diagnosis.

It's from a payment perspective that you may have a potential problem, because the LCDs and/or payer policies quite likely may simply not cover a Mohs procedure for a benign diagnosis. You'll want to be sure to review this patient's coverage in advance, obtain prior authorization if necessary, and if it appears that it may not be covered by their insurance plan, notify the patient and obtain any necessary waivers so that you can bill the patient for the services if these are denied. The provider should make every effort to document clearly the medical necessity of the procedure for this patient in the record since it is an unusual case and may need to be supported in an appeal. But if it turns out that the Mohs procedure will not be covered for this patient and the patient does not wish to proceed, then the provider may want to discuss alternative treatment options with them such as an excision instead, but that would be between the patient and the provider to decide.

 

[Sarahp941]

Thank you! Although, I have already had that talk with my Providers. They just don't understand the coding, so they think their medical decision trumps coding guidelines. From a medical standpoint I understand their thought process, but when I inform them it won't be covered/paid, that's when I have to go into depth on how their medical decision vs insurance reimbursement/coverage, don't always match. I will review our cases with my Medical Director and see how they want to proceed. Thanks again for you input.

 

[SharonCollachi]

... that's when I have to go into depth on how their medical decision vs insurance reimbursement/coverage, don't always match. I will review our cases with my Medical Director and see how they want to proceed. Thanks again for you input.

I'm right there with you. I have to remind my provider that health insurance is a BUSINESS, not a health service, and no insurance that I've ever run across will cover everything for everyone. When he starts getting irritated because his medical decision making should be enough, I then remind him that they are not saying it's not medically necessary, they're just saying they won't pay for it. The patient is free to pay for it themselves.