Mohs Surgery Documentation
Question:
What should be documented to support medical necessity for Mohs surgery?
Answer:
The patient should have a confirmed pathology report. Specific criteria must be documented: type of cancer, location, size, and other factors (healthy, immunocompromised, aggressive, etc.) for coverage. The medical records should clearly show that Mohs surgery was chosen because of the lesion's complexity, size and location and why other approaches are not medically necessary and reasonable. The operative notes and pathology documentation in the patient's medical record must clearly show that Mohs micrographic surgery was performed using the accepted Mohs technique, with the same physician performing both the surgical and pathology services. The notes should also contain the location, number, and size of the lesion(s), the number of stages performed, and the number of specimens per stage. The Mohs surgeon must describe the histology of the specimens taken in the first stage. That description should include depth of invasion, pathological pattern, cell morphology, and, if present, perineural invasion or the presence of scar tissue. For subsequent stages, you may note that the pattern and morphology of the tumor (if still seen) are as described for the first stage; if differences are found, note the changes. Some payors have additional requirements to support the medical necessity of Mohs. It is important to check payor policies to ensure compliance with the payor.
*This response is based on the best information available as of 5/23/24.
