Mohs exemption, PQRI top coding concerns

Key Points

The elimination of the Mohs exemption was scheduled to take effect Jan. 1. However, the American College of Mohs Surgery, the American Society for Mohs Surgery, the American Society for Dermatologic Surgery and the American Academy of Dermatology were working at press time to reverse Medicare's November 2007 final ruling on the subject, says Mark J. Zalla, M.D., a Florence, Ky., board-certified dermatologist and Mohs surgeon in private practice and volunteer associate professor of dermatology, University of Cincinnati.

But any potential reversal of Medicare's decision won't occur in time to prevent the Jan. 1 loss of the exemption, he adds.

For dermatologists and dermatologic surgeons, the PQRI, a voluntary program that began in July 2007, poses ongoing questions including when and how the Centers for Medicare and Medicaid Services (CMS) will make final payments to participating physicians, and whether the program one day will become mandatory, he says.

Under the PQRI, dermatologists must show that they've met a handful of quality measures at least once yearly for patients with melanoma or a history thereof.

The particular CPT Category II codes involved are the following:

1050F - documentation of new or changing moles (or lack thereof)

2029F - performance of complete skin exam

5005F - patient counseling regarding skin self exams.

"These are things we're all doing anyway. It's just a matter of ensuring that we document them in our notes," Dr. Zalla says.

Physicians who satisfactorily document performance of PQRI best practices for at least 80 percent of their melanoma patients will be eligible for bonus payments up to 1.5 percent of their Medicare revenues during the program period, he says.

"How much that will actually wind up being, we don't know," Dr. Zalla says.

The program's initial period covered July through December 2007, and its second will cover January to December 2008.

The PQRI also allows reporting of exclusion modifiers with each melanoma-related code. One of these modifiers covers medical reasons why the service associated with a particular code cannot be performed.

Blind patients, for example, couldn't discern whether they have a new or changing mole, in which case one would modify the 1050F code to 1050F-1P, Dr. Zalla says.

The 2P modifier covers patient-related reasons, such as patient refusal of a full-body skin exam. Modifier 3P applies to situations in which a system-related reason prevents a PQRI measure from being done.

For instance, if a general dermatologist refers a patient to a Mohs surgeon for melanoma removal, the Mohs surgeon might not do a full skin examination because the general dermatologist already has. Finally, modifier 8P applies to any reason not covered by the other modifiers.

Another PQRI-related issue that has arisen is that occasionally, private insurance carriers for whom the required codes are being submitted are unable to process claims.

"That's been a question in one of our patients. I recently heard of one claim that got denied because the carrier didn't know how to handle those codes," Dr. Zalla says.

This is a carrier-specific issue, because there's no charge submitted with those codes for non-Medicare patients, he adds.