Dermatology World September 2011 : Page 5

coding tips cracking the code (4) Further tissue analysis is necessary to complete the stag-ing of a tumor so that the need for additional therapy, such as radiation or chemotherapy, can be determined. (5) Unusual findings during frozen section evaluation, or during other portions of the Mohs case, lead the physician to conclude that a second pathologic opinion is necessary. (6) Despite proper processing technique, frozen section inter-pretation is not sufficient to assess the tissue margin with a high degree of reliability. (7) A biopsy specimen of tumor not previously biopsied is ob-tained and assessed by frozen section immediately before commencement of Mohs; the pathologic diagnosis is then confirmed by paraffin section. The AADA position statement also provides guidance as to when the criteria for Mohs surgery are not met. The position statement notes that “In general, this occurs when one or more of the tasks that must be performed by the operating surgeon are delegated to another physician.” Examples include: (1) When all specimens removed during the course of the procedure are sent to a pathologist for interpretation of paraffin sections, then Mohs is no longer being per-formed. Instead, the physician removing the tissue should characterize that process as an excision and document it as such. (2) When a separate physician, such as a pathologist, reads all the slides made from tissue removed by the physician during a particular stage, this will constitute “delegation of responsibility” and as such, makes the stage incompat-ible with Mohs surgery. This differs from the permissible case where, during a particular stage of Mohs surgery, the physician obtains and processes all the tissue, and reads all of the slides for margin assessment, but then obtains additional second opinion pathologic consultation on a portion of these slides. The position statement notes that “Routine review of histopathlogic features of a tumor being treated with Mohs by a pathologist is not compatible with Mohs surgery. In general, pathologic consultation should occur in a rare number of cases.” Example 1: You remove a large dermatofibrosarcoma protuberans from the chest, layer by layer, using frozen sec-tions with you acting as the pathologist. The final stage you examined yourself was equivocal, so you take an additional layer and send it to a pathologist for immunostaining. The pa-thologist reports clear margins the next day and you perform an adjacent tissue transfer. All services performed were medically necessary and prudent. In rare instances, it may be appropriate (before, dur-ing, or after the Mohs procedure) to send tissue for paraffin sections to a separate pathologist. This does not preclude re-porting the Mohs surgery for the prior stages where you acted as both surgeon and pathologist. It may also be appropriate for you to bill a staged excision reporting the diameter of the final additional margin that was sent to a separate pathologist as well as the adjacent tissue transfer on the subsequent day. Your documentation must succinctly indicate the reason the additional layer was submitted to the pathologist to document medical necessity in the interest of good patient care. The documentation should be clear and unequivocal, as it will be important in the event of an audit. The pathologist would bill separately for his or her services. Example 2: You remove a large lentigo maligna from the face, layer by layer. The sections are sent to a separate lab where they are read by a pathologist who is an expert in inter-preting pigmented lesion margins. At the end of the same day, you close the wound with an adjacent tissue transfer. You did not serve as both the surgeon and pathologist, so this should not be reported as Mohs. You report the adjacent tissue transfer. The staged excision is included in the payment for the adjacent tissue transfer and cannot be reported separately. The pathologist should bill for his or her professional services. The full position statement on Appropriate Uses of Par-affin Sections in Association with Mohs Micrographic Surgery is available online at www.aad.org/Forms/Policies/ps.aspx. dw Dermatology WorlD // September 2011 5

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