AI Solutions for Healthcare

Know Your Mohs – Part 1

Mohs micrographic surgery is performed by a dermatologist or a plastic surgeon to treat skin cancers, such as basal cell, squamous cell, and melanomas.  A dual specialty aspect exists during Mohs micrographic surgery because the surgeon also functions as the pathologist to determine if the margins are clear to ensure all cancerous tissue is removed.  

CPT code groups for Mohs procedures [Please refer to the AMA manual for complete descriptions]

Mohs [head, neck, hands, feet, genitalia] or [muscles, cartilage, bone, tendon, nerves, vessels]
17311 [Primary] 17312 [Add-on] 17315 [Add-on]
Mohs [trunk, arms, or legs]
17313 [Primary] 17314 [Add-on] 17315 [Add-on]

 

CPT code sets for special stains, interpretation, and report

88312 [Primary] Group I for microorganisms (eg, acid fast, methenamine silver)
88313 [Primary] Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry)
88314 [Add-on] Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry

 Guidelines:

    • The Mohs micrographic surgery codes are inclusive of the biopsy, excision, and pathology components.
    • The wound closures are separately reportable and will be covered in our next installment of the AI Alert.

 Common FWA Related Schemes:

    • Billing for a ‘special stain’, instead of a ‘routine stain’, pathology code in higher volume than their peers.
    • Upcoding of the wound closures which will be featured in our next AI Alert- Know Your Mohs Part 2 – The Closure

 How does the Codoxo Forensic Platform assist your plan with identifying potential issues with Mohs micrographic surgery and special stains?

Schemes, Top Specialties, Codes viewpoint identifies providers with outlier ‘special stains’ utilization.

Schemes, Top Detection Categories identifies outlier provider utilization of ‘special stains using AI detectors, specifically Frequent Combinations, Suspicious Trends, Time Behavior, PTP Edit Violations, MUE Violations and Upcoding.

In addition to the AI detectors, the Query toolkit allows users to identify Mohs micrographic surgery and special stains utilization across all claims using the following criteria: 

    • Claim Type= Professional
    • Run Queries Over = Claims
    • Billing Specialties = Select All
    • Procedure Code, Custom Editor = (17311 OR 17312 OR 17313 OR 17314 OR 17315) AND (88312 OR 88313 OR 88314)
    • Provider Payment Received, Within this Range, Minimum = 1
References:

  1. CPT Manual (AMA Version) page 119.
  2. NCCI Manual: Chapter 3, Surgery Integumentary System CPT Codes 10000-19999: https://www.cms.gov/files/document/chapter3cptcodes10000-19999final112021.pdf

If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.

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