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Checklist: Mohs micrographic surgery

This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for Mohs micrographic surgery services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.

Check

 Documentation description

 

 Documentation is for the correct beneficiary and date of service.

 

 Documentation is complete, legible, signed and dated by the physician or clinician.
  Physicians’ verification of training in Mohs surgery.
 

Documentation supports a medically necessary and reasonable need for the service billed through pre-procedure note and/or post procedure operative note that addresses the following:

  • Why the lesion will not be (was not managed by standard excision or destruction technique and (when applicable),

  • Why (when utilized or referred to as plastic surgeon) procedures for complex repair, adjacent tissue transfer or rearrangement, flap, or graft codes are employed.
  Documentation supports the options for care were discussed with the patient.
 

Documentation includes operative note with the following:

  • MMS technique

  • Location, number and size of the lesion(s)

  • Number of stages performed

  • Number of specimens per stage

  • Measurement of the primary lesion necessitating MMS

  • Any measurements n support of repair or related procedures

  • If defect requires reconstruction, the technique utilized
 

Documentation includes operative note with the following:

  • MMS technique

  • Location, number and size of the lesion(s)

  • Number of stages performed

  • Number of specimens per stage

  • Measurement of the primary lesion necessitating MMS

  • Any measurements in support of repair or related procedures

  • If defect requires reconstruction, the technique utilized
 

Documentation of pathology / histology includes the following:

  • First stage: if tumor present, depth of invasion, pathological pattern of the tumor, cell morphology;

  • Subsequent stages: if tumor characteristics are the same as first stage or if different from first stage a description of the differences.
  If applicable and required, submitted documentation should include a beneficiary waiver of liability.

 

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.