Update on CMS Ruling Regarding Reimbursement for Multiple Mohs Procedures

By now you have heard the the Final Rule Physician Fee Schedule is out at http://www.cms.hhs.gov/physicianfeesched/downloads/CMS-1385-FC.pdf

Page 179 states:

2. Application of Multiple Procedure Reduction for Mohs Micrographic Surgery (CPT Codes 17311 through 17315) .

Under the multiple procedure payment reduction policy, reimbursement for subsequent surgical procedures performed during the same operative session by the same physician is reduced by 50 percent. The Mohs surgery codes have been exempt from the multiple procedure payment reduction rules since the inception of the PFS (56 FR 59602, November 25, 1991).

The CPT Editorial Panel reviewed all of the codes on the list of codes exempt from the multiple procedure payment reduction (the “-51 modifier exempt list”) to identify which codes should be exempt from the multiple procedure payment reduction rules. Based on the revisions to the code descriptors and a clearer understanding regarding the technical elements of the procedure, in CY 2007, the CPT Editorial Panel removed the Mohs procedure from the -51 modifier exempt list. The codes for Mohs surgery were revised to take into account the different level of physician work intensity involved based on anatomic site. The RVUs associated with the codes for each anatomic location were recommended by the RUC, as they are for other procedures, after a thorough discussion by the RUC of all aspects of the service. Work RVUs were developed for each Mohs surgery base code based on an assumption that each code is performed separately.

Because the work RVUs for these services do not take into account the efficiencies that occur when multiple procedures are performed in one session, we do not believe that these codes should continue to be exempt from the multiple procedure payment reduction. Therefore, we proposed to eliminate the modifier -51 exemption and apply the multiple procedure payment reduction rules to these codes.

Comment: We received comments supporting our proposal and expressing the belief that our proposal is fair and consistent with our multiple procedure payment policies already affecting a wide range of procedures with codes in the Surgery/Integumentary System of CPT. Many commenters opposed our proposal to eliminate the modifier -51 exemption and apply the multiple procedure payment reduction to these codes. These commenters believed that eliminating these codes from the modifier -51 exempt list would negatively impact Medicare beneficiaries’ access to timely and quality care, and could lead to increases in pathology charges and increase the amount spent on multiple facility fees, thereby raising the overall cost of treating an individual with skin cancer. In addition to these concerns, many of the commenters do not believe we have sufficient justification to make the change, and suggest that this is an arbitrary decision. Further, the commenters asserted that the AMA-RUC and CPT decisions were in error and should not be followed.

Response: We verified with the CPT Editorial Panel that the application of the modifier -51 exempt status indicator, and subsequently, the inclusion of this series of codes (CPT codes 17311 through 17315) in Appendix E, Summary of CPT Codes Exempt from Modifier 51, of the 2008 CPT codebook would not be carried forward with the new series of codes created in 2007. The CPT panel confirmed with us that the exclusion of these codes from Appendix E was not an error. The AMA-RUC reviewed and valued the new and existing codes for Mohs surgery. Upon completion of a thorough review and discussion of the Mohs codes, the RUC valued these codes with the full understanding these codes were removed from the modifier -51 exempt list and would be subject to the multiple procedure payment reduction as well.

We believe the CPT Editorial Panel and the Mohs workgroup on the CPT Editorial Panel gave considerable time, effort and discussion in the creation of the new and existing codes for Mohs surgery. We also believe the AMA-RUC carefully reviewed the rationale and deliberations which lead to the creation of new Mohs surgery codes. In addition, we believe the specialty society had ample time and opportunity to express its point of view to both the CPT Panel and the AMA-RUC. As a result of the revisions to these codes and their respective valuation, we do not believe they should continue to be treated differently from other codes in the Surgery/Integumentary System section of the CPT book and see no reason not to accept the recommendations provided by the CPT Panel and AMA-RUC. Therefore, we are finalizing our proposal to eliminate the modifier -51 exemption and apply the multiple surgery procedure payment reduction rules to these codes.