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Last Modified: 5/18/2023 Location: FL, PR, USVI Business: Part A, Part B

Checklist: Mohs Micrographic Surgery

This checklist is intended to provide Healthcare providers with a reference for use when responding to Medical Documentation Requests for Mohs Micrographic Surgery services. It is not intended to replace the published guidelines. Healthcare Providers retain responsibility to submit complete and accurate documentation.

Check
Documentation description
 
Documentation is for the correct beneficiary.
 
Documentation is for the correct date of service.
 
Documentation contains a valid and legible signature of the MD or DO performing the service.
 
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.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.