Documenting Mohs Surgery

Question:

What should be documented in my note to support billing for Mohs surgery?

Answer:

This is a great question. To support Mohs surgery, comprehensive documentation should include several key components:

Pre-operative Documentation:

• Detailed pathology report confirming the skin cancer diagnosis (basal cell carcinoma, squamous cell carcinoma, etc.)

• Clinical photography showing the lesion's size, location, and characteristics

• Patient history including previous treatments, recurrences, or incomplete excisions

• Documentation of high-risk features (location on face/genitals, size >2cm on trunk/extremities or >1cm on face, aggressive histologic subtypes, perineural invasion)

• Medical necessity justification explaining why Mohs is preferred over standard excision

Operative Documentation:

• Detailed operative report describing the procedure, number of stages required, and final defect size

• Stage-by-stage documentation with tissue mapping and frozen section results

• Real-time photographs of each stage and the final defect

• Pathology reports for each Mohs stage confirming margin status

• Documentation of any complications or unusual findings

Post-operative Documentation:

• Reconstruction plan and methods used for wound closure

• Post-operative care instructions and follow-up schedule

• Final pathology confirming complete tumor removal

• Patient education materials provided

Insurance and Administrative:

• Prior authorization if required by the insurance plan

• Appropriate CPT codes (17311-17315 for Mohs surgery stages, plus reconstruction codes)

• Documentation supporting medical necessity, particularly for lesions that might be considered for standard excision

This thorough documentation ensures proper patient care, supports insurance reimbursement, and provides a complete medical record for future reference.

*This response is based on the best information available as of 8/28/25.