[Histonet] ACMS perspective on Aetna's new requirments.

Nicole Tatum nicole <@t> dlcjax.com
Thu Apr 12 12:32:30 CDT 2012

This is a letter From the American College of Mohs Surgery in reguards to
Aetna letter for CAP requiremnet.

April 5, 2012

I read your letter of March 23, 2012, outlining Aetna’s new requirement
for CLIA and CAP certification for certain pathology services with dismay.
I am very concerned these requirements could lead to lower cure rates,
increased tissue loss and scarring, and even unnecessary deaths in your
patients with problem skin cancer with Aetna insurance.

CAP certification will be almost impossible to achieve for small Mohs
Micrographic surgery frozen section laboratories. These labs can only be
CAP certified if directed by an anatomic pathologist or
dermatopathologist. Mohs surgeons, who have extensive additional training
in pathology, and training to run their laboratories, do not fit into
either niche. Mohs surgeons deal with the most difficult and recurrent
skin cancers.

Please find attached a copy of the CPT coding assistant from 2008
describing Mohs surgery, and detailing what services are included in it.
With your new restrictions, immunohistochemistry (CPT code 88342) cannot be
billed with Mohs surgery for malignant melanoma and spindle cell tumors.

This will restrict the use of Mart 1 immuno stains and other special
cytokeratin stains. This will result in lower cure rates and an increased
number of deaths. These stains on additional frozen sections are not part
of Mohs surgery, and are appropriately billed for separately.
In addition, Mohs surgeons will not be able to bill for the occasional
special stains on frozen sections (CPT code 8814) such as oil red O on a
sebaceous carcinoma, or toluidine blue (in addition to the hematoxylin and
Eosin stained frozen sections) to clarify an area of inflammation.
Performing these special stains on ambiguous frozen sections often saves
the patient additional surgery and tissue loss, and saves
Aetna money, because another stage of Mohs surgery is avoided. These
additional stains are not part of the Mohs surgery and are appropriately
billed for separately.

Denial of these CPT codes may result in more tissue being removed
unnecessarily, lower cure rates, higher recurrence rates, and potentially

Quality control of the frozen section laboratory is crucial, and mandatory
for CAP lab approval. This quality control involves processing of
“confirming” formalin sections off the frozen blocks of tissue is commonly
performed in Mohs surgery laboratories for quality control and
confirmation. This will no longer be a billable service (CPT
code 88305) per your letter.

This directly contradicts CAP own recommendations for the follow
up processing of frozen sections (see attached). These confirming formalin
sections are not part of Mohs surgery and are separately billable. Your
decision not to cover code CPT 88305 makes it impossible, or at a minimum,
fiscally prohibitive, to maintain quality control and to even
consider complying with the new CAP accreditation you are demanding in the
same letter.

>From the perspective of the American College of Mohs surgery, our patients
could continue to receive the best quality of care, and the overall cost
to Aetna may actually be lower (by avoiding additional stages of Mohs
surgery), if CPT Codes 88314, 88305, and 88342 were exempted for
providers who also bill the Mohs surgery CPT codes 17311 or 17313.

Brett Coldiron, M.D., F.A.C.P.
President American College of Mohs Surgery

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