Four dermatology societies joined together to create the first appropriate use criteria for Mohs surgery, consenting that in two-thirds of nearly 300 possible scenarios the micrographic procedure is appropriate.
The American Academy of Dermatology (AAD) developed the appropriate use criteria (AUC) for 270 scenarios for Mohs surgery in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery, and the American Society for Mohs Surgery.
The main driver behind the creation of the 46-page document, which is the first of its kind for any test or treatment option in the field of dermatology, is Medicare, said Dr. Mark J. Zalla, a member of the report’s ad hoc task force that developed the indications.
"The intent of the criteria is to help us maintain the value of Mohs in terms of reimbursement," added Dr. Zalla, who is in private practice in Florence, Ky.
Use of Mohs surgery increased by 400% between 1995 and 2009. (Dermatol. Clin. 2012;30:167-75). "And when Medicare sees use of a specific code increasing significantly over several years, they get concerned," said Dr. Zalla. Some Medicare carriers have already threatened to impose certain criteria for Mohs surgery reimbursement. "And if one carrier does it, it’s possible that [the criteria will become applicable] nationwide," he said.
But Dr. Zalla and advocates for the procedure argue that the sharp increase doesn’t necessarily mean that it is being overutilized. Rather, it’s most likely the result of several factors, including the nation’s skin cancer epidemic and an increase in the number of fellows trained in Mohs surgery.
The ACMS has been ramping up its efforts to raise awareness about the surgery among payers and policy makers. The college has so far spent $20,000 in education lobbying this year, according to the Center for Responsive Politics.
"The bottom line is that dermatologists and Mohs surgeons are the good guys," said Dr. Brett M. Coldiron, president of ACMS and a member of the AUC ad hoc task force. "We are part of the solution, not the problem."
The scenarios represent roughly 85% of anticipated clinical scenarios, the authors noted in their report.
The members of a 17-member rating panel, made up of Mohs surgeons and non-Mohs dermatologists, scored the scenarios on a 9-point scale. Scenarios scoring 7-9 were deemed appropriate, those scoring 4-6 were uncertain, and those scoring 1-3 were inappropriate.
"Those clinical situations for which use of Mohs was rated as uncertain are areas ripe for productive clinical research," said Dr. Suzanne M. Connolly, chair of the AUC task force.
The document breaks down the appropriateness of Mohs surgery by the following skin cancer types:
• For 69 basal cell carcinoma scenarios, 53 were rated appropriate, 6 uncertain, 10 inappropriate.
• For 143 squamous cell carcinoma scenarios, 102 were rated appropriate, 7 uncertain, and 34 inappropriate.
• For 12 lentigo maligna and melanoma in situ scenarios, 10 were rated appropriate, and 2 uncertain.
• For 46 rare cutaneous malignancies scenarios, 35 were rated appropriate, 9 uncertain, and 2 inappropriate.
• Invasive melanoma was not included in the AUC "due to the complexity of the issue," according to the task force.
A small number of low-risk tumors in trunk and extremities were rated as inappropriate for Mohs surgery.
Dr. Zalla said he anticipates a good reaction to the AUC. "There will be some minor changes in practice for some surgeons," he speculated.
Florida dermatologist and Mohs surgeon Terrence A Cronin Jr. noted in an interview that he was not expecting the AUC to change his practice. "But I think, optimistically, that this will help the lay people in the insurance world have a greater understanding of where Mohs is often the best choice for the treatment of skin cancer," noted Dr. Cronin, who was a member of the AUC’s ratings panel.
The document was approved by all four of the societies’ boards during the American Academy of Dermatology’s annual meeting in March. It will be published in the Journal of the American Academy of Dermatology and Dermatologic Surgery later this year.