I was just diagnozed with BCC and MOHS Surgery has been recommended. I am a self pay patient and the Dematologist stated that there will be a separate fee for the pathologist who has to be onsite. Is this normal or should I insist on a Surgeon who also acts as the pathologist? What kind of fees are usually associated with this procedure?
Should the Surgeon Also Be the Pathologist for MOHS Surgery?
Doctor Answers (10)
Moh's vs. frozen section
With modern frozen section techniques examining the edges of the specimen, the two techniques are very similar. They are both performed by fine physicians.
However, I prefer to have a board certified pathologist review all pathologic specimens rather than a dermatopathologist, a dermatoligist who has trained in Moh's surgery. There are enough borderline lesions that are difficult to interpret; I prefer to have a pathologist who lives and breathes pathology rather than a dermatologist who has also trained in the interpretation of pathology slides.
Having a reliable pathologist is critically important, in my opinion. I have personally seen a number of cases where a patient was "cleared" by various methods, yet they had considerable cancer still remaining. This is especially apparent at the Veteran's Hospital where patients have had considerable sun damage and often present with large or neglected cancers.
I also believe that there should a conduit in place for second opinions, or additional interpretations of difficult lesions. It is arrogant for any one doctor to think they can make a definitive diagnosis by visual inspection alone and not need further opinions on difficult pathologic specimens, especially if they require specialized stains, immunologic testing, etc. In some cases I have sent pathology specimens to a primary pathologist, our local medical center (UCLA), the Department Chief, and the AFIP (Armed Forces Institute of Pathology), and even specialized world experts such as Dr. Ackerman for melanoma diagnosis.
When a difficult lesion occurs, that is where experience and judgment come in. Do you proceed with the surgery? Do you do a temporary fix until the definitive pathology is ready, even if that takes weeks? Is your doctor prepared for all levels of reconstruction, for any surprises that may come up?
All issues worth considering.
Need for Pathologist for Mohs Surgery?
By definition Mohs surgery requires one individual to work as both surgeon and pathologist; if either of those roles is delegated to another doctor, by definition it is not Mohs surgery. If you are looking for a Mohs surgeon, I would recommend that you see a member of the American College of Mohs Surgery (ACMS). To be a member of the ACMS an individual has to complete an accredited fellowship in Mohs surgery, which includeds additional advanced training in Mohs surgery, reconstructive surgery and dermatopathology.
The Mohs Surgeon is the Pathologist
Mohs surgery by definition and to be billed as such is required to have the removal and the pathology performed by one single and same surgeon. Anything else is not Mohs surgery. The billing is not separate for the pathology it is all bundled into the removal and examination under the microscope. You do not get a separate bill from a pathologist. My suggestion is that if you desire the advantages of Mohs surgery including a 99% cure rate then you seek out a fellowship-trained Mohs surgeon to perform your surgery. The entire procedure from start to finish inclduing removal, microscopic examination and reconstruction is perfomed by the same person. Frozen section is not the same as Mohs surgery in anyway shape or form except for the fact that the tissue is frozen immediately for examination. The processing of the tissue is completely different in almost all cases where Mohs examines 100% of the margins in a horizontal fashion while "frozen section" looks at less than 1% of the margins in a vertical breadloafing manner. That being said, whether you are paying out of your pocket or your insurance is paying for your care you need to be sure you are getting what you are paying for.
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Mohs surgeon is both the pathologist and the surgeon, by definition
By the definition, Mohs surgeon is both the pathologist reading the frozen sections prepared by Mohs technician as well as the surgeon perform the excision. Mohs micrographic surgery is the standard of care for non-melanoma skin cancers on the face and neck. The insurance reimbursement bundles both pathology and surgical services. If your 'mohs surgeon' needs a pathologist onsite, you should look for another experienced Mohs surgeon.
Mohs surgery implies that the physician will act as both the surgeon and the pathologist
Hi Marcia72Q, Mohs surgery is a technique in which the dermatologist surgically removes the skin cancer and then reads the pathology. There is one fee which covers both components of this procedure. There will likely be the need for a surgical reconstruction or repair of the defect created from surgical removal of the tumor and that is typically not included in the fee for Mohs surgery.
I would strongly recommend finding a fellowship trained Mohs surgeon to treat your BCC as mohs surgery affords the highest cure rate because it give the surgeon the greatest control of the tissue margin whilst sparing the greatest amount of healthy tissue. This ensures for a lower recurrence rate and a frequently smaller scar than is afforded from other methods of treating non-melanoma skin cancer such as conventional excision. Check the American College of Mohs Surgery website to find a Mohs surgeon near you.
The Mohs Surgeon is the pathologist and the surgeon
By it's very definition, "Mohs surgery" implies that the surgeon (dermatologist) is the same one cutting as is acting as the pathologist to interpret the frozen section margins. If you are told that you are having "Mohs surgery" yet there is a separate pathologist from the surgeon interpreting the frozen sections, then most likely you are not being treated with Mohs surgery. In that scenario, you are having "frozen sections" performed by a pathologist that are most likely oriented vertically versus horizontally (typically Mohs sections).
Surgeon and pathologist for Mohs Surgery
Dr. Krant hit the nail right on the head. Mohs Surgeons examine 100% of the tissue margin. Standard frozen section techniques typically examine less than 1%. Peer reviewed studies have shown time and time again that the cure rate with Mohs Surgery for non-melanoma skin cancer is greater than any other technique.
Mohs surgery surgeon IS the pathologist
As most of the above answers state, Mohs micrographic surgery for skin cancer means by DEFINITION, the Mohs surgeon is also the pathologist reading slides for THAT particular skin cancer surgery case. The reason for this is that the surgeon knows best the orientation and location of the tissue, and the quality of the surrounding skin on the patient, for the best "clinicopathologic" correlation of what is under the microscope, to what is going on with the patient.
A properly, officially fellowship-trained Mohs surgeon is equally, and likely MORE, qualified to read the tissue because we have training in the reading of frozen sections that are oriented horizontally in the Mohs fashion, rather than the "bread-loafing" slices traditionally done with permanent section pathology reading. This gives a more complete 100% view of the tissue borders, rather than sample sections.
A surgeon who says that a separate pathologist is on site reading slides... is NOT performing legal Mohs surgery. The surgeon may perform the removal, and have a pathologist read the slides, but may NOT bill the removal as a "Mohs layer". The Mohs reimbursement codes already include a fee for removal, preparation, and pathology reading by the surgeon herself.
For a listing of official fellowship-trained Mohs surgeons in your area, go to www.MohsCollege.org.
In order to be a Mohs surgeon, by definition, the surgeon must act as both the physician and the pathologist. There is one fee that covers both services. A Mohs surgeon does not have a separate fee for the pathologist. If this is the case, you are not going to a Mohs surgeon. You can find one who is fellowship-trained (a must) and approved by the Mohs College at the Mohs College website. You can search by the area in which you live. In order to be a approved by the Mohs College, you must have trained in this technique which includes a separate pathology piece. BCC treatment is the bread and butter of a Mohs surgeon -- just make sure you go to a Mohs College trained surgeon and not someone simply posing as one.
By definition, with Mohs surgery, the same treating physician functions as both the surgeon and pathologist. There should be a single charge for the entire removal of the skin cancer (including tumor excision and pathology). There would probably be a separate charge for repair of the defect following Mohs surgery.
I hope this makes sense.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.