Should the Surgeon Also Be the Pathologist for MOHS Surgery?

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.

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.

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.

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.

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).