Mohs Surgery Question

Question:

We are having difficulty determining what needs to be documented in the Mohs procedure not to make sure we are compliant with our documentation.

Answer:

The procedure note for Mohs Surgery should always contain

1. Indication for procedure
2. Biopsy results
3. Location of lesion
4. Number of lesion(s)
5. Size of the lesion(s),
6. Number of stages performed
7. Number of specimens per stage
8. Type of closure

In addition, the first stage must describe the histology of the specimens taken including:
Depth of invasion

1. Pathological pattern
2. Cell morphology
3. Perineural invasion/presence of scar tissue (if applicable)

*This response is based on the best information available as of 04/13/23.