Economics of a Dermatology Practice.

Understanding the economics behind any medical practice comes down to one basic concept: Profit = Revenue - Expenses. This article aims to demystify the details that underlie this simple formula and to provide the budding dermatologist the information and the tools needed to determine their own profitability in the "real world."

E/M Coding in 2021: The Times (and More) Are A-Changin'.

Major revisions for commonly reported office and outpatient evaluation and management (E/M) codes were implemented on January 1, 2021, by the American Medical Association and Centers for Medicare and Medicaid Services. The goal of these changes was to simplify and streamline these service codes, with time and medical decision-making (MDM) now being the sole determinants of the overall E/M level. We present an overview of the new guidelines, requirements, and code descriptors to aid in accurate documentation and billing. Additional resources are provided if further billing and coding questions arise.

Advocacy Update: Is Your Practice Equipped to Handle Looming Changes in Dermatopathology?

In July 2021, the Centers for Medicare & Medicaid Services (CMS) published a proposed fee schedule that will negatively impact practices that perform dermatopathology services. In this article, we review the proposed new and improved codes and values for pathology consultation codes as well as new payment rates. We also discuss the proposed 2022 quality payment program (QPP), and we provide an update on the 21st Century Cures Act (Cures Act) and its impact on dermatopathology reports.

Therapies for Psoriasis: Clinical and Economic Comparisons.

BACKGROUND: Clinical and economic comparisons of therapies for plaque psoriasis are regularly updated following each new devel- opment in the field. With the recent availability of a novel accessory (Multi Micro DoseTM [MMD®] tip) for the 308nm excimer laser (XTRAC®, Strata Skin Sciences, Horsham, PA), which can determine and deliver an optimal therapeutic dose (OTDTM) of ultraviolet-B light in an improved protocol, the need for comparative health-economic assessment recurs. To this end, a comprehensive evaluation of treatment-related costs was undertaken from the payer perspective. Results show that outcomes are influenced by many factors; most importantly, the severity and extent of disease, treatment selection, and patient preference, as well as compliance, adherence, and persistence with care. Among study comparators, the 308nm excimer laser – XTRAC – with its latest MMD enhancement, is safe and delivers incremental clinical benefits with the potential for significant cost savings. These benefits are particularly relevant today in the context of SARS-CoV-2 virus and the COVid-19 pandemic. J Drugs Dermatol. 2020;19(11):1101-1108. doi:10.36849/JDD.2020.5510.

The evolving maintenance of certification process: update on the financial status of the medical boards.

Medical board organizations have accumulated large asset balances, in part due to the monetization of physician board recertification, as well as capital gains in positive investment conditions. Physicians across the country have raised concerns regarding the effectiveness and efficiency of existing recertification processes, to which the American Board of Medical Specialties and independent accreditation boards have responded with newly instituted changes. The present article analyzes the publicly available F990 tax forms of the medical boards in an effort to provide data to the ongoing debate. Although some boards have begun to mobilize assets in recent years, many continue to accumulate wealth. It remains to be seen whether the new recertification programs will bring about change or perpetuate organizational wealth.

New diagnostic procedure codes and reimbursement.

With the implementation of the new Medicare Physician Fee Schedule on January 1, 2019, it can be beneficial for all practitioners to grasp an understanding of how reimbursement is determined. With the new Physician Fee Schedule also came new relative value units (RVUs) and new billing codes. Biopsy codes, in particular, were changed to reflect the complexity of the sampling technique (ie, tangential, punch, incisional). In this article, we explain RVUs and how they determine reimbursement. This article also highlights changes and additions to billing codes, specifically for biopsies and telemedicine services.

Assessment of Provider Utilization Through Skin Biopsy Rates.

BACKGROUND: There have been recent claims of overdiagnosis and unnecessary treatment in dermatology. One potential manifestation of overutilization would be providers who perform numerous biopsies per patient. OBJECTIVE: To identify the frequency of skin biopsy rate outliers. MATERIALS AND METHODS: Data on biopsy rates at the individual provider level were obtained from Medicare Provider Utilization and Payment Data Public Use Files. The total number of biopsies for each provider was obtained by summing the number of claimed biopsy services for each unique National Provider Identifier. The visit count for each provider was obtained by summing all evaluation and management services claimed. Provider biopsy rates were calculated by dividing the total number of biopsies associated with each National Provider Identifier by the corresponding visit count. RESULTS: The mean provider biopsy rate was 0.31 services per visit, or approximately 1 biopsy every 3 visits. Defining outliers as providers who averaged 3 or more biopsies per visit, there were 38 outliers out of 18,260 providers. Physicians had a lower mean biopsy rate than nonphysician clinicians (p = 1.70E-28). CONCLUSION: Contrary to claims, the authors' results do not indicate widespread overutilization of skin biopsy services.

Economic Analysis of a Noninvasive Molecular Pathologic Assay for Pigmented Skin Lesions.

Importance: A recently described noninvasive gene expression test (the pigmented lesion assay [PLA]) with adhesive patch-based sampling has the potential to rule out melanoma and the need for surgical biopsy of pigmented lesions suggestive of melanoma with a negative predictive value of 99% compared with 83% for the histopathologic standard of care. The cost implications of using this molecular test vs visual assessment followed by biopsy and histopathologic assessment (VAH) have not been evaluated. Objective: To determine potential cost savings of PLA use vs the VAH pathway. Design, Setting, and Participants: This health economic analysis performed from a US payer perspective was based on consensus treatment guidelines and fee schedules from the Centers for Medicare & Medicaid Services. Data for model input were derived from routine use of the test in US dermatology practices and literature. Participants included patients with primary cutaneous pigmented lesions suggestive of melanoma. Data were analyzed from February 8 to December 1, 2017. Main Outcomes and Measures: The primary analysis consisted of the relative reduction in costs of diagnostic surgical procedures for PLA vs VAH management. Additional analyses included stage-related treatment costs associated with delays in diagnosis. Results: In the cost analysis for this economic model, the relative reduction in surgical procedure costs (biopsy and subsequent excision), assuming $0 for the PLA to facilitate multiple comparison scenarios, was -$395 compared with VAH. The relative reduction in stage-related treatment costs associated with the PLA was -$433 compared with VAH, primarily associated with avoidance of delays due to false-negative diagnoses. Surveillance costs were reduced by -$119 with the PLA. The total cost of fully adjudicating a lesion suggestive of melanoma by VAH was $947. At a mean selling price reference point for PLA of $500, cost savings of $447 (47%) per lesion tested could be realized. Conclusions and Relevance: The results of this analysis suggest that the PLA reduces cost and may improve the care of patients with primary pigmented skin lesions suggestive of melanoma.

Incidence and prevalence of basal cell carcinoma (BCC) and locally advanced BCC (LABCC) in a large commercially insured population in the United States: A retrospective cohort study.

BACKGROUND: Accurate evaluation of basal cell carcinoma (BCC) in the United States was not possible before the 2011 release of BCC-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes. OBJECTIVE: We sought to describe BCC (including locally advanced BCC [LABCC]) incidence/prevalence and the characteristics of patients in a commercially insured US population. METHODS: This retrospective cohort study used Truven Health MarketScan database insurance claims. Patients, aged 18 years or older with 2 or more BCC claims at least 30 days apart from October 1, 2011, to September 30, 2012, were continuously enrolled in medical and pharmacy benefits for 12 months before and after the index claim. A specific algorithm was used to classify patients with LABCC. RESULTS: A total of 56,987 patients with BCC were identified (39,035 incident cases; 17,952 prevalent cases). Age-adjusted BCC incidence and prevalence were 226.09 and 342.64 per 100,000 persons, respectively. These values project to 542,782 patients (incidence) and 822,593 patients (prevalence) in the 2012 US population. LABCC was uncommon (471 cases identified; projected US incidence and prevalence: 4399 and 7940 patients, respectively). LIMITATIONS: Use of medical claims data and retrospective analysis are limitations. CONCLUSION: In a study designed to distinguish patients with LABCC from the general BCC population based on BCC-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes, 0.8% were found to have LABCC, the majority having pre-existing disease.

Maintenance of certification and the financial status of the medical boards.

BACKGROUND: The Maintenance of Certification (MOC) program proposed by the American Board of Medical Specialties (ABMS) gained approval in 2006. The implementation of this program will impact all physicians who are board certified. Therefore, The Financial Status of the Medical Boards is an increasingly relevant topic of discussion amongst all physicians and those interested in medical education and certification. With this study we aim to bring greater attention to the already publicly available financial status of the Medical Boards (MB) so that it can become part of the ongoing discussion of MOC. METHOD: We analyzed the yearly revenue, expenses, net gain or loss and end of year balance for the ABMS and its 24 MB, additional member boards, as well as the Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA) and Accreditation Council for Continuing Medical Education (ACCME) organizations. RESULTS: We have commented on notable trends based on the available IRS Form 990s spanning from 1997 to 2012. When comparing the most recently available reported end of year balance to the first available reported end of year balance, 87% (27/31) of the member boards have reported an increase. All three of the additional organizations studied, ACGME, AOA and ACCME reported an increase as well. CONCLUSIONS: It is clear from the data and analysis that the majority of MB have financially benefited from the MOC program. It remains to be proven whether or not this economic benefit will translate into an improvement in physician education and patient care.