Expert Consensus on Nail Procedures and Selection of CPT Codes.

BACKGROUND: Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE: To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS: A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS: Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS: Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION: Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Treatment of cutaneous basal cell carcinoma with combined laser extirpation and methyl aminolevulinic acid: five-year success rates.

INTRODUCTION: Basal cell carcinoma is the most common cancer. Excisional surgery is associated with a high clearance rate, at the expense of significant functional and aesthetic morbidity, especially within the T-zone or for extensive lesions. We report five-year follow-up outcomes for carbon dioxide laser extirpation of cutaneous basal cell carcinoma, assisted by immediate methyl aminolevulinate photodynamic therapy and cost-benefit considerations. MATERIALS AND METHODS: Retrospective cohort database analysis of adult patients with biopsy-proven primary cutaneous basal cell carcinoma, completing five years of follow-up. Direct per-lesion cost was compared with conventional wide local excision. Patients with morphoeic basal cell carcinoma were excluded. RESULTS: Treated lesions were up to 1% total body surface area and up to 3.8mm (1.38 ± 0.695cm, mean ± standard deviation) in biopsy-proven depth. At the five-year follow-up mark, 93.6% of treated areas remained free of recurrence. Nodular basal cell carcinoma was the most common subtype (41.5%). A mean tumour depth greater than 2 ± 0.872mm was significantly associated with recurrence (Mann-Whitney, p = 0.0487). For a service delivered through the NHS at 2015 prices, we report a 43% saving, equating to a saving of £235 per basal cell carcinoma or a national annualised saving of £70 million by 2025 for the NHS. CONCLUSION: Our results suggest that CO2-assisted photodynamic therapy is non-inferior to excision but may offer better functional and cosmetic preservation at a fraction of the direct like for like cost of operative surgery. Investigation of this method by randomised controlled methodology is warranted.

A Novel Absorbable Stapler Provides Patient-Reported Outcomes and Cost-Effectiveness Noninferior to Subcuticular Skin Closure: A Prospective, Single-Blind, Randomized Clinical Trial.

BACKGROUND: Deep dermal suturing is critical for scar quality outcomes. The authors evaluated a new, fast medical device for dermal suturing, with the hypothesis of noninferiority with regard to clinical scar and cost-effectiveness. METHODS: A prospective, patient-blind, randomized, multicenter noninferiority study in 26 French hospitals was conducted. Patients were randomized 1:1 to suturing with conventional thread or a semiautomatic stapler. The Patient Scar Assessment Scale was rated at 3 months for primary endpoint effectiveness. Secondary endpoints were cost-effectiveness of the two suturing methods, prevalence of complications, suturing/operating time, Observer Scar Assessment Scale and Patient Scar Assessment Scale score, scar aesthetic quality 18 months after surgery, and occupational exposure to blood during surgery. RESULTS: Six hundred sixty-four patients were enrolled, 660 were randomized, and 649 constituted the full analysis (stapler arm, n = 324; needle arm, n = 325). Primary endpoint Patient Scar Assessment Scale score in the stapler arm was not inferior to that in the needle arm at 3 months or after 18 months. The mean operating time was 180 minutes in the stapler arm and 179 minutes in the needle arm (p = not significant). The mean suturing time was significantly lower in the stapler arm (p < 0.001). There were seven occupational exposures to blood in the needle arm and one in the stapler arm. The two arms did not differ significantly in terms of complications (p = 0.41). The additional cost of using the device was &OV0556;51.57 for the complete-case population. CONCLUSION: Wound healing outcome was no worse than with conventional suturing using a semiautomatic stapler and associated with less occupational exposure to blood. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Medical and socioeconomic challenges of private dermatocosmetology clinics during COVID-19 pandemic: A survey from Turkey.

BACKGROUND: Coronavirus 2019 (COVID-19) disease has rapidly spread worldwide with a multitude effects on daily life. Since the transmission risk increases with close contact, some cosmetic procedures are considered high risk and majority of them had to be postponed or canceled in private dermatocosmetology clinics especially during the heavy period of the outbreak. AIMS: We aimed to document the medical and socioeconomic problems emerged in dermatocosmetology clinics in Turkey caused by COVID-19 pandemic and to discuss the management strategies taken by dermatologists. PATIENTS/METHODS: This survey research was conducted with 100 dermatologists who work in private dermatocosmetology clinics. The survey included 38 questions about office re-arrangements including patient admission and office environment, safety precautions taken for cosmetic procedures, management of clinic staff, and financial impact of the pandemic. RESULTS: A remarkable decrease in major cosmetic interest was reported in private clinics; meanwhile, there was an increase in applicants for noncosmetic dermatological complaints. The most avoided cosmetic procedures were application of skin care devices, lasers, chemical peeling, and thread lifting, while botulinum toxin injection was the most performed procedure. Nearly half of the participants had severe financial damage. Of the participants, 55% reported that they worked anxiously during this period and 60% believed that they managed the early period of the pandemic successfully. CONCLUSION: Private dermatocosmetology clinics have to work in a totally different period that they have never experienced before. The pandemic has had serious impacts on both medical and socioeconomic issues which had to be managed carefully.

Skin Cancer Excision Is More Efficient and Cost Effectivein a Specialist Secondary Care Service.

Aim To compare the relative efficiencies of skin excisions in primary and secondary care. Methods We compared the benign: malignant ratio for specimens referred by General Practice, General Surgery and the Skin Cancer Service to the regional pathology laboratory over one month. We used cost minimization analysis to compare the relative efficiencies of the services. Results 620 excisions were received: 139 from General Practice, 118 from General Surgery and 363 from the Skin Cancer Service. The number (%) of malignant lesions was 13 (9.4%) from General Practice, 18 (15.2%) from General Surgery and 137 (37.7%) from the Skin Cancer Service. Excision was cheaper in General Practice at €84.58 as compared to €97.49 in the hospital day surgical unit. However, the cost per malignant lesion excised was €1779.80 in general practice versus €381.78 in the Skin Cancer Service. Conclusion Our results indicate that moving skin cancer treatment to General Practice may result in an excess of benign excisions and therefore be both less efficient and less cost effective.

Racial differences in time to treatment for melanoma.

BACKGROUND: Longer time from diagnosis to definitive surgery (TTDS) is associated with increased melanoma-specific mortality. Although black patients present with later-stage melanoma and have worse survival than non-Hispanic white patients, the association between race and TTDS is unknown. OBJECTIVE: To investigate racial differences in time to melanoma treatment. METHODS: Retrospective review of the National Cancer Database (2004-2015). Multivariable logistic regression was used to evaluate the association of race with TTDS, controlling for sociodemographic/disease characteristics. RESULTS: Of the 233,982 patients with melanoma identified, 1221 (0.52%) were black. Black patients had longer TTDS for stage I to III melanoma (P < .001) and time to immunotherapy (P = .01), but not for TTDS for stage IV melanoma or time to chemotherapy (P > .05 for both). When sociodemographic characteristics were controlled for, black patients had over twice the odds of having a TTDS between 41 and 60 days, over 3 times the odds of having a TTDS between 61 and 90 days, and over 5 times the odds of having a TTDS over 90 days. Racial differences in TTDS persisted within each insurance type. Patients with Medicaid had the longest TTDS (mean, 60.4 days), and those with private insurance had the shortest TTDS (mean, 44.6 days; P < .001 for both). CONCLUSIONS: Targeted approaches to improve TTDS for black patients are integral in reducing racial disparities in melanoma outcomes.

Cutaneous laser surgery for secondary burn reconstruction: Cost benefit analysis.

Thermal disease presents a major burden to individual patient morbidity, healthcare cost as well as to over all economy. Burns also also represent a significant per-patient utlilisation of finite healthcare resources. Secondary complications in these patients, such as multiple drug resistant organisms, may have a devastating effect. Laser surgery has recently come of age as an optimal tool in the secondary reconstruction of burn injury, that is able to simultaneously address significant sheet scar tightness, hypertrophic, atrophic, and keloid complications, pruritus, microstomia, ectropion, skin graft honeycombing, and improve range of movement whilst reducing the risk of infection to <1%. Yet, cutaneous laser surgery is often underutilised due to the perceived concerns about the sustainability of a new service with relatively high startup cost. We present a dual methodology to explore this concern: an evidence-based background review of the last 5 years of current best evidence, and a 22-year cost-analysis comparison at an established, high volume UK Centre of reconstructive surgery. We report that fiscal viability for laser surgery services for secondary burn reconstruction is supported by: level 2 (one systematic review) level 4 evidence (2 studies) and level 5 evidence (expert reports). Evidence over 22 years from an established super-regional NHS laser centre shows that introduction of this service led to sustained and substantial cost saving, producing excellent surgical results at a fraction of the cost of traditional surgery. Analysis of the potential dollar-effect of these advantages to the general population supports state investment in expertise and capital equipment as a medium to long-term cost saving strategy, which may also aid re-integrating patients into the workforce making a meaningful contribution to the economy.

Assessing the Feasibility of an Alternative Payment Model for Mohs Micrographic Surgery at an Academic Center.

BACKGROUND: Mohs micrographic surgery (MMS) is a cost-effective treatment for nonmelanoma skin cancer that bundles costs for surgical excision, tissue processing, and histopathological interpretation. A comprehensive MMS bundle would include all aspects of an episode of care (EOC), including costs of reconstruction, preoperative, and postoperative care. OBJECTIVE: To assess the feasibility of an alternative payment model for MMS and reconstruction. METHODS: Retrospective chart review and payment analysis for 848 consecutive patients with 1,056 tumors treated with MMS. Average Medicare payment of an EOC was compared with bundles based on specific repair types. RESULTS: The bundle for a flap/graft repair averaged $1,028.08 (confidence interval [CI] 95% $951.37-1,104.79), whereas the bundle for a linear closure (LC) averaged $585.07 (CI 95% $558.75-611.38). The average bundle including all repairs was $730.05 (CI 95% $692.31-767.79), which was statistically significant from both the flap/graft and LC bundles. CONCLUSION: Bundling surgical repairs with MMS based on an average payment does not represent the heterogeneity of the care provided and results in either underpayment or overpayment for a substantial portion of cases. Consequently, EOC payments bundling MMS and surgical repairs would inaccurately reimburse physicians for work completed. Current payment methodology allows for accurate payment for this already cost-effective therapy.

Ojo clínico vs. gold standard / Trained eye vs. gold standard

OBJETIVO: Conocer el grado de correlación entre el diagnóstico clínico previo al proceso de cirugía menor y su concordancia con los resultados de anatomía patológica, al igual que conocer los datos de cirugía de escasa trascendencia clínica frente a la realmente necesaria y coste-efectiva. MATERIAL Y MÉTODO: Para ello realizamos un estudio descriptivo, observacional, retrospectivo y transversal de las actividades de cirugía menor de una consulta del Centro de Salud Ciudad Real I. RESULTADOS: Se remiten 124 piezas para su diagnóstico histológico, de las cuales los principales diagnósticos clínicos son: nevus melanocíticos intradérmicos (34,67%), queratosis seborreica (11,30%) y quistes epidermoides o sebáceos (10,48%). Se obtiene una correlación clinicopatológica del 68%. Se han seguido los protocolos del centro de trabajo para la realización de este estudio en relación con la confidencialidad de los datos. CONCLUSIONES: Analizamos estos resultados y los comparamos con otros trabajos similares realizados en el ámbito de la cirugía menor en atención primaria, pudiendo afirmar que existe una buena correlación entre el diagnóstico clínico inicial y los resultados anatomopatológicos

OBJECTIVE: To determine the degree of correlation between the clinical diagnosis prior to the minor surgery process and its concordance with the results of histopathology report, as well as to determine the surgical data of little clinical importance compared to that which is really necessary and cost-effective. MATERIAL AND METHOD: A descriptive, observational, retrospective and transversal study was conducted of the Minor Surgery Activities of a clinic in the Ciudad Real Health Centre I. RESULTS: A total of 124 surgical specimens were sent for clinical diagnostic comparison, of which, the main clinical diagnoses were: intradermal melanocytic nevi (34.67%), seborrheic keratosis (11.30%), and epidermoid or sebaceous cysts (10.48%). A correlation of 68% was obtained. The protocols of the work centre have been followed to carry out this study in relation to the confidentiality of the data. CONCLUSIONS: These results were analysed and compared with other similar works performed in the field of minor surgery in Primary Care, being able to affirm that there is a good correlation between the initial clinical diagnosis and the histopathology results

Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post-Bariatric Surgery Population.

BACKGROUND: Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post-bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post-bariatric surgery population. METHODS: Post-bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body. RESULTS: A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the "desire" population; 44.1 percent of these patients met the weight criteria. CONCLUSIONS: Post-bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.

The doctor's office is the best setting for most cutaneous procedures.

Although most dermatologic procedures are done in an office setting, some providers are performing them instead in ambulatory surgery centers (ASCs). This relocation of care comes with significantly higher expenses for patients and insurers. Compounding the issue of increased costs is the paucity of evidence demonstrating better outcomes associated with the use of ASCs. The most common cutaneous procedures have low complication rates when performed in an office setting and regular use of ASCs for these procedures is not justified.

Comparison of Costs and Outcomes for In-Office and Operating Room Excision of Nonmelanoma Skin Cancer.

INTRODUCTION: With increasing health care expenses and limited resources, it is important to evaluate potential means of reducing cost while maintaining efficacy and safety. The purpose of our study was to compare the cost and outcomes of surgical excision of nonmelanoma skin cancer (NMSC) in the operating room versus an outpatient procedure clinic. METHODS: A retrospective review of patients undergoing excision of biopsy-confirmed NMSC at the Miami Veterans Affairs Hospital between December 1, 2015, and December 1, 2016, was completed. Patients treated in the operating room and procedure clinic were included. Treatment outcomes were assessed for all identified patients. Patients undergoing excision and primary closure were included for cost comparison.Procedure costs were estimated using Current Procedural Terminology codes for treatments provided and the 2017 conversion factor of $35.7751. If a second operation for positive margins was necessary, cost to treat the lesion included costs from both procedures. If multiple lesions were treated, total cost was divided by the number of lesions to calculate cost per lesion treated. Costs per lesion managed in the operating room and clinic were compared using the Student t test. RESULTS: Sixty-five patients underwent excision of 94 NMSCs in the operating room. Nineteen patients underwent excision of 20 NMSCs in the procedure clinic. One patient treated in the clinic required re-excision in the operating room with frozen section for a positive margin.Thirty-three patients managed in the operating room and 19 patients managed in the procedure clinic were included for cost analysis. Average costs per lesion excised in the operating room and procedure clinic were calculated to be $1923.43 ± 616.27 and $674.88 ± 575.22, respectively (P < 0.001). CONCLUSIONS: Excellent oncologic outcomes were achieved for both operating room and procedure clinic excision. Excision in the operating room excision was significantly more expensive than in the procedure clinic. Excision in a procedure clinic offers an opportunity to reduce costs while maintaining quality care.

Skin shop: A new model for high-volume skin cancer care.

INTRODUCTION: Non-melanoma skin cancer incidence is increasing in New Zealand. Increased cost of care has led to service pressure and a review of models of care. A high-volume skin surgery service at Waikato Hospital has been developed to reduce service costs. This study examines the oncological safety of the new model. METHODS: Prospective data for all skin lesions excised were collected from December 2014 to December 2016. Primary outcomes were rate of complete excision, rate of incomplete excision and rate of narrow excision. RESULTS: A total of 2076 lesions were excised: 92% were complete, 4.2% were narrow and 3.2% were incomplete. CONCLUSION: The rate of narrow and incomplete excisions was low in a service delivered by supervised surgical registrars. The Skin Shop model is safe, inexpensive and suitable for adaptation to safely reduce the cost of skin cancer surgery.