Updates on Coding in Dermatology.

Correct coding is an important component of effective dermatology practice management. Over the past several years there have been updates to many commonly used codes within dermatology. This review highlights many of these updates, such as: The skin biopsy codes have been subdivided to reflect the different biopsy techniques. The definition of complex linear repairs has been updated and clarified. Outpatient and inpatient evaluation and management visits have new coding guidelines to determine level of care. Dermatopathology consultation codes have been updated and Category III codes related to digital pathology have been created. Understanding the details and nuances of each of these categories of codes is vital to ensuring appropriate coding is performed.

Inconsistent Associations Between Risk Factor Profiles and Adjuvant Radiation Therapy (ART) Treatment in Patients with Cutaneous Squamous Cell Carcinoma and Utility of the 40-Gene Expression Profile to Refine ART Guidance.

INTRODUCTION: National Comprehensive Cancer Network (NCCN) recommendations for adjuvant radiation therapy (ART) use are similar for High Risk and Very High Risk cutaneous squamous cell carcinoma (cSCC) with negative post-surgical margins. Although studies report reductions in disease progression following ART treatment, ART use is likely inconsistent when guided by available risk factors. This study evaluated the association of ART with clinical risk factors in ART-treated and untreated patients and showed the clinical utility of the 40-gene expression profile (40-GEP) for guiding ART. METHODS: A multicenter study of 954 patients was conducted with institutional review board (IRB) approval. The 40-GEP test was performed using primary tumor tissue from patients with either a minimum of 3 years of follow-up or a documented regional or distant metastasis. Unsupervised hierarchical cluster analysis identified patterns of clinical risk factors for ART-treated patients, then identified untreated patients with matching risk factor profiles. Results were cross-referenced to 40-GEP test results to determine utility of the test to guide ART. RESULTS: Analysis demonstrated inconsistent implementation of ART for eligible patients. Cluster analysis identified four patient profiles based on clusters of risk factors and, notably, matching profiles in ART-treated and untreated patients. Further, the analysis identified patients who received but could have deferred ART on the basis of 40-GEP test result and biologically low risk of metastasis, and untreated patients who likely would have benefitted from ART on the basis of their 40-GEP test result. CONCLUSIONS: ART guidance is not determined by the presence of specific clinicopathologic factors, with treated and untreated patients sharing the same risk factor profiles. cSCC risk determination based on NCCN recommendations for clinical factor assessment results in inconsistent use of ART. Including tumor biology-based prognostic information from the 40-GEP refines risk and identifies patients who are most appropriate and likely to benefit from ART, and those that can consider deferring ART.

Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Private Payer Engagement.

Private payers or commercial insurers play an ever-increasing role in physician payment policy. Effective interaction with these groups is an important part of organized dermatology's function.

Contribution of Beta-HPV Infection and UV Damage to Rapid-Onset Cutaneous Squamous Cell Carcinoma during BRAF-Inhibition Therapy.

PURPOSE: BRAF-inhibition (BRAFi) therapy for advanced melanoma carries a high rate of secondary cutaneous squamous cell carcinoma (cSCC) and risk of other cancers. UV radiation and α-genus human papillomavirus (HPV) are highly associated with SCC, but a novel role for ß-genus HPV is suspected in BRAFi-cSCC. Cutaneous ß-HPV may act in concert with host and environmental factors in BRAFi-cSCC. EXPERIMENTAL DESIGN: Primary BRAFi-cSCC tissue DNA isolated from patients receiving vemurafenib or dabrafenib from two cancer centers was analyzed for the presence of cutaneous oncogenic viruses and host genetic mutations. Diagnostic specimens underwent consensus dermatopathology review. Clinical parameters for UV exposure and disease course were statistically analyzed in conjunction with histopathology. RESULTS: Twenty-nine patients contributed 69 BRAFi-cSCC lesions. BRAFi-cSCC had wart-like features (BRAFi-cSCC-WF) in 22% of specimens. During vemurafenib therapy, BRAFi-cSCC-WF arose 11.6 weeks more rapidly than conventional cSCC when controlled for gender and UV exposure (P value = 0.03). Among all BRAFi-cSCC, ß-genus HPV-17, HPV-38, HPV-111 were most frequently isolated, and novel ß-HPV genotypes were discovered (CTR, CRT-11, CRT-22). Sequencing revealed 63% of evaluated BRAFi-cSCCs harbored RAS mutations with PIK3CA, CKIT, ALK, and EGFR mutations also detected. CONCLUSIONS: We examined clinical, histopathologic, viral, and genetic parameters in BRAFi-cSCC demonstrating rapid onset; wart-like histomorphology; ß-HPV-17, HPV-38, and HPV-111 infection; UV damage; and novel ALK and CKIT mutations. Discovered ß-HPV genotypes expand the spectrum of tumor-associated viruses. These findings enhance our understanding of factors cooperating with BRAF inhibition that accelerate keratinocyte oncogenesis as well as broaden the knowledge base of multifactorial mediators of cancer in general.

Enhanced cosmetic outcome with running horizontal mattress sutures.

BACKGROUND: Cutaneous sutures should provide good wound eversion, firm closure, and cosmetically elegant results. Simple running sutures are commonly employed in cutaneous surgery but may not always be effective in achieving wound eversion. OBJECTIVE: We compared the cosmetic results of simple running nonabsorbable sutures with running horizontal mattress sutures in primary closures of facial defects. METHODS: Fifty-five patients with facial Mohs surgery defects appropriate for primary multilayer repair were randomized into one of two arms. Either the superior or the inferior half of the wound was closed with a running horizontal mattress suture. The other half of the wound was closed with a traditional simple running suture. At 1 week, 6 weeks, and 6 months, the cosmetically superior half of the wound, if any, was blindly determined by the investigators. RESULTS: The running horizontal mattress suture was significantly more cosmetically pleasing than the simple running suture. Forty-seven patients completed the study. At the 6-month follow-up, 25 patients did better with the horizontal suture and 5 did worse, and with 17 patients, there was no clinically perceptible difference. The 6-week scores predicted the outcome at 6 months, but the 1-week scores did not. CONCLUSIONS: In primary closures of the face, the running horizontal mattress suture is a cosmetically elegant alternative to a traditional running cutaneous suture. The final scar appears smoother and flatter than those produced by traditional simple running sutures.

Anesthesia for office-based oculoplastic surgery.

BACKGROUND: Many common oculoplastic surgical procedures can be performed in an office-based setting. OBJECTIVE: To describe a system of local anesthetic use that provides superb anesthesia administered in a nearly painless manner. METHODS: Combined conjunctival, topical, and injected local anesthesia is used in outpatient oculoplastic surgical procedures. The use of optional adjuvant oral sedation can decrease pain and anxiety in selected patients. RESULTS: We have successfully employed our described system of local anesthesia for office-based oculoplastic surgery. CONCLUSION: In suitable patients, the shifting of operative location from the hospital or ambulatory surgery center to the office provides many benefits to both the patient and the surgeon.

Collagen remodeling after 585-nm pulsed dye laser irradiation: an ultrasonographic analysis.

BACKGROUND AND OBJECTIVES: Nonablative dermal remodeling is an evolving technology that has generated great interest among both laser surgeons and patients. Evidence indicates that dermal collagen formation is the key mechanism of action for the nonablative techniques. We studied, with ultrasound, new collagen formation after nonablative laser irradiation. METHODS: Ten patients with facial rhytids underwent a single treatment with a 585-nm pulsed dye laser. The patients were all female, ranging in age from 47 to 67, and were Fitzpatrick skin types I-III. Laser parameters were as follows: an energy fluence of 2.4 to 3.0 J/cm2, a pulse duration of 350 microsec, and a spot size of 5 mm with no overlap. Ultrasonographic assessments of dermal collagen were taken at baseline and at 30 and 90 days after treatment. RESULTS: Ultrasonography demonstrated an increase in dermal collagen after a single treatment with the 585-nm pulsed dye laser. The greatest degree of neocollagenesis occurred periocularly. CONCLUSION: A single treatment with a 585-nm pulsed dye laser appears to increase dermal collagen. This increase in dermal collagen can be assessed with noninvasive cutaneous ultrasound.

Standing cone avoidance via advancement flap modification.

BACKGROUND: Tissue redundancy manifesting as a standing cutaneous cone is a common surgical problem. OBJECTIVE: We describe modifications to traditional advancement flap design that allows for standing cutaneous cone avoidance. METHODS: In addition to traditional incisions employed in advancement flaps, an additional curvilinear incision is made along one or more limbs of the flap. By removing tissue along the length of the flap incision, redundant tissue is redistributed along the length of the incision. A standing cutaneous cone is thereby avoided. RESULTS: Use of the technique provides standing cone avoidance without lengthening a surgical scar. There has been no increase in flap failure or other complications with the described technique. CONCLUSION: The modified advancement flap allows for standing cone avoidance. Improved cosmesis can also be achieved when the modified flap limb is placed in a facial line or subunit junction.

Surgical rosacea.

BACKGROUND: Rosacea is a common cutaneous disease. The dermatologic surgeon will frequently encounter rosacea in the surgical patient. OBJECTIVE: To describe observations regarding surgical and wound care techniques that facilitate and improve outcomes in the rosacea patient. METHODS: We present a compilation of our clinical experience and observations regarding rosacea in the dermatologic surgery. CONCLUSION: Simple interventions such as disease recognition and treatment, proper wound care and suture selection, as well as patient counseling have proven beneficial in optimizing surgical outcomes in the rosacea patient.