Rules, Regulations and the End of Dermatology



Doctors have been targeted

The public does not know the rules healthcare providers have to follow. This is a sample of what’s coming in the very near future. Drastic cuts and limits to the scope of service offered by the practice of Dermatology threatens public safety and the very specialty of Dermatology itself.

If you need a simple boil removed, your doctor won’t get paid. If you have a freckle that looks like melanoma, your doctor won’t get paid in some cases. How many of you expect your doctor to work for free?

Dermatology is under siege

August 19, 2013

Never in the history of the American Academy of Dermatology (AAD) has the profession of Dermatology faced such an array of challenges. In the midst of unprecedented attacks from both regulators and legislators, there is public scrutiny of specialty reimbursement and the RUC process as CMS and private payers attempt to control health care spending.

The recently released 2014 proposed Medicare Physician Fee Schedule serves as a strong indication that the specialty will be subject to drastic cuts in the near future. Coupled with recent congressional efforts to eliminate our ability to perform in-office ancillary services, these actions compromise patient safety, and may undermine our ability to provide high-quality, integrated care for our patients.

It is not only reimbursement that is threatened, but our very scope of practice. We need to take action to preserve our ability to practice the full scope of dermatology for the benefit of our patients. And such action includes scrutinizing ourselves and our practice patterns.

The issues:

There is strong momentum in Congress, at CMS, and among private payers to control health care spending, and dermatology is vulnerable in several areas:

  1. Procedures and visits performed at the same time are under the microscope because of the perception of overutilization and overpayment. CMS and private payers are proposing that time associated with the cognitive portion of a procedure should be removed from the value of the procedure and questioning the payment of separate cognitive service on the same day. Private insurers are eliminating payment for either the procedure or the E&M visit, when both are performed on the same day – despite the fact that patients are often found to have multiple, separate issues.
  2. 10-day global visits. The 10-day follow-up visit to check on patients after treatment has become increasingly scrutinized because of the perception that follow-up visits rarely occur. A significant portion of the value of many procedural codes relates to the bundled follow-up visit.
  3. Destruction codes. We face potential devaluation of destruction codes for malignant, premalignant and benign lesions. Multiple facets of the current value of these codes are being challenged, and the codes are a major focus of attention because of high utilization. Please remember to report only medically necessary services to an insurer. For destruction of benign lesions, adhere to government regulations and private insurer rules. Inappropriate utilization of these codes makes them a prime target for devaluation and could result in the entire specialty losing the ability to care for patients with serious lesions.
  4. Mohs Micrographic Surgery has also become a target for policymakers to cut costs because of increased and sometimes inappropriate utilization. The AAD developed appropriate use criteria (AUC) to help guide members on appropriate utilization of Mohs. Despite the rising incidence of skin cancer, overutilization of this treatment remains an issue. Both the value of the codes and our continued ability to perform Mohs surgery are at risk. Changes in the rules for in-office ancillary services driven by rising utilization of dermatopathology codes could put Mohs into a regulatory gray zone.
  5. Dermatopathology is being scrutinized because utilization of pathology services (especially 88305) has skyrocketed. While we have concerns regarding the methodology used, a recent Government Accountability Office (GAO) reportfound that practices that bring dermatopathology in-house, bill many more biopsies to Medicare than they did prior to internalization of pathology. The implication is that financial gain is a factor in overuse of pathology services and Congress is considering restricting office-based pathology services as a way of controlling Medicare costs. Client billing for financial gain is also placing dermatopathology at risk and threatens the ability of dermatologists to bill globally for pathology services. Further devaluation of pathology codes is likely and our very ability to practice dermatopathology may be threatened. I urge you all to read the GAO report to see first-hand what our members of Congress are reading. We cannot dismiss the legitimacy of these concerns.
  6. Phototherapy code reduction. The 2014 proposed Fee Schedule proposes to cut reimbursement for dermatology-related phototherapy services by up to 50 to 60 percent. Cuts to phototherapy services will reduce our ability to treat patients with serious diseases, such as psoriasis, vitiligo, cutaneous lymphoma, and eczema.

I firmly believe that the vast majority of physicians work hard and simply want to be reimbursed fairly for the work they do. The wellbeing of the patient is our primary concern and no service or procedure should be performed solely to enhance the revenue of the provider. The majority of our members are at risk of losing both fair reimbursement and fundamental scope of practice because of the abuses of a few.

How AAD is responding:

AAD is responding to this changing environment and threats to our ability to practice the full scope of our specialty by:

  1. Strengthening our advocacy efforts — alone and in coalition with other specialties — to emphasize the patient value of office-based pathology, its role in Mohs surgery and the importance of clinicopathologic correlation. At the same time, we must acknowledge abusive practices and not waste advocacy capital defending them. We simply cannot defend practices that are indefensible.
  2. Developing comment letters to CMS as they refine and finalize their fee schedule. We are fortunate to have dedicated physician leaders with extensive experience in public policy and the development and valuation of CPT codes. Take the time to find out who is representing our specialty in Washington and thank them when you see them. View a full list of AAD committee and task force members.
  3. Working with patient advocacy groups to educate Congress about the impact proposed changes will have on quality patient care.
  4. Putting Mohs Micrographic Surgery Appropriate Use Criteria in front of payers, while continuing aggressive member education on applying them.
  5. Developing resources and educational programs to benchmark best practices and assist members who may question whether they overuse services.

The AAD is working to protect and ensure the continued viability of dermatology, and to prevent the erosion of appropriate, evidence-based practice patterns. However, members must understand that some practice patterns MUST change and others will be forbidden by government legislation because of abuses.

We must stand together to protect our ability to provide the full range of dermatological services to our patients. I call on all AAD members to join me in reaffirming our commitment to the highest level of professionalism by promoting evidence-based care, appropriate utilization of services, and life-long dedication to the ethical practice of medicine.

Here are a few things that all AAD members can do:

  • Take Action – Be Alert and Be Ready: Urge Congress to oppose efforts that threaten dermatologists’ ability to provide necessary services to their patients. Through the AAD’s Dermatology Advocacy Network (DAN) join your colleagues in responding when the AAD issues calls to action. Rep. Jackie Speier (D-Calif.) has recently introduced H.R. 2914, the Promoting Integrity in Medicare Act of 2013 which would limit our ability to provide pathology services. The AADA encourages members to log on to DAN to contact their members of Congress to oppose this legislation(Please note that the DAN website now requires your member ID without preceding zeros and birth date to login.)<
  • Study up: The AAD offers a suite of coding and reimbursement resources on its website and through various publications to help its members ensure that they are properly coding and documenting services through Medicare and Private Payers. Click on the links in blue for more information.
  • Ask questions: Take advantage of the Academy’s staff and resources. Read every issue of Derm Coding Consult and contact the AAD’s Regulatory and Federal Legislative Affairs staff at for help understanding changes to reimbursement and practice policies. (If you have forgotten your AAD website login information, reset it here.)
  • Meet the players. Get to know your federal and state legislators and local payer representatives. The AAD staff can help connect you. Get involved and help us represent dermatology well.
  • Demonstrate the value of our specialty to our primary care colleagues. As Congress grapples with the future of American medicine, we need to ensure that we remain relevant to national healthcare priorities. Every interaction with another physician is an opportunity to demonstrate our dedication and expertise in the diagnosis and treatment of skin disease.

All of medicine is moving through a time of tremendous change fraught with real and significant threats and the viability of our specialty is at risk. We all need to be aware and engaged.

Look for more on the issues raised here in upcoming issues of Dermatology World and Member to Member.

As President of the AAD, I feel obligated to alert you to the dangers our profession now faces and the essential role each of us plays in protecting our ability to care for our patients.

As a profession, we cannot tolerate inappropriate actions by a minority of our members that place our entire specialty at risk. We must act with unity and an eye towards providing the best care for our patients. Our specialty can prevail if we stand united and hold ourselves to the highest ethical standards within the practice of medicine. I call on each of you to join me in defending our future.

Dirk M. Elston, MD, FAAD
President, American Academy of Dermatology