Practice Management

Q: I have known for quite a while that there are site-specific codes for biopsies. I don't know why I never used them but perhaps I was a little afraid to try something new (new to me, that is).

San Diego - Electronic medical records are more efficient than paper charts, but dermatology practices have been slow to catch on because of its costs, said Lawrence Martinelli, M.D. He said EMRs can actually save time and money for physicians who learn to adapt their office systems and buy only what they need. He spoke at the 41st Infectious Disease Society of America annual meeting here.

It's no big news to anyone doing medical billing that getting paid gets more and more time consuming. It seems that each month carriers devise new schemes not to pay us. The latest one is that CPT code 17000 is denied when billed with another service, but 17003 is paid. When asked why the 17000 code was not paid, carriers state it is bundled into the other surgical service billed, such as 11100. They state they are following CPT guidelines. Where is that written?

Does this sound familiar? Every year at Christmas time, you make a decision to provide a bonus to your employees. You check with your accountant or office manager to see what you gave last year, and you increase the amount from 5 percent to 15 percent, depending on the profitability of the practice.

Dermatologists who administer chemotherapy and other drugs in their offices could see significant reductions in reimbursement levels as a result of an effort by the federal government to curtail Medicare's costs for drugs used to treat cancer.

Las Vegas - Though Medicare reform is the hostage of legislative gridlock, and tort reform is the victim of pre-election year inertia, American Academy of Dermatology President Raymond L. Cornelison Jr., M.D., has at least one piece of positive news for dermatologists. According to Dr. Cornelison, the AAD's recently formed Ad Hoc Task Force on Skin Care for Developing Countries, in conjunction with the Centers for Disease Control (CDC), in Haiti has begun an initiative providing for volunteer dermatologists to train primary care givers to treat filoriasis.

Despite the trend over the past decade for the formation of larger and larger group medical practices, more than 70 percent of dermatologists still practice in one- or two-doctor offices. For a time, young physicians shied away from becoming solo practitioners, but once again, more are considering the possibility of starting or taking over solo dermatology practitioners.

Q: Is there a way for me to charge for dressing changes in my office?

Physicians, including dermatologists, would face a 4.2 percent cut in Medicare reimbursement levels if a proposed payment update published in August by the Centers for Medicare & Medicaid Services (CMS) takes effect.

Q: I recently saw a minor patient's mother in our office. The minor patient is under my ongoing care for acne. I spent approximately 15 minutes reviewing the patient's condition, prognosis, and various options for treatment including Accutane therapy. I also provided the mother with several new prescriptions for her son. Should I bill this to the insurance company under the mother's name or under the patient's name?

The January FDA clearance of Biogen Inc.'s Amevive (alefacept) for thetreatment of moderate-to-severe chronic plaque psoriasis officially usheredin the era of biologic treatments for dermatologists. Amgen Inc.'s biologic,Enbrel (etanercept), FDA-cleared for treating psoriatic arthritis, has alsobeen prescribed (off-label) for psoriasis. Amevive, administered by IM injectionor IV infusion in the physician's office, is purchased directly from Biogenby the physician or institution while self-injected Enbrel is purchasedby the patient at the pharmacy.

The January FDA clearance of Biogen Inc.'s Amevive (alefacept) for the treatment of moderate-to-severe chronic plaque psoriasis officially ushered in the era of biologic treatments for dermatologists.

Q: As HIPAA moves ahead at full speed, it has brought my attention to many other issues in our practice ?? among them chart audits. We have four physicians and two physician assistants in our practice. I plan to perform chart audits personally but don't know where to start. How do I get started?

As Congress moves toward possible approval of a new prescription drug program for Medicare recipients later this summer, how payments for cancer drugs and therapeutic services are determined may well hang in the balance.

Q: Recently it seems I am getting a significant number of patients whose appointments are very time-consuming. Although I can quickly ascertain their chief complaints, do the examination, and determine the treatments, it takes a long time to go over the various diagnoses, the treatment options, and risks. Frequently, I go over the information two or three times before I can leave the exam room. I'm unclear about billing visits based on time. Must I meet the regular documentation criteria in addition to charting the time I spent? How is time documented? Do I count the time spent with the patient during the entire encounter or do I separate out the time I spent discussing diagnoses, treatment options, etc.?

Q: I am aware that there are several "site specific" biopsy codes that can be used by dermatologists, such as biopsy of the ear (69100), penis (54100), eyelid (67810) and lip. My question regards the CPT code 40490 (biopsy of the lip).

There are signs that House Republicans and the Bush Administration may be preparing to pull out the stops to pass malpractice reform legislation this year as a way to placate physicians who face another projected reduction in Medicare reimbursement levels next year.

HIPAA is finally in effect! I must say this has been a momentous day in my office, as we have been busily preparing for the ultimate in patient privacy protection for the past year. Even though my office had to file an extension, as did all other dermatologists and governmental agencies, I assure you we have a plan that will "knock your socks off," as we commonly say in North Carolina. Prior to this time, I used to lay awake at night wondering who was going to break into my office and steal patient charts. Why, one of my recurring nightmares was opening the office door, only to find a completely bare chart rack. Can you imagine the horror of having to report this catastrophe to the police? But worry no more, I sleep at night knowing that my office is under 24-hour surveillance by a security guard and my HIPAA

Action by Congress last month wiping out the expected 4.4 percent Medicare reimbursement cut and replacing it with a 1.6 percent increase came just in time for doctors to decide whether to participate in the federal healthcare program for the remainder of this year.

Relationships with payers range from quite content to quite contentious, but physicians are beginning to reap huge rewards from lobbying efforts aimed to stop the bundling of procedures and to boost reimbursement up to Medicare levels.

Many dermatologists perform pathology services in their offices. Some read their own slides and purchase the slide (e.g., the technical component from an outside reference laboratory), some have a totally equipped office laboratory and make and read their own slides, while others still don't do any of these services but just bill the insurance company for them.

Their plight is one told a countless number of times by the press: a physician in a high-risk specialty endures medical liability premiums of $200,000 a year or more - a price that is so debilitating that the doctor is forced to limit services, retire early, or move to a state with medical liability reforms that keep premiums more stable.

Despite the combined fiscal pressures of a defense buildup, promised tax cuts, and a growing federal deficit, intense pressure by physicians - including dermatologists - has resulted in a 1.6 percent Medicare physician-reimbursement increase rather than the 4.4 percent cut that had been slated for 2003.

With the new Republican-controlled 108th Congress now in business, there is an improved chance that lawmakers will get the message about sky-rocketing cost of malpractice insurance and provide some relief.

Dr. Derm runs a small, efficient, single-physician dermatology practice. He is a participant in many managed care plans, accepts Medicare payments and has no interest in changing either the thrust or the way he operates his practice.

Q: My doctors commonly use the following example in their dictation: "IDN back, no other suspicious lesions noted on complete general cutaneous skin exam." Would this documentation support a 99213, 99202, or 99242 level of care since six body areas are required to meet the documentation guidelines for the examination?

Not only did dermatologists not get relief from the Medicare payment cuts imposed in 2002 because of a fee schedule glitch, now more cuts are on the way unless the

Enhanced solidarity. These two words sum up what Boni E. Elewski, M.D., wants to accomplish during her tenure as president of the American Academy of Dermatology, beginning in February 2004. Dr. Elewski, a Birmingham, Ala., dermatologist, becomes president-elect of the academy in March.

Medicare spending for hospital outpatient services will increase by nearly 6 percent in 2003 under a final regulation published by the Centers for Medicare & Medicaid Services late in October. However, the new rate schedule will reduce reimbursement of some drugs significantly, including blood products, medical devices, and high-technology procedures that do not require an overnight stay.

Now that many of us have been online for a number of years, we are getting as many as 200 e-mails a day from friends, family, business associates, and spanners.