Overusing acne antibiotics?

56 Pages·2015·13.5 MB·English

08.2015 A Publication of the American Academy of Dermatology Association www.aad.org
Navigating Practice, Policy, and Patient Care
Overusing acne
antibiotics?
Resistance concerns lead to new
therapeutic recommendations 20
+
05 Coding
10 Research
14 Legal Issues
18 Practice Management
46 Academy News
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from the editor
in this issue
DEAR READERS,
It probably won’t surprise you to
learn that I am a people person.
Maybe it was because I grew up as a middle child, or my genetic
make-up, but evaluations of me from the time I was in nursery
school to the present day are always similar. As an affable four-
year-old they basically stated that I “played well with others.” VOL. 25 NO. 8 | AUGUST 2015
Want to play in the sand box? Okay with me so long as friends were
going to be there.
Generally speaking we dermatologists do play well with others. It’s PRESIDENT PHYSICIAN EDITOR
Mark Lebwohl, MD Abby Van Voorhees, MD
why we get a kick out of talking to our patients. For many of us, it is why
EXECUTIVE DIRECTOR PHYSICIAN REVIEWER
we went into health care to begin with. However, in the playground of medicine there are Elaine Weiss, JD Barbara Mathes, MD
some “big kids” that don’t necessarily play that way. PUBLISHER CONTRIBUTING WRITERS
Lara Lowery Jan Bowers
For much of my career, we in dermatology have been regularly irked by the “big kids” Rachna Chaudhari
in the rest of the house of medicine. We viewed them as biting at our feet, trying to cut into EDITOR Kathy Frale
Katie Domanowski Shannon Gignac
our turf, and not appreciating our talents and needs. It didn’t help that the other branches of Susan Jackson
MANAGING EDITOR
Clifford Lober, MD, JD
medicine were, in almost all cases, bigger and stronger than us, and therefore could be truly Richard Nelson, MS
Alexander Miller, MD
formidable adversaries. However, the issues we face in medicine now are ever more chal- ASSISTANT MANAGING EDITOR Victoria Pasko
Victoria Houghton, MPA Joan Tenut
lenging. Our leadership has recognized this and has engaged the rest of medicine; we are Yvonne Urbikas
CONTENT SPECIALIST
reaping the benefits. We write this month about dermatology’s recent successes that have Emily Margosian, MA EDITORIAL ADVISORS
Lakshi Aldredge, MSN, ANP-BC
emerged from this collaboration. The most obvious is the SGR repeal, but this is only one
DESIGN MANAGER Annie Chiu, MD
of many. Working with others has helped us in the areas of narrowing networks, formulary Ed Wantuch Jeffrey Dover, MD
Rosalie Elenitsas, MD
transparency, patient safety, and telemedicine, to name a few. Getting others to see things SENIOR GRAPHIC DESIGNER John Harris, MD, PhD
Theresa Oloier
our way is not always successful, and having the wisdom to know when to bend and when to Chad Hivnor, MD
DESIGN TEAM Sylvia Hsu, MD
stand alone is key, but working within the house of medicine has been a fairly fruitful path of Nicole Torling Risa Jampel, MD
Michel McDonald, MD
late. So while we in derm need to remain steadfast, for example, in our commitment to fight ADVERTISING SPECIALIST Christen Mowad, MD
Carrie Parratt
pathology’s intrusion into our ability to read our slides or in our right to perform office-based Robert Sidbury, MD
Oliver Wisco, DO
surgery, it makes sense to me that joining with others is here to stay. Maybe it is time for
many of us, myself included, to reconsider supporting the AMA as the next step…then our
seat at the table would be even stronger.
Printed in U.S.A. Copyright © 2015 by the
The over-usage of antibiotics is a national public health concern, and it is having an American Academy of Dermatology Association
impact in dermatology. We write about the need to change the acne paradigm in this month’s 930 E. Woodfield Rd. Schaumburg, IL 60173-4729
Phone: [phone] Fax: [phone]
issue. Resistance to tetracycline antibiotics has grown hugely. When I was a resident we were
MISSION STATEMENT: Dermatology World is
predicting that these medications would become less useful as resistance developed like published monthly by the American Academy
it had with erythromycin, but we kept prescribing anyway. I think that we were convinced of Dermatology Association. Through insightful
analysis of the trends that affect them, it provides
that antibiotics were still the safest and most effective option for the patient in front of us. members with a trusted, inside source for
However, the new acne guidelines, which are about to be published, will shift this treatment balanced news and information about managing
their practice, understanding legislative and
paradigm for our patients. While oral antibiotics will not go away, hormonal therapies such regulatory issues, and incorporating clinical and
research developments into patient care.
as spironolactone and OCPs have become increasingly important. You’ll also want to read
Dermatology World® (ISSN 10602445) is
about the need to get patients using topicals such as tretinoin, dapsone, and benzoyl peroxide
published monthly by the American Academy
for maintenance therapy to prevent further antibiotic resistance. It is a big deal when one of of Dermatology and AAD Association, 930 E.
Woodfield Rd., Schaumburg, IL 60173-4729.
our most common diseases shifts its recommendations for care. Benzoyl peroxide, I guess,
Subscription price $48.00 per year included in
just plays well with others, and that is a paradigm that I find easy to embrace. Granted: I like AAD membership dues. Non-member annual
subscription price $108.00 US or $120.00
things that way.
international. Periodicals Postage Paid at
Wish I had more space to highlight some other pieces in this month’s magazine — Schaumburg, IL and additional mailing offices.
wrong-site surgery is a must-read as is the one on how to create a patient-friendly bill. Too POSTMASTER: Send address changes to
Dermatology World®, American Academy
little time and space for my musings, but trust that you will enjoy your reading. of Dermatology Association, P.O. Box 4014,
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ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR DERMATOLOGY WORLD // August 2015 1
2015
08. A Publication of the American Academy of Dermatology Association www.aad.org
Navigating Practice, Policy, and Patient Care
features depts
01
FROM THE EDITOR
05
CRACKING THE CODE
ICD-10: Documentation
and coding.
“There’s good
08
data to suggest that ROUNDS
AADA fights for patient
there has been access to pharmaceuticals.
20 10
an emergence of
ACTA ERUDITORUM
resistance to, really, Scoop-shave biopsy:
When should it be used?
all antibiotics, but 14
COVER STORY
OVERUSING ACNE ANTIBIOTICS? LEGALLY SPEAKING
particularly the
Resistance concerns lead to new therapeutic Wrong patient/wrong
recommendations site surgery.
ones that have been
BY JAN BOWERS
18
used in the past ANSWERS IN PRACTICE
28
Creating a
to treat acne.” patient-friendly bill.
STRENGTH IN NUMBERS
44
Exploring dermatology’s fruitful alliances
with the house of medicine FROM THE PRESIDENT
BY VICTORIA HOUGHTON
46
ACADEMY UPDATE
36
DW wins awards, more.
2015 Awards for Excellence 2013 HOW InHOWse
Writing – Feature Writing Design Award –
Writing – Departments and Columns Cover/Feature Design 52
TALKING SHOP
Magazines, Journals and Tabloids
– Print – 32+ pages Insuring employees under the Affordable Care FACTS AT YOUR
Act’s Small Business Health Options Program FINGERTIPS
BY VICTORIA HOUGHTON What care are
2011, 2012, 2013, and 2014 non-physician
Graphic Design USA Award – clinicians providing?
2015 ASHPE Gold award Cover/Feature Design.
Best Cover: Photo 2014 Graphic Design USA
Joining Up - July 2014 American Web Design Award
2011 Ozzie Silver Award,
Best Redesign:
2014 AM&P Excel Bronze Association/Non-profit.
Award, Design Excellence 2014 Eddie Honorable
Mention, Association/
Non-profit video
2 DERMATOLOGY WORLD // August 2015 www.aad.org/dw
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cracking the code
coding tips
Laterality
In addition to describing the general location
of a tumor or condition one must also define
BY ALEXANDER MILLER, MD whether it is on the left or right side of a struc-
ture that has laterality, such as left versus right
ICD-10: hand, left versus right eyelid, etc. Depending
on the condition being coded, the fifth or sixth
character (last digit) in a cutaneous tumor
Documentation diagnosis code specifies laterality. For invasive
and in-situ melanomas and in-situ cutaneous
carcinomas, a last digit of “1” indicates the right
side, and “2” denotes the left side. To keep you
and coding
alert the ICD-10 presents a different numerical
convention for basal and squamous cell car-
cinomas as well as for malignant neoplasms,
not otherwise specified. For these latter three
ALEXANDER MILLER, MD, addresses important coding and documentation
entities the last digit “2” specifies the right side,
questions each month in Cracking the Code. Dr. Miller, who is in private practice
and “9” applies to the left side. Go figure!
in Yorba Linda, California, represents the American Academy of Dermatology on
the AMA-CPT® Advisory Committee. Comorbidities
The medical record should record complica-
tions and conditions associated with a primary
Repeated messages from the AAD and other sources have stressed the impor- disease. These may then be used to appropri-
tance of practicing ICD-10 coding in anticipation of the hard transition to ately select diagnostic codes in addition to a
ICD-10 on Oct. 1. If you have an electronic health records program that auto- primary code. Specifying additional data and
matically extracts ICD-10 codes and presents them for billing, you may believe diagnostic codes associated with the primary
that you are fully protected from errors and are set for Oct. 1. Wrong. Electronic code provides greater information to the payer,
health records (and paper records, for that matter) can only direct diagnostic coding and may serve to validate the complexity of
based upon what is entered into the record. If one is unaware of the ICD-10 coding a given patient care episode. Such detailed
requirements, then one may neglect to enter pertinent data that will determine coding will become essential as alternative
optimal diagnostic codes. payment models begin to vary reimbursement
Specifically, ICD-10 brings the following coding distinctions: levels for episodes of care, basing at least some
• Alphanumeric codes with up to seven characters of the reimbursements upon the complexity of
• Specificity the conditions undergoing treatment.
• Laterality
• Comorbidities Encounter types
• Encounter types The seventh and last spot in the sequence of
ICD-10 alphanumeric codes is reserved for de-
Alphanumeric codes scribing special circumstances, such as initial
ICD-10 codes contain up to seven characters, starting with a letter. Many dermato- or subsequent encounters resulting from in-
logic codes are located in the “Diseases of the Skin and Subcutaneous Tissue” section juries or poisonings, or for ensuing sequelae.
of the ICD-10, in chapter 12. These all begin with the letter “L”. However, cutaneous A sequela is a morbidity arising consequent
neoplasms are listed elsewhere, in chapter two, and typically begin with the letter “C” to a prior injury or poisoning. For example, a
for melanoma, basal cell carcinoma, and squamous cell carcinoma, or “D” for in situ keloid resulting from a dog bite would be ap-
tumors and benign tumors, including nevi, and neoplasms of uncertain behavior. propriately described with the ICD-10 code for
keloid followed with the additional pertinent
Specificity dog bite code ending with an “S” for sequela.
The medical record should provide sufficient detail (“granularity”) about a disease or The types of encounters following an injury
encounter so as to allow for the greatest specificity in coding. Insufficient chart detail or poisoning are uniformly coded with one of
may lead to an “unspecified” diagnosis or “unspecified” location of a condition. List- three letters:
ing an “unspecified” tumor location (usually designated by a last character of “zero” A = Initial
or “nine” in the code) may lead to delayed claim adjudication and/or denials. Conse- D = Subsequent
quently, specifying necessary detail is crucial to proper coding and reimbursement. S = Sequela
DERMATOLOGY WORLD // August 2015 5
cracking the code continued
coding tips
Here is an example:
Letters and numbers Laterality
W58.03XA: Crushed by alligator, initial
encounter (as alligators do not climb trees, The new code set, unlike ICD-9, Depending on the condition being
nor do they fly, or jump, just how they includes both letters and numbers. coded, the fifth or sixth character (last
would come to land on top to crush you Of the letters, three are most important digit) in a cutaneous tumor diagnosis
challenges one’s imagination) for dermatologists to remember: code specifies laterality.
W58.03XD: Crushed by alligator, subse-
L: corresponds to the “Diseases of the Invasive and in-situ melanomas and
quent encounter (in case you survived the
Skin and Subcutaneous Tissue” section in-situ cutaneous carcinomas
crushing to appear for a follow-up visit) of the ICD-10, chapter 12. A last digit of “1” indicates the right side.
W58.03XS: Crushed by alligator, se- A last digit of “2” denotes the left side.
C: melanoma, basal cell carcinoma and
quela (I bet there would be several of these)
squamous cell carcinoma, located in
Now, if you feel that crushing really Basal and squamous cell carcinomas
chapter two.
and malignant neoplasms, not
refers to a crunching bite, maybe not: there
D: in situ tumors and benign tumors, otherwise specified
is a distinct code set for alligator bites, also
including nevi, and neoplasms of A last digit of “2” specifies the right side.
stratified by initial encounter, subsequent
uncertain behavior, also in chapter two. A last digit of“9” applies to the left side.
encounter, and sequela. So, maybe if an alli-
gator were to nip at you, you would use the Answer: Correct. 1 or 2. Based upon the type of associated
bite code, but if it were to bite and latch on, It is prudent to
diabetes one would select the precisely
methodically grinding you into a crush arti- await the final pathology report when coding
descriptive ICD-10 code for necrobiosis
fact, then you would use the crush codes. for a malignant entity, as it will allow for the
lipoidica diabeticorum associated with Type
greatest specificity in coding.
1 diabetes, E10.620, or Type 2 diabetes,
Example 1: E11.620. Although coding for necrobiosis
1
A patient comes in for Example 3: 3 lipoidica alone is technically acceptable,
an examination following an excision of a You excise a melanoma
it is best to include codes that more fully
Merkel cell carcinoma six months ago. You on the right chest. Your insurance biller
describe the patient’s interrelated diagnoses.
do a complete skin examination, palpate submits a bill with ICD-10 diagnostic code
Note that laterality (left side, right side, or bi-
nodal basins, and evaluate any pertinent C43.59. You are surprised at the coding, as
lateral NLD) is not specified, as dermatology
laboratory results. As no new tumor is you specified the right side and expected
codes for laterality are limited principally to
identified, you append a diagnosis code for the last digit in the code to be a “1”, denot-
neoplasms, burns and ulcers.
“Personal history of other malignant neo- ing a melanoma located on the right side of
plasm of skin” (not melanoma): Z85.828. the patient. Was the billing done correctly?
Incorrect. Answer: Correct. Example 5: 5
Answer: Laterality is not You evaluate a child
The ICD-10
applied to certain structures, including the with a facial hemangioma. As there is no
lists a specific code for a personal history of
lip, face, neck, trunk, breast, chest, back and location-specific ICD-10 code for a heman-
Merkel cell carcinoma: Z85.821. Code Z85.828
buttocks. Therefore, C43.59, melanoma on gioma, the diagnosis is coded as D18.00,
pertains to a history of all other cutaneous ma-
trunk, is correct. Sites with laterality codes “hemangioma, unspecified site.”
lignancies except for melanoma, which is speci-
Incorrect.
are: ear, eyelid, axilla, arm, hand, finger, leg, Answer:
fied with Z85.820. Note that although this visit
The zero at
foot, toe.
is consequent to a prior Merkel cell carcinoma
the end of the code sequence should act
treatment, no sequela codes are appropriate, as
as a tip-off to a possibly incorrect code. In
these are reserved for complications resulting Example 4: 4 many, but not all, instances of cutaneous
A patient with diabetes
from injuries or poisonings.
tumor codes a zero at the terminus of a
mellitus presents with a bilateral pretibial
line of ICD-10 code indicates an unspeci-
eruption that you diagnose as necrobiosis
Example 2: fied location or an unspecified type of tu-
lipoidica diabeticorum (NLD). Your biller
You biopsy and simulta-
mor, and should prompt one to search for
selects ICD-10 code L92.1, necrobiosis
neously destroy with curetting and electro-
a more specific code. In this case, a more
lipoidica, and sends the bill to the insurer.
desiccation a lesion located on the left arm
Incorrect. optimal code choice is D18.01, denoting
that you are certain is a basal cell carci- Answer:
Although “hemangioma of skin and subcutaneous
noma. You hold billing until the receipt
code L92.1 does specify necrobiosis tissue.” dw
of the pathology report. Whoa! The lesion
lipoidica, the patient also has diabetes mel-
is actually an amelanotic melanoma! You
litus. Optimal chart granularity would have
then apply ICD-10 code C43.62, malignant
revealed whether the diabetes was Type
melanoma, left arm, and bill the insurer.
6 DERMATOLOGY WORLD // August 2015 www.aad.org/dw
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AADA fights for
research, and medical practice. The AADA
and the New York State Society of Dermatol-
ogy and Dermatological Surgery support the
patient access to bills, which are awaiting a hearing in their
respective committees.
The language of the New York legislation
is mirrored in bills introduced in California,
pharmaceuticals
North Carolina, and Massachusetts, which
are all based on the SAIM Coalition-devel-
oped model legislation. Legislation in Cali-
fornia has passed the Assembly and awaits
STATE NEWS ROUNDUP
action in the Senate Committee on Health.
After similar legislation passed out of the
Bills that are pending Bills that have died
House Rules Committee in North Carolina,
step therapy language may be attached to
another bill. The bill in Massachusetts is
stalled at the committee referral stage.
Step therapy legislation in Maine differs
from the model legislation being pursued
in other states, in that the bill states that
the clinical review criteria used by a carrier
in approving prescription drugs may not
prevent a health care practitioner from
prescribing a medication for an off-label
use, may not require failure on the same
medication on more than one occasion
for enrollees continuously enrolled in a
health plan offered by the carrier, and may
not prevent a health care practitioner from
prescribing a medication on more than one
As part of a multi-faceted advocacy effort to ensure patients have access to prescrip- occasion when the health care practitioner
tion medications, the AADA and other members of the State Access to Innovated determines it is medically appropriate.
Medicines (SAIM) Coalition organized a virtual town hall about step therapy on June Similar step therapy legislation passed both
4. Step therapy protocols place drugs into various pricing categories and require pa- chambers last year, but it was vetoed.
tients to fail the lowest tier (cheapest) drug before moving to a more expensive drug therapy.
Speakers discussed step therapy from the patient perspective — represented by the National ILLINOIS, FLORIDA, AND MISSOURI
Alliance on Mental Illness and the National Psoriasis Foundation — and the provider After passing the House and a committee
perspective — represented by Bruce Brod, MD, who represented dermatology, as well as a in the Senate, step therapy legislation in Illi-
rheumatologist. The town hall speakers also discussed efforts underway at the state level to nois will not progress any further in the 2015
secure policy changes on step therapy protocols. To watch the archived version of the town legislative session. Although the bill success-
hall, visit www.youtube.com/watch?v=bq3OECJEChY. fully passed out of committee — which was
aided by the testimony of Illinois Derma-
NEW YORK, CALIFORNIA, NORTH CAROLINA, MASSACHUSETTS, AND MAINE tological Society President Amy Derick,
In New York, Assembly and Senate companion bills would provide physicians with a clear MD — ultimately, SAIM members agreed
process for appealing step therapy protocols when managing patients who need a specific that the compromises sought by the health
treatment. The bills would require that the clinical review criteria for establishing step plans would not have improved patient ac-
therapy protocols be based on clinical practice guidelines that are developed and endorsed cess to their prescription medicines. Debate
by an independent, multidisciplinary panel of experts, and based on high-quality studies, between stakeholders involved the inclusion
8 DERMATOLOGY WORLD // August 2015 www.aad.org/dw