Medicare, coding and reimbursement challenges that lie ahead

The number of skin biopsies within Medicare has grown 200 percent in the past 15 years while skin cancers are up around 80 percent, said Brett Coldiron, M.D., of the University of Cincinnati. As a result, dermatologists can expect reductions in shave skin biopsy CPT codes that were the subject of a Medicare Relative Value Update Committee (RUC) survey in 2017. "Anything that goes to the RUC usually gets cut. We're not sure exactly how much right now." 

Speaking at the American Academy of Dermatology annual meeting in February, Dr. Coldiron described challenges dermatologists should be prepared for this year, including Medicare payment reductions, insurers' cost-saving strategies and practice consolidations.

Under UnitedHealthcare's new laboratory benefit program, "your skin biopsies must go to one of their preferred labs, and they have established a discount pathology service you have to use."

UnitedHealthcare's doubling of the number of skin biopsies performed every year is unsustainable, he said. "You've got certain dermatologists and other physicians out there setting up skin biopsy clinics," staffed by nurse practitioners and physician assistants who admittedly have far less training than dermatologists. If mid-level providers have any doubt, "they biopsy. That's part of the reason the number of biopsies has increased so much."

If the Centers for Medicare & Medicaid Services (CMS) eliminates the global periods associated with treatment of actinic keratoses and destruction of benign lesions, the value of these codes could drop up to 65 percent, he said.

CMS is currently engaged in a survey of nine states, but the survey exempts physician groups of 10 or fewer dermatologists. "In those nine states, they're looking for the use of code 99024, which is a no-charge follow-up visit. If you look at those nine states, there are probably not more than three or four groups of 10 dermatologists" suggesting that dermatologists do few follow-ups, he said.

Along with income losses for Medicare providers, he said, "it would be a preposterous situation where if you cut something out of a patient, you'll have to charge them to remove their stitches 10 days later." Rather than pursuing another legislative fix, "It would be much better if we (in survey states) just use that 99024 code whenever we talk to on the phone or see a patient, if we don't use another E&M code."

Amid such pressures, said Dr. Coldiron, selling one's practice to a hospital or large group may sound appealing. "Venture capital groups offer this terrific buyout, but they cap your salary and do other things so they get their money back in three to five years. They're giving you a free loan for the value of your practice that you pay back. Tax-wise it's beneficial. But they're really not buying your practice, and you give up control."

REFERENCE

F096 - The Future of Dermatology: What Changes are Coming and How Can We Prepare? "Future of Dermatology and Strategic Planning for Dermatologists." Brett Coldiron, M.D., 1:45 p.m., February 18, American Academy of Dermatology 2018 annual meeting.