TEAM APPROACH Efficient care teams address rising demand. 04 Coding 08 Research 12 Legal Issues 19 Practice Management 39 Academy News

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1 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care TEAM APPROACH Efficient care teams address rising demand Coding 08 Research 12 Legal Issues 19 Practice Management 39 Academy News

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3 in this issue from the editor DEAR READERS, I like what Albert Einstein had to say about flexibility: measure of intelligence is the ability to change. It s not that I find change always easy; it challenges me as it does the rest of us. But somehow I inherently like it. Like when I move the furnishings around my house. All of a sudden I can t help but think The that the couches will look better if simply turned 90 degrees, or it might spice things up to have my bed in a different place in my room. My kids groan and my husband gives me that patient look that says, I am only doing this since I know it will make you happy. While sometimes these efforts are a complete bust with the pieces of the room returning once again to their baseline positions, often there is something refreshing and newly engaging about having my very same stuff hanging out in a different way. So while others resist change, I sort of welcome it. Therefore you can guess my reaction when you notice this month that we only have two feature articles. We made this change since these two pieces were so comprehensive that we needed the extra space. This isn t a permanent change, but we felt that depth was more important than number of features, and we trust that you agree. I hope that each of you reads our piece on dermatologic care teams this month. I doubt that this will be a passing phase. For the skeptics amongst you, the Institute of Medicine has proclaimed that the clinician operating in isolation is now seen as undesirable in health care. As we ve seen so many times before, what Washington wants in health care it gets in health care. Many of these strategies are not new; we all work with our staffs to try to take care of patients as efficiently and sensitively as possible. However, the degree to which we need to embrace this new paradigm is what makes this article so important. By the way, I loved hearing from Randall Roenigk, MD, about the identification of the Sister Mary Joseph nodule by one of the Mayo Clinic nurses. This type of thinking is also apparent in cosmetic dermatology, where leaders understand that a little flexibility can maximize the good results, while minimizing the less appealing ones. More injections with less volume in each one sounds simple but it requires being open to handling patients differently, and it is giving patients better results. Be sure to read our piece on neurotoxins and fillers to get news about the latest developments. It seems that our patients faces will look better as a consequence of these changes too. Not everything can be flexible though, and knowing what can from what cannot is critical. Be sure to read our legal column on HIPAA privacy violations and how to handle them, our coding piece on the exact coding definitions for biopsies and excisions of lips and eyelids, as well as our story on cloud storage for EHR. It s best, in these situations, to be a bit of a bore, and just handle these things exactly as outlined each and every time. I wanted also this month to say a word about my column from last December. One of you wrote that I seemed to suggest that residents in Botswana were not adequately supervised. I certainly intended no such implication. I very much appreciate it when you either write or tell me your thoughts about anything we do in DW. We take your comments quite seriously as we keep striving to make this publication better and better. And by the way, my living room truly does look better with the couches shifted! Enjoy your reading. VOL. 24 NO. 02 FEBRUARY 2014 PRESIDENT Dirk M. Elston, MD PHYSICIAN REVIEWER Barbara Mathes, MD EXECUTIVE DIRECTOR Elaine Weiss, JD PUBLISHER Lara Lowery EDITOR Katie Domanowski MANAGING EDITOR Richard Nelson ASSISTANT EDITOR John Carruthers DESIGN MANAGER Ed Wantuch EDITORIAL DESIGNER Theresa Oloier ADVERTISING MANAGER Brian Searles ADVERTISING SPECIALIST Carrie Parratt PHYSICIAN EDITOR Abby Van Voorhees, MD CONTRIBUTING WRITERS Jan Bowers Rachna Chaudhari Clifford Lober, MD, JD Alexander Miller, MD Morris Stemp, MBA Susan Treece EDITORIAL ADVISORS Lakshi Aldredge, MSN, ANP-BC Jeffrey Dover, MD Rosalie Elenitsas, MD John Harris, MD, PhD Chad Hivnor, MD Sylvia Hsu, MD Risa Jampel, MD Christopher Miller, MD Christen Mowad, MD Robert Sidbury, MD Ravi Ubriani, MD Oliver Wisco, DO Printed in U.S.A. Copyright 2014 by the American Academy of Dermatology Association 930 E. Woodfield Rd. Schaumburg, IL Phone: (847) Fax: (847) MISSION STATEMENT: Dermatology World is published monthly by the American Academy of Dermatology Association. Through insightful analysis of the trends that affect them, it provides members with a trusted, inside source for balanced news and information about managing their practice, understanding legislative and regulatory issues, and incorporating clinical and research developments into patient care. Dermatology World (ISSN ) is published monthly by the American Academy of Dermatology and AAD Association, 930 E. Woodfield Rd., Schaumburg, IL Subscription price $48.00 per year included in AAD membership dues. Non-member annual subscription price $ US or $ international. Periodicals Postage Paid at Schaumburg, IL and additional mailing offices. POSTMASTER: Send address changes to Dermatology World, American Academy of Dermatology Association, P.O. Box 4014, Schaumburg, IL ADVERTISING: For display advertising information contact Richard Sieber at (301) or rsieber@townsend-group.com. ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR DERMATOLOGY WORLD // February

4 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care The care team is a way to help meet patient demand with the workforce that we have. 22 features COVER STORY TEAM APPROACH Efficient care teams address rising demand BY JOHN CARRUTHERS 32 A NATURAL LOOK Striving for subtle changes in toxin use BY JAN BOWERS depts 01 FROM THE EDITOR 04 CRACKING THE CODE Location, location, location. 07 ROUNDS Tanning bans advance. 08 ACTA ERUDITORUM Pattern recognition and melanoma. 12 LEGALLY SPEAKING Handling a HIPAA privacy violation. 15 TECHNICALLY SPEAKING Using the cloud for data storage. 19 IN PRACTICE Complying with CLIA. 38 FROM THE PRESIDENT 39 ACADEMY UPDATE Advisory Board resolutions sought, more HOW InHOWse Design Award Cover/Feature Design 2011 Ozzie Silver Award, Best Redesign: Association/Non-profit 2011, 2012, and 2013 Graphic Design USA Award Cover/Feature Design 2011 AM&P Excel Bronze Award, Magazine Redesign 40 ACCOLADES 44 FACTS AT YOUR FINGERTIPS Academy accomplishments. 2 DERMATOLOGY WORLD // February

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6 cracking the code coding tips BY ALEXANDER MILLER, MD Location, location, location ALEXANDER MILLER, MD, addresses important coding and documentation questions each month in Cracking the Code. Dr. Miller, who is in private practice in Yorba Linda, Calif., represents the American Academy of Dermatology on the AMA-CPT Advisory Committee. You identify a lesion suspicious for a basal cell carcinoma on the eyelid and do an incisional biopsy. You code CPT 67810, as this is a site-specific eyelid biopsy code. Is your code selection correct? Both the CPT and the ICD-9 specify various procedural and diagnostic codes based upon procedure and lesion location. It is therefore crucial to proper coding to be clearly familiar with code and anatomical location definitions. The skin biopsy code, CPT 11100, can be used for any skin or mucosa location. The shave, destruction, and excision codes are uniformly separated into the same three repeated location areas: 1. Trunk, arms, or legs; 2. Scalp, neck, hands, feet, genitalia; 3. Face, ears, eyelids, nose, lips, mucous membranes Repair codes ( ) stratify locations slightly differently from the above, and the adjacent tissue transfer or rearrangement codes ( ) are based upon smaller anatomical units. For the purposes of precise coding based upon lesion location it is necessary to understand the anatomical demarcation zones on the head and neck. Everyone has an intuitive understanding of where the neck, scalp, and face are located. However, what are their defined demarcation lines? The separation between the face (forehead) and the scalp is at the hairline. However, one must take into account receding hairlines. The scalp does not recede along with a hairline. The scalp starts and the forehead ends above the line of demarcation of a youthful hairline. The face ends and the neck starts below the level of the mandible. The scalp ends and the neck starts inferior to the junction of the hard bony skull and the soft tissues below it. On the posterior aspect of one s head and neck both the scalp and the neck bear coarse terminal hairs. The hairline is therefore useful for demarcating the face from the scalp but not the scalp from the neck. There are select location CPT codes for the lip, oral mucosa, and eyelids. CPT code 40490, biopsy of lip, refers to biopsies done on the lip internal to the vermilion-skin margin (that is, on the lip vermilion or mucosa). Any biopsy done on the skin of the lip only merits an skin biopsy CPT code. Note that CPT is defined as biopsy of skin, subcutaneous tissue and/or mucous membrane. Consequently, one may use either code or for specifying a lip biopsy done on the vermilion or mucosa. There is a specific CPT code for eyelid biopsy: 67810, Incisional biopsy of eyelid skin including lid margin. This code was revised in the 2013 CPT to limit its use to procedures where the full thickness of the eyelid margin is biopsied. The lid margin is the portion of the eyelid edge extending from the skin and lash line to the palpebral conjunctiva. A biopsy involving the eyelid skin only is coded with CPT CPT 67840, excision of lesion of eyelid (except chalazion) without closure or with simple direct closure, refers to an excision of the lid margin tissue with or without primary closure. Dermatologists would typically treat malignant lid margin lesions with Mohs surgery. Consequently, dermatologic use of this code is rare. Code 67850, Destruction of lesion of lid margin (up to 1 cm), may be used when the destroyed lesion is on the lid margin, as defined above. Destruction of eyelid lesions located on the skin outside the lash line should be specified with the appropriate premalignant (CPT ) or benign (CPT ) destruction codes. Example 1: You excise an eyelid nevus that overlaps the lid margin from the skin of the eyelid through the lash line and onto the eyelid conjunctiva. You repair the defect with a flap. As you both excised the lesion and then repaired it with a flap you bill CPT for the excision and 4 DERMATOLOGY WORLD // February

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8 coding tips CPT 14060, adjacent tissue rearrangement, eyelids, for the flap repair. AAD Annual Meeting - Booth 995 Answer: Incorrect. The adjacent tissue rearrangement code definition includes both the excision and the repair of the lesion. Only CPT should be billed. Example 2: You identify a lesion suspicious for a basal cell carcinoma on the eyelid rim and do an incisional saucerize type of biopsy. No suturing is done. You code CPT 67810, as this is a site-specific eyelid biopsy code. Answer: Correct. The incisional biopsy of the lesion includes more than skin, involving the full thickness of the eyelid rim extending from the lash line into the conjunctiva. This fits the definition of CPT Note that the code specifies a full-thickness eyelid margin biopsy only. Suturing is not mentioned in the code descriptor and is not required for use of this code. Example 3: You do a punch biopsy of a lip lesion suspicious for a squamous cell carcinoma located on the junction of the vermilion and the internal lip mucosa. Your biller codes the procedure as a biopsy, CPT Answer: Correct. CPT is defined as biopsy of skin, subcutaneous tissue, and/or mucous membrane. Thus it may appropriately be used for a lip vermilion or mucosa biopsy, with or without suturing. However, in this case CPT 40490, biopsy of lip, is also fitting, as the biopsy is from the non-skin portion of the lip. The choice is yours. If the biopsy had been performed only on wet mucosal tissue, CPT 40808, biopsy of vestibule of mouth, would be appropriate. See the May 2013 issue of Dermatology World, for more details. Example 4: You do a saucerize incisional biopsy of a clinically atypical eyelid nevus. The biopsy extends from the skin across the eyelid rim lash line to the tarsal glands orifices. You code CPT 67810, eyelid biopsy. Answer: Incorrect. The full thickness of the eyelid margin was not captured in the biopsy. The biopsy involved skin and a partial thickness of the eyelid, as the biopsy did not extend full thickness across the eyelid rim to the conjunctiva. The correct code would be 11100, biopsy of skin, subcutaneous tissue, and/or mucous membrane. dw 6 DERMATOLOGY WORLD // February

9 news in brief rounds Tanning bans, Mohs surgery classification arise in early legislative sessions STATE NEWS ROUNDUP As the new year brings new legislative priorities throughout state legislatures, dermatologists continue to advocate for the specialty, for patient safety, and to maintain access to high quality dermatologic care. ACADEMY MEMBERS OPPOSE LEVEL 2 MOHS CLASSIFICATION IN TEXAS Dermatologists in Texas face a significant challenge with an office-based surgery bill currently working through the Texas state senate. The measure, which advocates says would improve patient safety, would effectively move Mohs surgery to Level 2 classification by defining maximum levels of local anesthetic dosage per outpatient visit. The American Academy of Dermatology Association (AADA) sent a letter to the Texas Medical Board in November asking that Mohs be specifically excluded from the requirements due to its superior safety record. The AADA recommends the Board use this opportunity provided by Senate Bill 978 to adopt regulations or guidelines that are consistent with the studies concerning local anesthesia rather than implementing additional requirements that would impede access to life-saving procedures, AADA President Dirk M. Elston, MD, said in his letter. TANNING BANS CONTINUE TO ADVANCE After 2013 saw significant advances in tanning bans for minors, a trio of state bills and one measure introduced in the nation s capital would continue the momentum. Delaware s legislature is preparing to act on a measure introduced in mid-2013 that would amend the state code relating to tanning facilities to effectively ban all minors under 18 from using tanning beds while mandating signage and warning statements in the facilities themselves. Washington s legislature reintroduced a bill in November 2013 that would likewise prohibit those under 18 from using any ultraviolet tanning device. The bill prescribes penalties for facilities that violate the ban. Nebraska s proposed ban, known as the Skin Cancer Prevention Act, features similar measures. It also lays out warning language for tanning facility owners, reading in part: Ultraviolet Radiation causes: Skin Cancer Injury to the Eyes and Skin Skin Aging. In addition to these states, the District of Columbia is pursuing a ban for those under 18, directed by D.C. Council member Mary Cheh. The district s current ban applies only to those 14 and under. JOHN CARRUTHERS DERMATOLOGY WORLD // February

10 acta eruditorum research in practice Q&A Pattern recognition and melanoma IN THIS MONTH S ACTA ERUDITORUM COLUMN, Physician Editor Abby S. Van Voorhees, MD, talks with Jean-Jacques Grob, MD, about his recent Journal of Investigative Dermatology article, Evidence of a Limited Intra-Individual Diversity of Nevi: Intuitive Perception of Dominant Clusters Is a Crucial Step in the Analysis of Nevi by Dermatologists. DR. VAN VOORHEES: Let s begin by talking about what is known about how dermatologists detect melanoma. We teach students the ABCD algorithm; don t we use it? DR. GROB: ABCD was a model invented to summarize and recognize nevi. A lot of nevi are ABC, at least, and sometimes D. Many melanoma are not ABCD, and a lot of seborrheic keratoses are ABC. So although it s easy to remember, it has limitations. We demonstrated a few years ago that if you tried to teach melanoma recognition by ABCD, by just showing pictures, or by doing both to samples of the general population, the most efficient way to train people is just showing them pictures. When you just give the ABCDs people tend to see melanoma everywhere, and when you mix the two they do worse than with pictures alone. Why? Recognition is a cognitive process; we don t know exactly how it works, but we do not use an algorithm. We don t say something is a cow because it has four legs and is black and white; we recognize a cow because we ve seen cows. And we each establish a pattern of recognition. A good example is someone s face. If I tried to describe myself very precisely to you, if we meet in one hour you will not recognize me. But if we meet for only 10 seconds, you will build a pattern of recognition and you will still recognize me in a year. And my face is closer to your face than a melanoma is to a nevus. We are all able to recognize anything provided we have some opportunity to see it beforehand and build up a recognition pattern. In fact, recognition is covering different processes. I was speaking about direct recognition if I see something, I can recognize it if I see it again. If I ve seen 100 melanomas it s very likely I will recognize another. There s also differential identification. That means we are able to detect something which is not expected 8 DERMATOLOGY WORLD // February

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12 acta eruditorum continued somewhere. Let s say I put a tortoise in your office. You ll immediately see that this is not expected there. This is what we do on the skin of a patient. The analysis of a single lesion out of context is a very difficult task because, in the usual clinical situation when you see a patient, you see all of his skin and all of his pigmented lesions, which provides you with a lot of information; you intuitively tend to build up different clusters of lesions that tend to look the same and there might be one lesion that is different. This is the ugly duckling. You see a patient and he has two or three patterns of nevi and one nevus that is quite different. How it is different in this given individual is different than it would be in other patients. Out of context it might not be suspicious, but it is in this patient. This is something humans can do: see that something is different. A given nevus that is an ugly duckling on my skin might not be on yours, depending on the clusters we each have. Then you have the third process involved in recognition of a potential melanoma being based on chronologic criteria. This is often considered as D, changing diameter, or E, evolution, in the ABCDE algorithm. But you need a reference to know this, either a photo or the memory of the patient. A melanoma is usually growing faster than other pigmented lesions around it. To summarize: If a lesion is fitting with one of the different patterns of melanoma stored in your brain, and/or if it s an ugly duckling, and/or the patient says it s changing fast you have to consider melanoma. Another point is that the recognition pattern we each build is not the same. When you meet a young guy and you say he looks like his father, your wife might say he looks like his mother. You re both right. But you ve built your pattern of recognition of his face using points that are present in his father; she has built hers using points of recognition that are present in his mother. You don t use the same patterns of recognition, but they both work you re both able to recognize him. When we see a melanoma we can both say it s melanoma, but not for the same reasons. When I explain my reasons, they spoil your system. Provided your system works, we shouldn t care how you recognize melanoma and how I recognize it. DR. VAN VOORHEES: What was the objective of your study? DR. GROB: To see whether we were able to see the common patterns of all nevi in a given individual. I was pretty sure that each individual had his own nevus profile, but once you say that you have to demonstrate it. This idea is the basis for the ugly duckling not like the others but that presupposes that you have some common pattern for the others. That s what we called perceived similarity clusters (PSCs). DR. VAN VOORHEES: Were perceived similarity clusters an effective tool to look at an individual s nevi? How did dermatology experts compare with each other? Were PSCs similar amongst them? Was there a lot of group concordance? How did the novice group do? Was there much difference compared with dermatologists? DR. GROB: We let a number of people cluster all the nevi of each given patient, just on their perception of similarities, any way they wanted two groups, three, 10. Each may cluster them differently. What we showed is that when you take the best experts and the people with the least knowledge possible people who don t even know what a nevus is in fact those two groups clustered the nevi in a very similar way. Of course there is much more concordance between experts and other experts than between experts and naives, but even between the two groups there s a large concordance. Pattern recognition is a characteristic of the human brain, not just of dermatologists. We showed that however many nevi there were, any human being can cluster them into a few groups (usually two or three) that reasonably cover the reality. We didn t test the expertise of experts; we just tried to understand how they were functioning. We found that they tended to do the same clustering. Among eight experts who saw the same pictures of patients only one clustered them in a different way. And that one person is still an expert his brain just works differently. Just like in tennis you may find that most of the best are playing one way, but there may be another path to success. DR. VAN VOORHEES: How did the novice group do? Was there much difference compared with dermatologists? DR. GROB: Not so bad. Not for the diagnosis of melanoma, of course; they weren t tested for that. But for the clustering of nevi into groups they were not that different than the dermatologists. Even the naives could have picked out an ugly duckling; we re doing more studies on that now. DR. VAN VOORHEES: Did dermoscopy assist dermatologists in grouping nevi? DR. GROB: Dermoscopy is taught in exactly the way it should not be taught, by description: spots, lines, networks. Words to describe images. We should teach dermoscopy by showing pictures and let each of our brains build up its own cognitive process at the dermoscopic scale. The way we teach it now is a less natural recognition process. We use visual recognition every day; dermoscopic scale is less intuitive. This may explain why the concordance in dermoscopy is lower than pure visual recognition. We re not intuitive in dermoscopy; we re using artifical algorithms that we have learned. DR. VAN VOORHEES: How can this enhanced understanding of the consensus clusters help us going forward? Can this information be used in computer models? Do you see technological advances that can come from this work? DR. GROB: We are working on technical models that could do this. This clustering idea isn t used in any computer-aided system so far, but it could be. They don t take into account the environment of the lesion; that s why dermatologists are better at diagnosing. If you don t give the computer the information you have it won t do better than you. 10 DERMATOLOGY WORLD // February

13 research in practice acta eruditorum DR. VAN VOORHEES: Do the results of this study tell us more about how we teach dermatology? Do we need to more concretely teach pattern recognition? DR. GROB: Yes, we should start young doctors in dermatology by telling them they need to train their brains by looking at a lot of pictures so they build up their own recognition process for many important situations. Show an eczema, tell the student is is an eczema, but do not explain why. Same thing for psoriasis and so on. His brain will make that connection straight from the images, and explanation on color, distribution, and size of lesions may disturb the building of his intuitive recognition process rather than help it. Written description used to be useful, when students did not have enough opportunities to see images, but it is so easy now to see hundreds of images to train one s own recognition process. What I ve told you is broader than just what we found in our paper. Melanoma recognition is an important issue, but recognition of situations applies across both dermatology and other medical specialties, like radiology. This is why you have an instant diagnosis when you see a patient, though you may not be able to explain why and when you try to explain you start saying stupid things, because you do not know how your brain does the job. Every time you try to explain visual information by words you lose or distort information. I used to explain why something was psoriasis when teaching now I just show students 100 cases of psoriasis and 100 eczemas and they become able to recognize each one. When you try to explain you spoil the information you d say psoriasis is welllimited and eczema is not. That s more or less true, but there are exceptions. Once you ve seen them both, you don t need to go back to criteria that often fail. dw JEAN-JACQUES GROB, MD, is professor of dermatology at Hopital Ste Marguerite in Marseilles, France. His article was published in the Journal of Investigative Dermatology. J Invest Dermatol 133: ; advance online publication, May 16, 2013; doi: /jid Expand Your Expertise! Join us in Denver and experience an array of dermatologic educational sessions like no other! Sharpen your skills with over 360 educational sessions covering a wide variety of topics Registration Now Open! Enjoy full access to the high-energy exhibit floor showcasing the latest products and services from hundreds of exhibitors Network with colleagues from across the globe and build valuable professional relationships Discounted rate expires February 12 at 12 p.m. (CT)! To register, visit DERMATOLOGY WORLD // February

14 legally speaking BY CLIFFORD WARREN LOBER, MD, JD Handling a HIPAA privacy violation EVERY MONTH, DERMATOLOGY WORLD covers legal issues in Legally Speaking. Clifford Warren Lober, MD, JD, presents legal dilemmas in dermatology every other month. He is a dermatologist in practice in Florida and a partner in the law firm Lober, Brown, and Lober. Bryan returns from lunch expecting a quiet afternoon. His receptionist tells him that Erin has been frantically trying to reach him. Bryan immediately returns Erin s call. Bryan: Erin, this is Bryan. How are you? Erin: I really need your help. My nurse just told me that she tried to reach one of our patients, Ms. Roberts, to give her the results of a laboratory report. The patient did not answer her telephone, and her answering machine just said Sorry we are not home. Please leave a message. My nurse then left the report on the answering machine. This morning, however, we were called by a Mr. Echols who was quite upset and asked who Ms. Roberts was and why we left her test results on his answering machine! I suspect this is a violation of HIPAA. Bryan: This type of violation, referred to as a breach, occurs when there is acquisition, access, use, or disclosure of protected health information in a manner not permitted by the HIPAA privacy rule. Under the most recent modification of HIPAA, which was effective last September, a breach is assumed to have occurred unless you can demonstrate a low probability that the protected health information has been compromised. This determination must be based, at a minimum, upon the nature and extent of the information disclosed, the person to whom the disclosure was made, whether the information was actually acquired or viewed, and the extent to which the risk has been mitigated. In this case, the information was clearly acquired and the person to whom the disclosure was made is upset and may or may not agree to disregard the information. 12 DERMATOLOGY WORLD // February