Spring 2018 Skin Lines

SPRING 2018 President’s message By: Lorraine Rosamilia, MD

PAD Silent Auction.......................2 Annual Meeting Preview............3 Melanoma Awareness Month..............................................4 Legislative Update.......................5 Practice Management Tips.......6 Factoid............................................7 Policy Updates and Changes.........................................8 UnitedHealthcare Policy Changes...................................10 Independence Blue Cross Changes................................... 14 Modifier 25 Policy Update..................................... 22 Residency Program Corner.... 30

“Declare the past, diagnose the present, foretell the future.”

— Hippocrates

2018 is already declaring itself as an eventful year in medicine, especially in Pennsylvania. I am proud to be part of an organization so dedicated to physician advocacy, community service, education, and promotion of the highest standards of patient care delivery.

This year, the Pennsylvania Academy of Dermatology and Dermatologic Surgery (PAD) was awarded its 14th ‘Model State Society’ award from the American Academy of Dermatology (AAD) with special honors for Outstanding Volunteer Projects, particularly the Silent Auction at our annual meeting benefitting elementary school sun safety across the state. The AAD also awarded us a State Advocacy Grant this year to aid in our efforts to pass the school sunscreen bill below.

As you will learn in the articles that follow, our accomplishments and projects recognized at a national level in our field only touch the surface of the grass roots efforts that are ongoing in our state. This spring, the Pennsylvania State House of Representatives passed a sunscreen bill allowing children to conveniently apply their own sunscreen at school without the previouslyrequired physician-signed note and school nurse visit. This important legislative initiative was spearheaded by the PAD’s own Dr. Bruce Brod.

PAD leadership was recognized on the floor of the House on Melanoma Wednesday (May 2) for this achievement, and the bill is promisingly now in the Senate.

Additionally, PAD leadership in collaboration with the Pennsylvania Medical Society, has its ear to the ground regarding any legislation that affects physicians and their ability to continue to provide excellent patient care.

We support positive legislation, such as a prior authorization bill promoting

CONTINUED ON PAGE 31

2017 PAD Silent Auction – Funding a Need in 2018 By: Joslyn Kirby, MD The proceeds from the 2017 PAD Silent Auction ($5,090!) replenished the PAD’s Public Health Education Fund.

Thank you to everyone who donated, bid, and purchased items at the recent PAD meeting!

Planning another win-win with the 2018 Silent Auction!

We are planning the 2018 Silent Auction to be held at the PAD Annual Meeting at the Kalahari Resort (September 14-16, 2018).

Solicitations for donations will begin soon! Do you have: Maclaine Povlish accepts a certificate on behalf of the PAD for his winning Sun Defense essay.

The PAD recently recognized Maclaine Povlish, a fifth grader from Rostraver Elementary School in Westmoreland County, as the 2018 Sun Defense Essay winner. As part of this essay competition, Rostraver Elementary School was awarded a $5,000 grant, which they are using to purchase a gazebo for their playground. Overall 14 schools submitted essays for consideration and every school in the state received educational resources to help teach all PA students about sun safe practices.

About the Author Dr. Joslyn Kirby is an Associate Professor of Dermatology at Penn State Hershey Medical Center. She serves as Treasurer of the PAD and is chair of the Skin Cancer Screening Committee

2

The 2015 Winning School, Crooked Billet Elementary School, used the grant to purchase a gazebo for their playground. Students use it every day at recess and the teachers use it for small reading groups when the weather permits.

•

Tickets to a professional game, concert, or theatre event that may be in high demand but you cannot attend?

•

A vacation home you could share for a week?

•

A favorite restaurant? Give a gift certificate.

•

Are you a great cook or baker – donate a basket filled with your best goodies!

•

Are you a terrible cook or baker – give a gift subscription to a monthly wine club!

•

Are you an aficionado on something? Wine? Coffee? Chocolate? Donate a basket with your ‘Best of ___’ selections!

Please tell us what you want to bid on and win at the next Silent auction – Email us your ideas at info@ padermatology.org. Watch your inbox for more details as we get closer to the Annual Meeting!

SPRING 2018

Your Donations

Are Needed!

The PAD Public Health Education Fund which supports the annual Sun Shade Essay Contest is in need of funds. The PAD Health Education Fund was established to support grants and educational outreach regarding skin and sun safety. Your donation is tax-deductible.

Annual Meeting Preview By: Lorraine L. Rosamilia, MD The PAD’s 51st Annual Scientific Meeting will be held on September 14-16, 2018, at Kalahari Resort in the Poconos.

The conference will commence on Friday through Sunday with a range of expert commentary. UCSF’s Kieron Leslie will outline his experience with immunosuppressed patients in the dermatology setting, particularly those with HIV. Harvard’s Emily Ruiz and Hensin Tsao will share their insights regarding high risk nonmelanoma and melanoma skin cancer respectively, including up-todate guidelines and management.

Vikash Oza from NYU with pediatric dermatology, Molly Hinshaw from University of Wisconsin-Madison with nail diseases, and UPenn experts Misha Rosenbach with inpatient dermatology and George Cotsarelis

with hair disorders will round out this exciting conference lineup.

In addition, we’re presenting the annual socioeconomic session with hot topics for all practice types, a cosmetic workshop with patient demonstrations, and the return of the resident ‘Mole Bowl’ as a lively competition for our resident attendees and concurrently an MOC credit opportunity for all other attendees.

Our website will provide you with more information over the next few months, including registration details, event schedule, and lodging options. You can also visit the Kalahari Resort website to learn about its amenities and regional offerings. It is the first year our meeting has been held there, and as you will see, it is certainly a venue for all ages!

Join us for an enjoyable and informative annual conference!

Go to the Foundation’s online giving page to make your gift to PAD...

Click the “Designating my gift” drop down menu and choose “PAD Public Health Education Fund” to donate to this fund.

The Foundation will acknowledge your tax-deductible gift.

3

May is Melanoma Awareness Month!

The Pennsylvania Academy of Dermatology and Dermatological Surgery continued to recognize Melanoma Awareness month with its annual free skin cancer screening and prevention program at the State Capitol on Wednesday, May 2nd.

During the screening, resolutions were passed in both the House and the Senate, recognizing May and Melanoma Awareness Month in Pennsylvania. The PAD would like to thank Representative Becky Corbin and Senator Pat Brown for sponsoring these resolutions.

We know skin cancer is preventable and treatable when caught early. The signs of skin cancer are visible on the surface, so we need to involve patients and all clinicians in spotting skin cancer – to call when you see something unusual, growing, or changing on your skin. This annual event allows our organization to continue to promote the importance of self-exams and safe sun practices.

PAD Members (from left to right) Representative Corbin, Dr. Mowad, Dr. Patel, Dr. Brod, Dr. Rosamilia and Dr. Sundlass participated in legislative meetings during Melanoma Wednesday.

The PAD would like to thank our volunteers for continuing to make this annual public health event a success!

The PAD would like to thank our volunteers for their participation in the screening event that also took place at the Capitol. It was another successful event and we are confident that “Melanoma Wednesday” will continue to be a great service to our community.

4

SPRING 2018

Legislative Update By: Bruce Brod, MD Sunscreen Access Legislation Pennsylvania House Bill 1228 was passed unanimously on April 26, 2018 and is currently in the Senate Education Committee.

This bill would amend the Education Code and create a uniform policy in Pennsylvania so that children are able to apply their own sunscreen without requiring a physician note and application by a school nurse.

May is Skin Cancer Awareness Month in Pennsylvania A resolution was passed in both the Pennsylvania House (prime sponsor Representative Becky Corbin, R-Chester) and Senate (prime sponsor Senator Pat Brown, R-Lehigh). declaring May as Melanoma and Skin Cancer Protection and Prevention Month. In fact, during Melanoma Wednesday, May 2, 2018, at the State Capitol, several PAD members were recognized on the floor of the House as these strides were announced by Representative Corbin of the 155th District.

Prior Authorization Bill Pennsylvania is leading the way nationally with PA House Bill 1293 introduced in spring 2017, now in the House Insurance Committee,

addressing a more streamlined and transparent prior authorization process.

With support from the AMA, PAMED, and the PAD, this legislation is gaining traction but we are calling for members and patients to contribute cases in which prior authorization inconsistency and injustice affected patient care and outcomes. https://www.pamedsoc.org/detail/ article/Prior-Auth-Bill

Support for Team Based Care We continue to oppose the current versions of House Bill 100 (granting nurse practitioners independence practice) and Senate Bills 895/896 (requiring less physician and Board of Medicine oversight of physician assistants) to preserve safe, effective, and accessible patient care in the physician-led team model. https://www.votervoice.net/PAMED/ Campaigns As Chair of the Congressional Policy Committee of the American Academy of Dermatology Association (AADA), I had the privilege of testifying earlier this year before the Health Subcommittee of the U.S. House Energy and Commerce Committee in Washington D.C. on the impact certain provisions of the Drug Quality and Security Act have on the practice of dermatology. In short, I brought to light some of the limitations we face if there are only a limited choice of federally licensed pharmacies from which we can procure office use compounded medications such as podophyllin and squaric acid. Further, our in-office

preparation of, for instance, buffered lidocaine should not require the same specifications as a sterile compounding pharmacy such as gowns and laminar flow hoods. The full testimony is linked below. We await clarification and specialty-specific recommendations from the FDA and US Pharmacopeia in the near future. https://energycommerce.house.gov/ hearings/examining-implementationcompounding-quality-act/ Do you like being involved in the legislative process? Let us know, and we can tell you more about the House of Delegates, the governing body of the Pennsylvania Medical Society.

Also, plan to be involved in physician advocacy days at the Capitol, like Melanoma Wednesday!

About the Author Dr. Bruce Brod is a Clinical Professor of Dermatology and is on the faculty of the University of Pennsylvania Department of Dermatology.

He is also the Co-Director of the Contact Dermatitis Clinic at Penn. In addition, he is an attending physician at Children’s Hospital of Philadelphia. Dr. Brod is currently a board member of the PAD and is the Congressional Policy Chair of the American Academy of Dermatology.

5

PRACTICE MANAGEMENT TIPS

Take Advantage of HISP! By: Scott Lim, DO Sadly, where I live, most of the EMR-utilizing practices that I have spoken with have never heard of HISP or Direct Mail, despite the fact that it has been around for years. If they were aware, then they would be happy to know how it can save a lot of time and money.

there is no central directory of Direct Exchange Addresses. If a provider with whom you exchange data uses an HER with a different HISP, you will likely have to manually enter the provider’s Direct Exchange Address somewhere in your HER interface, similar to how you enter other practices’ fax numbers.

HISP stands for “Health Information Services Provider”- an organization that manages security for health information exchange among health care entities or individuals. HISP functions can be performed by existing organizations, like your HER vendor or hospital, or standalone organizations specializing in HISP services.

Spread the word and get on board with HISP. It will benefit your office efficiency, and the shared information can help your patients.

Two of the key functions of HISP is issuing security networks and issuing direct addresses. A direct address is akin to an email address between your HER and that of another HER that is secure and HIPAA compliant. One may also think of it like e-prescribing, which sends patient information securely to pharmacies.

In my practice, HISP is especially useful for when I referring patients out for Mohs surgery. All of the Mohs practices I work with share their HISP address (Direct Mail Address)

6

You can learn more of Direct Mail at: https://www.healthit. gov/sites/default/files/ directbasicsforprovidersqa_ 05092014.pdf with me so that my chart notes, pathology reports and high-resolution photographs can be sent to and received by them at a click of a button.

Yes, that’s right-no printing, faxing, scanning, nor shredding anymore!

Needless to say, my staff appreciates it. My bottom line appreciates it, too. I am currently working with my dermatopathology lab to have my high-resolution photographs shared with the dermatopathologist via HISP to provide better clinicohistopathologic correlation.

Imagine if all our communication and data could be done securely with a click of a button. This is ultimately where the future is headed. Ask your HER vendor whether you have a Direct Exchange Address and how you may obtain it. Share it with practices to which you send referrals. Different EHRs may use different HISPs and

About the Author Dr. Lim is a private practice dermatologist in Erie, PA. He currently serves as Vice President of the PAD.

SPRING 2018

FACToid By: Geoffrey F.S. Lim, MD and Timothy Patton, DO

Case 60-year-old white male with history of primary lambda light chain AL amyloidosis status post heart transplantation, autologous peripheral stem cell transplant, post-transplant chemotherapy, and history of voriconazole use presented to the dermatology clinic for a skin cancer screening.

He does not carry a personal or family history of skin cancer, and he also denies prior blistering sunburns and use of tanning beds. His skin has been in fair condition since his last screening two years prior, however, his wife noticed the gradual appearance of an asymptomatic brown plaque on the left posterior helix.

What’s the diagnosis?

A. Seborrheic keratosis B. Benign nevus C. Malignant melanoma D. Nodular localized cutaneous amyloidosis

Continue to page 30 for the diagnosis

7

Policy Updates and Changes UnitedHealthcare Announces Policy Change on Office Based Procedures Effective April 1, 2018 UnitedHealthcare has changed their policy for OfficeBased Procedures. A copy of the new policy is listed on pages 10-13.

Click on the image to read full document

Independence Blue Cross to Change Policy on Reimbursement for In-Office Pathology Billing Independence Blue Cross (IBC) has issued a policy change limiting and clarifying their reimbursement for in-office pathology billing for all specialties starting April 1. In the original iterations of the policy earlier this year, it was unclear how this would specifically affect Dermatology practices in PA. After in-depth discussions with IBC’s medical director about differing practice models in our specialty, the following are takeaway points: •

IBC permits direct billing by a dermatology practice performing their own dermatopathology lab services. It does not permit billing by board certified dermatopathologists when they are not board certified or eligible dermatologists.

•

It bans unbundling of dermatopathology lab services as applies to the technical or professional component.

•

It limits dermatology practices referral access to a number of participating dermatopathology labs to which specimens can be sent for processing and interpretation.

View the letter from IBC on pages 14-21 to the PAD outlining more details about our inquires, including the reference labs noted above.

8

We would invite any members to contact us at info@padermatology. org if you have questions or are experiencing differing interpretations of this policy in your practice billing and reimbursement.

Your membership offers you our support and detailed research into issues such as these!

Click on the image to read full document

SPRING 2018

Independence Blue Cross – Modifier 25 Policy Update

•

Effective August 1, 2017, Independence Blue Cross (IBC) changed its policy on payment when Modifier 25 is used.

When an evaluation and management (E/M) service is provided on the same day as a procedure with a 0-day or 10-day global period, IBC now reduces reimbursement for the E/M by 50 percent. It also reduces reimbursement for the E/M when it is provided on the same day as a preventive service.

To date, the AADA, PAD, and Dermatological Society of New Jersey requested an opportunity to discuss our concerns regarding this new policy.

A copy of this letter can be found on pages 22-29. Unfortunately, despite several requests by both the AADA and PAD, IBC has been unwilling to meet and discuss our concerns. In addition, multiple other state specialty societies worked with the Pennsylvania Medical Society (PAMED) to voice their concerns to IBC. This issue continues to be a high priority for the PAD, AADA, AMA and PAMED. While we are actively working to have this policy reversed, we recognize the current reality of this policy change and are providing our members with tips on how to properly use the Modifier 25 code.

Quick Facts on Appropriate Usage of the 25 Modifier: •

Don’t bill an E/M code automatically every time you perform a minor procedure in your office.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented in the patient’s medical record to support the need for Modifier 25.

Please review these two excellent articles from the AAD for more information and examples regarding the 25 Modifier. The second article describes what E/M components are already included in the surgical fee for each of our minor surgical codes.

Click on the image to read full document •

Append Modifier 25 to the E/M code on the claim, not to the procedure code.

•

Recognize that minor procedures include as part of the surgical fee at least the following components: an assessment and physical exam of the lesion or problem area; explanation of indications, risks, and consent for the procedure; and post-procedure care and instructions.

•

If you perform an E/M service above and beyond what is associated with the procedure, make sure that the extended E/M work is significant and medically necessary; don’t bill an office visit for incidental findings unless a good clinical rationale for doing so is apparent.

1.

https://www.aad.org/dw/monthly/2018/march/modifier-25-revisited

2.

https://www.aad.org/dw/monthly/2013/july/to-25-or-not-parttwo#allpages

9

UNITEDHEALTHCARE POLICY CHANGE ON OFFICE BASED PROCEDURES

10

SPRING 2018 UNITEDHEALTHCARE POLICY CHANGE ON OFFICE BASED PROCEDURES

11

UNITEDHEALTHCARE POLICY CHANGE ON OFFICE BASED PROCEDURES

12

SPRING 2018 UNITEDHEALTHCARE POLICY CHANGE ON OFFICE BASED PROCEDURES

13

INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

14

SPRING 2018 INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

15

INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

16

SPRING 2018 INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

17

INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

18

SPRING 2018 INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

19

INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

20

SPRING 2018 INDEPENDENCE BLUE CROSS TO CHANGE POLICY ON REIMBURSEMENT FOR IN-OFFICE PATHOLOGY BILLING

21

INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

22

SPRING 2018 INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

23

INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

24

SPRING 2018 INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

25

INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

26

SPRING 2018 INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

27

INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

28

SPRING 2018 INDEPENDENCE BLUE CROSS- MODIFIER 25 POLICY UPDATE

29

FACTOID continued from page 7

Residency program corner

Temple University Hospital, Department of Dermatology

Diagnosis C. Malignant melanoma

Discussion By: Brandon Rowe The Department of Dermatology at Temple University Hospital reopened its residency program in 2016 after a 25-year hiatus.

It is led by the Department Chair, Sylvia Hsu, MD. The residency program features six residents who serve the underserved population of North Philadelphia. The program emphasizes its training on correctly identifying dermatologic conditions by mastering the physical examination and clinicalhistopathologic correlation. Residents are encouraged to identify a single leading clinical diagnosis for each case and complex cases are discussed by the residents and attending physician as a group. In cases where histopathologic correlation is required, residents are updated on biopsy results in order to continue to improve their accuracy of correctly identifying dermatologic conditions. It is the philosophy of Temple Dermatology that through these training exercises, the resident physicians are able to achieve the pinnacle of their physical diagnostic abilities.

30

Residents receive four hours of attending-lead didactic sessions per week through presentations, kodachromes, and quizzes that correlate to the weekly readings.

Each week attending physicians and residents relay their experiences with dermatologic diseases, medical, and surgical therapies that enhance the residents’ base knowledge of dermatology. This knowledge is enhanced by weekly resident continuity clinics, which provide the follow up required to fully understand medical therapies and disease courses.

Abhishek Aphale, MD leads the resident surgical training, with micrographic surgery at Fox Chase Cancer Center and monthly surgery clinics at Temple University Hospital. Residents receive their dermatopathologic training at weekly sessions with Jason Lee, MD at Jefferson Hospital where residents learn the histopathologic basis to the diseases they see in clinic and view their biopsy slides.

About the Author Brandon Rowe is currently in his second year of residency at Temple University Hospital.

Histologic evaluation with H&E and SOX10 staining confirmed a diagnosis of malignant melanoma, superficial spreading type, with a Breslow depth of at least 0.9 mm, no ulceration, and a mitotic rate of 3 per square mm. According to the revised 8th edition AJCC Melanoma Staging System, tumor mitotic rate is removed as a staging criterion for T1 tumors, and T1 is now subcategorized by tumor thickness at a threshold of 0.8 mm. Specifically, T1a melanomas are now defined as nonulcerated and <0.8 mm in thickness, while T1b represents melanomas 0.8-1.0 mm in thickness regardless of ulceration status or ulcerated melanomas <0.8 mm in thickness. Hence, our patientâ&#x20AC;&#x2122;s melanoma demonstrated at least primary tumor stage T1b, with further staging workup currently in progress.

The clinical presentation of this melanoma is striking for its resemblance to an otherwise benign seborrheic keratosis (SK). Carrera et al. (2017) examined a subset of SK-like melanomas and retrospectively reviewed dermoscopic features suggestive of melanoma.

The presence of a blueblack sign, pigment network, pseudopods or streaks, and/

SPRING 2018 or a blue-white veil, despite the presence of other SK features, were most helpful criteria in correctly diagnosing these melanomas using dermoscopy, which can aid in the detection of these otherwise disguised malignancies.

As a consequence of chronic immunosuppression, transplant recipients have a reported 2- to 5-fold increased risk of malignant melanoma. Cardiothoracic transplantation requires a greater degree of immunosuppression to maintain graft function as a direct consequence of its higher rate of organ rejection.

Unsurprisingly, patients with cardiothoracic transplantation experience a greater incidence of cutaneous complications from immunosuppression, and melanoma in this population has been associated with worse outcomes compared to the nontransplant population.

REFERENCES Gershenwald JE, Scolyer RA, Hess KR, et al. Melanoma staging: Evidence-based changes in the American Joint Committee on cancer Eighth Edition Cancer Staging Manual. CA Cancer J Clin.

2017;67:472-492.

Carrera C, Segura S, Aguilera P, et al. Dermoscopic clues for diagnosing melanomas that resemble seborrheic keratosis.

JAMA Dermatol. 2017;153(6):544551.

Dahlke E, Murray CA, Kitchen J, Chan AW. Systematic review of melanoma incidence and prognosis in solid organ transplant recipients.

Transplant Res. 2014;3:10.

PRESIDENT’S MESSAGE continued from page 1 more transparent and streamlined guidelines from insurance companies; we are also advocating for fairer pharmaceutical compounding regulations that improve access to necessary medications for patients.

We also actively oppose any legislation that sacrifices or fragments physician-led team-based care, and we consistently stress the importance for all medical providers to practice within their safe and legal scope.

Further, we are in constant contact with medical directors from major insurance companies to share experiences our patients and practices encounter regarding new policies, such as the 25-modifier reimbursement cut from Independence Blue Cross and the isotretinoin prior authorization policy change with more stringent access to the drug from Highmark Blue Cross/Blue Shield. In fact, input from our executive committee aided in officially reversing this policy, in that as of May 11, no prior authorization for isotretinoin will be required with this health plan. Your membership contributes to these crucial ongoing efforts, and we welcome any feedback on new or unresolved issues affecting your practices.

We also have an exciting annual meeting planned for September 14-16, 2018, at Kalahari Resort in the Poconos (see page 3) with fantastic speakers, workshops, and topics for all practice types. In addition, we welcome resident participation in this conference at the resident symposium and Mole Bowl, and we appreciate their input and insight as committee members and volunteers for our many projects throughout the year.

As president, my goals for 2018, as evidenced by our priorities above, reflect a commitment to delivery of impeccable patient care. Too often, the political, legal, and commercial issues in medicine create an environment where we as physicians feel as though we are ‘fighting’ for the preservation of our training, our specialty, and most importantly our delivery of care.

I hope that as part of this effective organization and its hardworking executive committee including our tireless Executive Director, Jennifer Keeler, and Drs. Scott Lim, Renee Mathur, Joslyn Kirby, and Rosalie Elenitsas, that we can effectively do some of the ‘fighting’ for you and improve our patients lives and our own.

About the Author Dr. Lorraine Rosamilia practices dermatology at Geisinger Scenery Park in State College, PA. She currently serves as President of the PAD and is on the 2018 Annual Meeting Planning Committee.

31