Thursday, January 17, 2019

Recommended Dermatology Meetings #PACPearls

Dermatology conferences and meetings offer great resources to network, learn from industry experts, and bring back useful information which can be used in your everyday practice. The WDS Practice Advisory Committee (PAC) has put together a list of their recommended meetings to attend related to business and practice management for both dermatologists and office managers.

AAD - American Academy of DermatologyI love the "Hands On" courses at the AAD! These are a fantastic way to update existing skills and learn new skills one-on-one from experts around the country and world.

- Molly Hinshaw, MD

ADAM - Association of Dermatology Administrators and Managers Annual MeetingOur office manager feels ADAM, Association of Dermatology Administrators and Managers Annual Meeting, is the most comprehensive and efficient way to learn about changes that happen each year. This meeting happens in conjunction with the AAD.

It is better than attending general dermatology meetings because the meeting focuses on only the manager role. Often other meetings include medical, surgical, or other clinical highlights that do not pertain to the office manager or business. Other management courses are often broad overviews, and this meeting is very focused and detailed. It includes more than just the basic information.

ADAM discusses everyday problems and resolutions that managers can benefit from. Interaction and networking with other practice managers is invaluable. ADAM has a fantastic annual survey that gives insight into trends in dermatology and is not weighted by a company selling anything.

- Sarah Jackson, MD and Deirdre Hooper, MD

ASDS - American Society for Dermatologic SurgeryThe ASDS annual meeting features diverse learning topics covering skin care, new techniques, new technologies as well as providing a great forum to connect with colleagues practicing procedural and aesthetic dermatology. I particularly enjoy the Unplugged session that takes place before the official start of the conference - there I learn about unique practices, pearls and perspectives on products, devices and approaches.
- Monica Li, MD, FRCPC, FAAD

ASLMS - American Society for Laser Medicine and SurgeryThe ASLMS Annual Conference is great for both for dermatologists with experience in lasers and those looking to expand their practice with laser medicine. As technology with medical lasers and energy-based devices are rapidly expanding, this conference offers insights into cutting edge evidence-based research and real-life experiences from some of the best laser experts in the country. If you are looking to purchase a new device or grow your expertise in using devices that you already have access to this conference is a must!
- Jeanette M. Black, MD

Tuesday, December 18, 2018

CMS Final Rule and Telederm #PACPearls

By Dr. Mark Kaufmann

There’s been a lot of talk about CMS approving Telederm for reimbursement. I am going to lay out what we know so far. Below are the two G codes that will be available to us starting January 1, 2019.

G2010 - Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours (or soonest available appointment).

G2012 - Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

*PLEASE NOTE: These two G codes are considered communication technology codes, and NOT considered “Medicare Telehealth services.” That being the case, they are NOT subject to geographic restrictions, and are NOT billed using E/M codes with modifiers.

G2010 is essentially “store-and-forward” telederm and it requires follow-up with the patient within 24 hours of receipt. G2012 is essentially a 5-10 minute medical discussion using a “communication technology-based service.” This may require further clarification, but so far, CMS has stated that the code allows “audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.”

A couple of take-homes
First, these are only available to use on established patients, not on new patients. These codes are both predicated on not having seen the patient in the last 7 days, and not setting up an “in-person” appointment with them within the following 24 hours or “soonest possible appointment.”

Also, “beneficiary consent” is required prior to providing a remote service, and this must be noted in the medical record for each service (the consent itself can be verbal consent, but it must be documented that it was obtained). This consent should include knowledge that you will be billing Medicare for this remote visit.

Based on what was published in the CMS Final Rule, G2010 will reimburse $12.61, and G2012 $14.78. These amounts are national average.

New Skin Biopsy Codes
Just a reminder, we also will have six new skin biopsy codes going into effect on January 1, 2019. Review these changes in the August 2018 PAC Pearls.

Wednesday, November 14, 2018

Tips to Manage Hiring and Firing in your Dermatology Practice #PACPearls

A collection of PAC Pearls from the Women’s Dermatologic Society

Managing staff employment is an essential element to a successful private practice. The WDS Practice Advisory Committee (PAC) has put together a list of pearls to help navigate staff hiring and firing in your Dermatology practice. 

1. Hire Slowly and Fire Quickly 
Consider a prolonged new employee interview after initial screening, where the candidate spends time in the department they will work in. Get feedback from your current employees and make sure that the candidate is someone they can see themselves working with. Have a 90 day trial employment with assessment by the office manager and the physicians at the end of the 3 months. Be clear that if they are not working out after 90 days, they will be let go. This makes everyone re-evaluate the candidate. If someone is not performing, or is a negative energy in your office, let them go. Delaying firing a weak or negative employee, no matter how difficult, drains the entire staff!      
- Sara Jackson, MD

2. Clear Communication
Clear communication and expectations are important for effective management of staff members within a dermatology team.  A written delineation of roles and goals is particularly useful when it is time to give feedback and serves as a reference for what staff need to do to ensure that the practice functions at its best.
- Molly Hinshaw, MD

3. Be Organized and Know Thyself
Two things I have learned in my twelve years of business ownership: 1) organization is key and 2) know thyself — you must know who you are and what you want out of your career/business. As to hiring, a new person must fit into your culture. If you can provide a detailed list of job duties, an understanding of your philosophy and values and allow candidates to spend a morning with you on your busiest day, both of you can see if the position is a good fit. As to firing, you must recognize when it is time for someone to leave your organization. Sometimes it is clear that a toxic person is holding you and your staff hostage, other times, it is subtle. Regular evaluations can help both you and the employee know if the fit is still good.
- Elizabeth Long, MD

4. Seek Feedback
Do an exit interview. Whether you are firing, or the person is choosing to leave, this is a great time for candid discussion of the pros and cons of working at your office. Sometimes it hurts your feelings! Sometimes it's sour grapes from someone unhappy, but often there are some nuggets of feedback that can help you be a better boss.      
- Deirdre Hooper, MD

5. Develop Resources
Create a handbook that can be passed along from previous to current employees. It will serve as a basic guide for day to day clinic tasks and also provide instructions for managing issues such as trouble shooting computers, cameras, or lasers. The handbook can be periodically updated and is a great resource for current employees, but especially helpful for new hires.     
 - Jeanette Black, MD

Wednesday, October 10, 2018

Managing Angry Patients #PACPearls

The Practice Advisory Committee has put together a list of pearls to help manage angry patients.

Anger in some situations is a secondary emotion. I try to identify and address the primary emotion instead of the anger. For example, fear and anxiety are two primary emotions that can result in anger. Reassuring the patient by addressing their fear and anxiety helps dissipate the anger.
- Molly Hinshaw, MD

Listen, 90% of the time an angry patient just wants to be heard. And often they have a valid point. I always say I hear you, let me take care of your skin, and then I’m going to make sure that your problem gets taken care of. And if it’s my fault, for example running late, I apologize and move on.
- Deirdre Hooper, MD

Listen with empathy. Let the patient express what they would like to say and acknowledge their frustration to deescalate the situation as much as possible. Even several minutes of letting the patient talk without interruption can really help to turn the tide for mood in the room.
- Monica Li, MD

When dealing with an angry patient, I find it most helpful to acknowledge, apologize and then move forward. If you walk in and immediately acknowledge that they are angry, tell them you understand why they are angry and apologize immediately it can deescalate the situation. I think most people just want to be heard and can then move on.
- Sarah Jackson, MD

Take a deep breath, allow them to vent for 1-2 min, then give a calm, thoughtful response including re-stating the patient’s concerns.
- Mark Kaufmann, MD

Managing an angry patient takes a lot of time and effort and can become emotionally draining. After the situation is resolved it is important not to let one negative patient interaction effect you for the rest of the day. It isn’t fair to your other patients or your staff if your mind is distracted and you remain upset all day. Additionally, taking home this negativity isn’t healthy for yourself or your family. After an interaction with an angry patient take a moment to reset and refocus so you can move on and don’t internalize the anger.
- Jeanette Black, MD

Wednesday, September 12, 2018

Tips to Avoid Burnout in Your Practice #PACPearls

WDS Practice Advisory Committee PAC Pearls: Tips To Avoid Burnout in Your Practice

The Practice Advisory Committee has put together a list of pearls
to avoid burnout in your practice.

Focus on Your Strengths
You should spend your day doing what you were trained to do, and minimize the time you spend on regulatory and administrative tasks. 
- Dr. Mark Kaufmann, MD

Get the Support You Need
We hired a coder/biller who reviews our notes after we are finished. She verifies that what we have recorded in the note meets the level of service that we have billed. This has saved me hours of tediously going through notes to make sure I have coded correctly. This has increased my job satisfaction tremendously. Well worth it!
- Dr. Sarah Jackson, MD

Expand Your Passions
Find a passion (or a hobby) outside of medicine. My outside interests in art and design have led me to engage more in my community, travel, and improve the visual state of both my home and office. A happy visual space makes for a place I want to be in.
- Dr. Elizabeth Long, MD

Connect with Nature
Nature is a great way to soothe the mind and soul - schedule a hike, day by the lake/ocean or an outdoor activity at least once a month to recharge and reflect.
- Dr. Monica Li, MD

Give Back and Get Inspired
Get involved in training programs. This could mean anything from letting residents or medical students shadow or spend time rotating with you, lecturing at medical schools and residency programs, or helping to staff resident clinics. It could be a small time commitment as little as 1-4 times a year or more regularly. 

It is a nice break from our regular clinics and the time to interacting with medical students, residents, or fellows can be inspiring and refreshing. The energy and excitement of young, eager physicians helps to remind us of how far we’ve come and what it was that first inspired our passion for dermatology. 
- Dr. Jeanette Black, MD

Engage Your Curiosity
Find a topic that interests you outside of your day to day practice grind, learn more about it, and get involved! Join a committee, volunteer to review a journal, get involved in advocacy, or write a paper. Dermatologists are such an interested, smart bunch of people and expanding your knowledge will help you engage with others and broaden your support network.
- Dr. Deirdre Hooper, MD

Tuesday, September 11, 2018

Young Physician Spotlight - Dr. Arisa Ortiz, MD

Dr. Arisa Ortiz, MD

Arisa Ortiz, MD, is a board-certified dermatologist and director of laser and cosmetic dermatology at UC San Diego Health. She specializes in the latest noninvasive procedures, including laser skin resurfacing, dermal filler and toxin injections, body contouring, skin tightening, and the treatment of scars.

Dr. Ortiz is a frequent speaker at the American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, and currently serves as chair of a national aesthetic meeting. She was a guest editor for Journal of Lasers in Surgery and Medicine and serves as a reviewer for Dermatologic Surgery Journal. In addition, she has published over 30 original medical articles and chapters on new innovations in cutaneous laser surgery.

She completed a laser and cosmetic dermatology fellowship at Massachusetts General Hospital, Harvard Medical School and Wellman Center for Photomedicine. She acquired additional fellowship training in Mohs micrographic surgery at UC San Diego. She completed her dermatology residency at UC Irvine and the Beckman Laser Institute. Dr. Ortiz earned her medical degree from Albany Medical College in New York and is board-certified in dermatology. She is a fellow of the American Academy of Dermatology (FAAD). Dr. Ortiz has received many honors and awards including the 2014 Doctor’s Choice Award in dermatology for La Jolla. (Source)

How did you become involved in the WDS and what benefits do you think WDS membership provides for residents/young physicians?
My first introduction to WDS was through one of my mentors, Dr. Tina Alster. She invited me to the annual luncheon at the AAD. I think that’s probably one of the main benefits of WDS is establishing mentorship, lifelong membership, with women that you can look up to and emulate and go to with any of your questions about your career or about how to balance life with career. I think those relationships that you maintain have been the most significant benefit for me.

At what point did you decide that you wanted to do academics versus private practice? What's the biggest challenge you've faced in academia?
Throughout residency I assumed I would go into private practice, but my career path sort of led me towards academics because I ended up doing multiple fellowships after residency and I felt like academic medicine would help to make use of those fellowships. I also felt like continuing my research interests would be more supported in an academic setting. Also, I had the opportunity to develop the cosmetic practice at UCSD since there really wasn’t one at the time. It was an opportunity to build something from the ground up.

There’s always different hurdles whether you’re in private practice or academics. One of the biggest challenges in academia is just being patient. There’s always a process to getting things approved or adding new procedures. Even sometimes adding a consent can take 6 months to get approved. I think I’ve just learned to be more patient. Change takes longer in academics.

What advice do you have for residents and young physicians who want to become more involved in research?
Start early. It’s nice to build research skills while you have someone guiding you, so starting early while you’re still in training is helpful. This way, when you’re out on your own, you already have that skill set. Regarding research topics, it’s good to always be thinking of what’s missing in your daily practice- what could we be doing better, where could we advance medicine, etc. Also, just being excited and passionate about the research topics you choose.

Who were/are your mentors?
My very first mentor in Dermatology was Dr. Gary Lask. I met him when I was 18 years old, he was my dermatologist. I had gotten the chicken pox later in life and had developed scars on my face. Initially, I thought I wanted to be a pediatrician, but then I was introduced to Dr. Lask because I was seeking out scar revision. I literally chose him out of the yellow pages. It was just kind of serendipitous that I found a great lifelong mentor and he’s still my mentor to this day.

What are you working on now?
My passion right now is trying to find a way to non-invasively treat basal cell carcinoma. I have been doing a lot of 1064 Nd:Yag laser work which I think is very promising but is still very new. I think we need some more long-term data which we are currently working on. Also looking at how to optimize those treatments. I am also looking at nanoparticle-assisted laser therapy for basal cell carcinoma.

What future goals do you have?
In a year from now when I’m technically 5 years out of fellowship, I would like to start a cosmetics fellowship through the ASDS.

Do you have advice to young physicians on achieving work/life balance?
Schedule things in, because if you don’t, you’ll have a tendency to just get wrapped up in work. For example, if you want to exercise more, just dedicate the time to do it and just commit to it and make it part of your routine. I find that if you just dedicate the time then you find a way to fit it in. Regarding time for family, I’m lucky enough to live close to the office so I can go home at lunch to see my daughter. It breaks up the day for me. Also, when I come home from work, I dedicate my attention to my daughter and husband, I don’t talk about work, or check emails. Then when she goes to bed I have time to catch up on work.

What do you like to do in your free time?
In my free time, I like to spend time with my family. We like to go to SeaWorld a lot, the zoo, and we like to go hiking. We have this trail in the back of our house (Rancho Penasquitos) where you can walk to a waterfall. I also just picked up Pilates. My guilty pleasure is shopping!

Tuesday, August 14, 2018

New Skin Biopsy Codes #PACPearls

By Dr. Mark Kaufmann

On July 12, 2018 CMS published their proposed rule on the Medicare Physician Fee Schedule. This 1,440 page document is filled with some very broad ranging proposals.

These proposals include a blended E/M code system (one E/M code to replace 99202-99205, and 99212-99215), a 50% cut in E/Ms billed with a modifier -25, and another call for comments on whether global period visits are happening, just to name a few.

While many of these changes could have wide ranging effects on all of our practices, today’s pearl will deal with the one change that will definitely happen on January 1, 2019- 6 new skin biopsy codes to replace the 2 that we are used to using.
  1. Current CPT codes 11100 and 11101 will be deleted from the CPT book AND will be denied payment if used on or after January 1, 2019.

  2. Replacing them will be 6 NEW codes- 3 base codes and 3 “additional biopsy" codes.

  3. The three new categories will be “Tangential Biopsy of Skin" (think Shave Biopsy), one for “Punch Biopsy of skin,” and one for “Incisional Biopsy of Skin (think wedge biopsy).”

  4. If you do more than one biopsy, using more than one modality, you would use the base code for the more valuable service, and the “additional biopsy” code from the lower value service. (eg if you do a punch and a shave, you would code the punch base code, and the tangential add-on code).
The following tables will help you to better understand the proposed work RVUs and payment for these new services: