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Winter 2016 e-Newsletter

President’s Message

Dear Colleagues –

As the holidays arrive and many of us travel to spend time with family and friends, I reflect on the value of the communities we are all a part of—from our neighborhoods and cities, our practices and teams, and the groups and organizations we are a part of. One of these, of course, is the Mohs College. I hope you find as much value and satisfaction as I do in the camaraderie, learning, support and advocacy our members offer one another and our profession.

In our membership survey last year, a majority of you indicated that the mixture and frequency of communications from the College—including the e-Newsletter, Cutting Edge news brief, emails and more—was just right. It’s important to point out that this e-Newsletter is an important means of informing and engaging members. Because it’s only sent three times a year in April, August and December and contains information we usually don’t deliver in other ways, I strongly encourage you not only to read its contents but to consider what topics or updates you might like to see included. Let us know at info@mohscollege.org.

For the first time, you’ll find included in this issue a column by the Fellow-in-Training Board Observer, Dr. Adele Haimovic. The Board Observer plays an important role, as he or she not only gains the benefit of more deeply understanding the issues undertaken by the Board, but also serves as the voice of an important group of incoming/future members. I’ve written before in this space about the importance of supporting these young surgeons, their research and their perspectives, and I’m grateful that, starting with Dr. Haimovic, each year’s FIT Board Observer will be a member of the Newsletter Committee to ensure representation and dialogue.

As we await the arrival later this month of responses to the RFPs sent to potential Registry vendors, progress on this critical piece of the College’s future continues. Ashley Wysong has written an update in this issue that outlines some of the challenges the National Registry and Outcomes Committee faces as we move toward the creation of a Mohs registry that will benefit the College in a number of ways. My thanks to committee chair Ian Maher and the NRO subcommittees for their ongoing leadership of this effort.

You’ll find other informative content in this issue, including a number of your recently submitted Mohs coding questions and responses provided by Glenn Goldman, information on another Mohs Technician Quality Assurance initiative training session scheduled for March 2017, a collection of some favorite flaps, and a reminder to submit an abstract for the 2017 Annual Meeting in San Francisco by January 12.

The match just took place for fellowships beginning in July 2017. This year there were many more participants than positions. Fifty-two applicants were matched to positions. Thirty additional positions were filled outside the match through exemptions approved early last summer. Unfortunately, 52 fellowship applicants were unable to find a position for 2017. The College leadership is very sensitive to the unhappiness and disappointment produced by such a competitive situation. Through the Fellowship Training Committee, we strive to keep the process as fair and transparent as possible.

With 2016 drawing to a close and 2017 approaching, may we look to one another and to our future with optimism and with gratitude for being able to practice one of man’s most noble professions. Together, let’s make 2017 our best year yet. I look forward to seeing you in San Francisco; until then, Happy Holidays to you and your family!


Thomas Stasko, MD, FACMS

ACMS President, 2016-17
president@mohscollege.org


ACMS HAPPENINGS

2017 Annual Meeting Call for Abstracts

Submit an abstract for consideration of an oral or poster presentation at the 49th American College of Mohs Surgery Annual Meeting in San Francisco. There are two categories of abstracts:

  1. Scientific abstracts: original research that addresses the most urgent needs of our patients and the ACMS. Scientific abstracts with a primary author who is a fellow-in-training or who is in his or her first year of practice after completing a fellowship in Micrographic Surgery & Dermatologic Oncology will be eligible for the Tromovitch Award Competition.
  2. Rapid Pearls abstracts: two-minute anecdotal pearls regarding Mohs surgery technique, frozen section pathology, reconstructive surgery, or practice management.

The deadline for abstract submissions is 11:59 pm PST on Thursday, January 12, 2017.

In addition to abstract submissions, fellows-in-training are invited to submit a case for the Clinicopathologic Case Competition: fellows-in-training may submit clinicopathologic slides and photographs of Mohs cases that have uncommon or rare pathology or that illustrate prototypical diagnostic challenges and keys to diagnosis or tumor detection. Case submissions must be received in the ACMS office by February 15, 2017.   

To learn more about each of these opportunities, please see the full Call for Abstracts for details at the link below. If you have questions about the submission process, please contact info@mohscollege.org. We look forward to your contribution and seeing you in San Francisco!


ACMS HAPPENINGS

Call for Mohs Award Nominations

The ACMS Board of Directors is requesting nominations for the Frederic E. Mohs, MD Award for Career Achievement.

This award, which was first presented in 2004, is named in memory of the esteemed physician who developed the micrographic surgery technique and founded the College, Frederic E. Mohs, MD. The objective of this prestigious lifetime achievement award is to honor individuals who promote Mohs surgery throughout their career with their teaching, clinical practice, scientific contributions, innovation, mentorship, or service to the organization, in the spirit of Dr. Mohs. The award will be presented at the Business Meeting taking place Friday, April 28, 2017 during the Annual Meeting in San Francisco.

Nominations for this award may be submitted by completing the designated spaces in the questionnaire linked below. You can re-enter the questionnaire at any time to update your responses, however nominations must be completed on or before Tuesday, January 31, 2017.

Enter the nomination questionnaire

If you have any questions, contact Becky Brandt at the ACMS office at (414) 347-1103 or rbrandt@mohscollege.org.


ACMS HAPPENINGS

MACRA for Mohs Surgeons Webinar Recording and FAQ Available Online

The Centers for Medicare and Medicaid Services (CMS) recently released its long-awaited final rule implementing the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Medicare Physician Fee Schedule (MPFS), programs established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These unified policies to promote greater value within the healthcare system are referred to as the Quality Payment Program (QPP), and are set to begin on January 1, 2017.

This webinar, which took place on November 10, provides an overview of the final rule, highlighting key provisions of interest for Mohs surgeons. Don’t miss out on this opportunity to learn about the future of Medicare physician payment.

View the webinar recording and FAQ document here. (member login required)
Fellows-in-Training: use this link to access the webinar recording.

Presenter
Emily L. Graham, RHIA, CCS-P
VP, Regulatory Affairs
Hart Health Strategies, Inc.


ACMS HAPPENINGS

Slide Quality Review Program Yields Results

The ACMS frequently receives requests for technical tips and pearls to best prepare frozen sections. Because of the need to continuously demonstrate the high quality of Mohs surgery performed by its members, the College developed an anonymous review and feedback mechanism for the membership in 2015. This free pilot program was initially offered to the fellowship training programs prior to being offered to the general membership.

Slides are anonymously reviewed by two ACMS Mohs surgeons as well as a histotechnologist from the American Society for Mohs Histotechnology. Slides are evaluated for having a complete epidermis, dermis and fat tissue without holes or gaps, appropriate tissue thickness, staining quality, and presence of tissue, staining or preparation artifacts. An overall evaluation is made, and any suggestions for improvement are sent to each participant. All participants receive a certificate of participation.

Results thus far have been positive:

  • Membership Slide Review: Seven groups of 100 members each received invitations to submit a slide, and 151 submissions have been received as of October 2016.
  • MSDO Training Program Review: Directors of Micrographic Surgery and Dermatologic Oncology fellowship training programs were also invited in November 2015 to submit slides for review; 18 submissions have been received to date.
  • Fellow-in-Training Clinicopathologic Case Competition: The third annual competition was held in 2016 for fellows-in-training to submit interesting cases for review. A total of 29 submissions were received in 2016. The 2016 winner, Dr. Thomas J. Knackstedt, presented at the ACMS Annual Meeting in Orlando. These cases will also be used to build the ACMS teaching slide library. The competition will be held again in 2017—see details here.

The ACMS is committed to improving slide quality, so please consider participating in these programs by submitting your very best slide preparation. If you would like to submit slides for review and have not yet received an invitation letter or email, contact Mary Randall at (800) 500-7224 for slide preparation guidelines and a submission form.


ACMS HAPPENINGS

Ask Glenn: Answers to Your Mohs Coding Questions

Responses provided by Glenn Goldman, MD, FACMS

Q: I would appreciate your input on 2 coding questions:

  1. You do a biopsy with frozen section processing, confirms skin cancer, you proceed with Mohs surgery. Could you code for: shave biopsy, CPT 88331 pathology consultation during surgery with frozen sections, Mohs layer?
  2. What if you do the biopsy with frozen section processing but also send the tissue for permanent dermpath evaluation and confirmation. Then proceed with Mohs surgery the same day. Could you still code for shave biopsy, CPT 88331, Mohs layer?

A: The billing is 11100 (biopsy) -59, 88331, 17311. If you then send the tissue for permanent sections that is legal per CMS, however, doing this often is likely to trigger a RAC audit. If I send for any permanents I always explain in the note exactly why that is being done.

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Q: I have asked my hospital billing department certain questions about Mohs billing/collections and am not getting answers that fully explain my questions. The questions are primarily regarding our university’s average collection per Mohs surgery case. Using publicly available Medicare data from CMS, I am able to deduce that our average collections per case is approximately 50% that of our peer state Mohs surgeons and our peer academic institutions. Our hospital billing department has explained some of the discrepancy, but the majority of the discrepancy is unexplained.

A: The average collections per Mohs case at a University are based on the following:

Payer mix – If you are heavily Medicaid-based then your average will be low. In many locations the only Mohs providers who accept Medicaid are university based. This can have a very large impact on remuneration per case.

Negotiated fees – If you are at an institution which negotiates / carves out well, you will get higher remuneration per case

Method of billing – Many academic institutions do facility billing. In those cases the fee for the facility may be very substantial and this is reflected in a somewhat diminished fee paid to the provider. It is imperative in a situation such as that that the provider is paid based on wRVU output rather than collections, as the overall collections for the institution and provider are greater when facility fees are charged. If your institution is charging Mohs and repair as an OFFICE SITE without facility fees then the remuneration per Medicare patient must be by law the same at your site as per other Medicare sites in the same jurisdiction.

How cases are performed / billed – If you do multiple sites at once, which is common in academia, you will receive lower pay on average. Other factors may be at play, but in the absence of the specifics / payer mix / etc it would be hard to comment further.

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Q: I am a current Mohs fellow, planning to enter academic practice next year. My coding question is as follows: It is commonly the case that subcutaneous tumors (Leiomyosarcoma, DFSP, etc) are treated with wide-margin Mohs (>1-2cm margin of normal tissue). The 2016 CPT codebook defines "radical resection of soft connective tissue tumors" as, "resection of the tumor with wide margins of normal tissue". Does wide margin excision with subsequent Mohs evaluation of margins qualify as radical resection with intraoperative frozen section analysis? The wRVU assigned to radical resection is significantly higher, and may more accurately reflect the complexity of these cases. Your input would be appreciated.

A: Generally Mohs surgery is billed as Mohs surgery. If you do Mohs, you should bill Mohs, no matter what margin is taken. That being said, if you write the note simply as radical resection and then document the use of frozen sections with en face margins you are technically following CPT. My recommendation is to bill the Mohs surgery and reconstruction, as this is MOST accurate.

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Q: I have been getting a lot of reports from numerous sources of "at least squamous cell carcinoma in situ, invasion cannot be ruled out."  I have been coding these as SCCis (D04.__) unless I find evidence of invasion on Mohs in which case I code as SCC (C44.__).  I find it frustrating as I often do not do Mohs on SCCis even if it qualifies according to the 2012 Mohs AUC opting for ED&C or Efudex or a combo, but I feel that this particular read forces my hand toward Mohs as it implies the possibility of invasive tumor.

Another CYA call I have been sent frequently is the report of "atypical squamous proliferation" or its various other nomens. I have been doing these cases as frozen section excisions (Mohs with different CPT codes) unless I find evidence of invasive SCC in which case I change to the Mohs codes. I hate to vacillate on billing when the intention is the same, but I feel these biopsy report hedges force the issue. I guess I just was wondering if I was doing the right thing with these scenarios?

A: Two questions are asked. The first is what to do with SCCIS vs SCC on biopsy. I treat these based on clinical nature of lesion, and that is a personal/practice decision. I agree that pathology reports can be nebulous. We have had several “SCCIS” which have proven to be invasive SCC with perineural involvement. Unless the biopsy report says “AK with focal SCCIS” you are ok to do Mohs, however, we do plenty of CE and shave removal for SCCIS also, so use your judgment.

The second question is how to bill atypical squamous proliferation. This is, of course, a pretty useless pathology reading. I try to assess clinically, take a photo (is it a nodule? Or ulcerated plaque?), then rebiopsy at time of Mohs. I have also asked our pathologists to limit their use of this vague term. If I rebiopsy and feel that the lesion is a wart or irritated SK, which it sometimes is, then we will destroy and/or excise and bill appropriately. MOST lesions we see that are atypical squamous proliferations end up being either hypertrophic AK or SCCIS or SCC.

As an aside, it is important to note WHERE the lesion is. Specifically, the Mohs AUC is different for SCC in situ of the head and neck as opposed to trunk and extremities. Mohs is not generally appropriate for SCC in situ of the trunk and extremities.

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Q: Can I bill a new or established patient visit on day of Mohs without a second diagnosis? Does Medicare assume consultation is included as part of the Mohs code? 

A: If you do Mohs alone – no. IF you do Mohs and an intermediate or complex closure – no. If you do a flap or graft in addition to Mohs you may bill a visit with a 57 modifier – decision to do surgery. Must be a 90 day global period.

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Q: 2 coding questions:

  1. Incisional biopsy on a large cutaneous plaque that requires a layered closure (presumed inflammatory dermal plaque - nonneoplastic).  Biopsy code + repair code OR excision benign code + repair code?
  2. J codes for 5 FU or Bleomycin. Those codes have units associated with them (Bleo- 15U and 5FU - 500mg).  What do you do when you use less than that? Can you only use those codes when you hit those numbers?  Or is it "up to 15 Units of Bleomycin" or "Up to 500mg 5FU?"

A: Question one: There is as of yet no perfect code for this. If you do an elliptical excision it is reasonable to bill D48.5 with the dimensions of the wound and code benign or malignant based on pathology. If the excision is over 5 mm and the wound is closed with two layers of sutures, then an intermediate repair may be billed. We generally do not do this unless we are actually excising a lesion with a margin, but it is not entirely unreasonable. The most conservative billing is to bill as a skin biopsy which encompasses all methods, and that is what we do at our institution.

Question two: For the J code it is appropriate to bill the full unit dosage up to that unit amount for 5-FU and for others. And also bill the injection codes along with this. Document carefully. This may be billed as a pharmacy benefit in some instances depending on the plan/your location.


ACMS HAPPENINGS

MTQA Training: Help Your Histotech Improve Skills

In early October, the American Society for Mohs Histotechnology held a new, customized, hands-on training program through its Mohs Technician Quality Assurance (MTQA) Training Initiative, This off-site, two-day event took place at the Avantik Academy in Springfield, New Jersey.

Thirty attendees came from as far away as New Zealand and Canada to hone their technical skills, learn new techniques, network, and troubleshoot problematic issues. Presentations included mapping/ inking, various embedding methods, H&E staining, management of irregular-shaped tissue and CLIA regulations. Trainer demonstrations and lab instruction reinforced the lecture topics where attendees participated in customized, hands-on workshops. The trainees were receptive and enthusiastic in trying the different embedding methods. A staining wet workshop gave the trainees a better understanding of the histochemistry and the importance of the H&E staining procedure in producing high quality slides. Their own prepared slides were presented for microscopic review with faculty. All trainees practiced preparation of irregular-shaped tissue for cryosectioning. Frozen section technique was of tremendous interest, along with its troubleshooting “pearls.”

Stay tuned for details on MTQA training events scheduled for March 9-10, 2017 and October 12-13, 2017. Upon completion, trainees will be able to claim 12 CEUs through the National Society for Histotechnology, and will receive a certificate of completion from the ASMH/ACMS.

The MTQA Training Initiative was created by the ACMS to elevate the national standard of Mohs histotechnology and is the only ACMS-approved training program designed to help current Mohs technicians improve their skills and learn new techniques. MTQA trainers are approved for the program after an application process and slide review by a panel of ACMS surgeons, and are complete subsequent slide reviews periodically to maintain their status as trainers. Learn more.


VIEWPOINTS

My Favorite Flap

Experienced Mohs surgeons share flaps they love and tips on their execution

By Todd V. Cartee, MD, FACMS

I attended numerous fabulous reconstructive talks at this year’s ASDS meeting and never fail to be impressed by the skill and creativity of our colleagues. I left the meeting inspired to tap into some of that knowledge and asked a few accomplished surgical colleagues to offer up their one “favorite flap.” That is, a reconstruction they relish because of consistent results and, of course, the fun of executing it. While every patient and defect is unique, each of us has certain “go-to” flaps that just seem to always render excellent results in our own hands.

My personal favorite flap is the bilobed for distal third nasal defects, especially for the tip and supratip. I am always amazed at the size and depth of wounds that can be reliably reconstructed with this flap. The one tip I would pass on, I learned from my very talented partner, Christie Travelute. For deep defects that are more lateral, where some internal nasal valve collapse is possible, you can often spare the patient a cartilage graft by just taking a bite of the deep tissue in the wound bed and tacking it to the underside of the primary lobe. This effectively stents open the nasal valve and has made cartilage grafts much less common in my practice for partial thickness defects.

Here are some of the replies I received from College members:

Trilobed
“My favorite flap is the trilobed. It's really changed the way I practice nasal reconstruction, and reduced the number of PMFF I perform while maintaining excellent cosmetic results. I think about using the trilobed in the "4-L's"; large defects (greater than 1.5 cm in diameter), low defects (where the tension bearing defect of the bilobed would fall low enough on the nose so as to be difficult to close), lateral defects (ala), and little noses (where the wound area makes up a greater proportion of the total nasal surface area). I generally use laterally based trilobeds to repair tip and infratip defects and medially based trilobeds to repair alar defects.”

-Ian Maher, MD, St. Louis, MO

Island pedicle
“My favorite flap is the island pedicle flap. These flaps are most useful for the repair of small to medium sized defects of the lateral upper cutaneous lip that are located just inferior to the nasal ala. Limited flap mobility may be a problem with island pedicle flaps. Flap mobility can be enhanced by increasing the length of the flap, narrowing the pedicle of the flap, undermining deeply and widely around the flap, and by removing excess subcutaneous tissue in the base of the postoperative Mohs defect. All or some of these maneuvers can improve the mobility of this useful and robust flap for the repair of post Mohs defects."

-Hugh Gloster, MD, Cincinnati, OH

Cheek advancement plus Burow’s FTSG
“When surgical defects include both the ala and cheek cosmetic units, recreating the alar-facial groove is often challenging. With these defects, I generally bring a cheek advancement flap into the sulcus and tack it down to periosteum at the alar-facial junction. I then use the redundant tricone formed from the cheek advancement flap as a full thickness skin graft to cover the alar component of the defect (provided it is shallow enough for a graft). I use standard interrupted sutures around the graft except where the ala meets the cheek. At this alar-facial junction, I suture the graft back down to the alar wound bed and not to the cheek advancement flap. Likewise, I do not suture the cheek advancement flap in this area. I leave this small gap to heal by second intention and allow the contraction that occurs to help recreate the alar groove.”

-Thomas Rohrer, MD, Boston, MA

Alar rotation
“My favorite flap is the alar rotation flap. This flap is for small defects limited to the alar cosmetic subunit, ideally not much larger than half the vertical dimension of the ala and located adjacent to the crease. The flap is incised along the alar crease laterally and then carried out onto the apical triangle following the melolabial fold. If the defect is 8 mm, extend the incision 8 mm along the NLF. At that point, a back-cut is made extending to the alolabial junction at the base of the ala. The triangle formed by this back-cut is roughly the same area as the defect. The flap is rotated into the defect and a diminutive Burows triangle is excised. The key suture is placed closing the back-cut donor site and is positioned precisely at the junction of the alar base and the apical lip. Another important key is to incorporate as much of the back-cut tissue onto the nose to replenish the alar skin deficit. This prevents distortion of the ala and mitigates most wound tension."

-David Brodland, Pittsburgh, PA

Axial-based conchal transposition
"One of my favorite flaps is the axial-based conchal transposition flap (See Figure). It is ideal for small to large full-thickness loss of the upper ear. The flap is a composite of skin and cartilage lifted from the conchal bowl and centered on the crus of the helix, where cadaveric studies reveal a branch of the superficial temporal artery consistently courses between the skin and cartilage. Composite replacement of tissue provides a structural framework, restores ear projection, and mimics the helical rim curvature with minimal donor site morbidity. The axial supply is quite reliable and I have used this flap to reconstruct full-thickness loss of up to 1/3 of the ear (Perry et al Dermatol Surg 2016 Epub ahead of print). The key to this flap is inclusion of the entire helical crus in the pedicle."

-Joe Sobanko, MD, Philadelphia, PA

Tragal cartilage graft
Dr. Albertini wanted to offer a favorite technique for difficult alar defects (not a flap but a fantastic reconstructive option)

“For thin full-thickness defects of the ala and alar rim amenable to skin grafting, I like to support the alar rim with a thin cartilage graft underlying the skin graft. The pretragal area is highly efficient to harvest both grafts. I draw the graft template anterior to the pretragal crease and incise the template just through dermis and then the ellipse to fat in series. The templated graft is essentially ‘perforated’ so it is very quick to excise, isolate and then thin. Through the pretragal defect, I then incise a narrow strip of tragal cartilage measuring 2-3 mm in width and secure the cartilage graft with a 'lasso’ stitch of 5.0 polyglactin 910 ensuring that it does not drift superiorly. The skin graft is then sutured into the defect and secured with a bolster dressing.”

-John Albertini, MD, Winston-Salem, NC


HOT TOPIC

Update on National Registry and Outcomes Committee

By Ashley Wysong, MD, MS

After the 2014 ACMS Annual Meeting, the National Registry and Outcomes (NRO) Committee was formed as a way to prospectively collect information regarding Mohs procedures by ACMS members. Since inception, the NRO has grown to include six subcommittees and dozens of active members dedicated to designing and implementing the registry in a way that is beneficial for patients and ACMS members.

We recently checked in with committee leadership on goals for 2017. Dr. Ian Maher, chair of the NRO Committee, stated that “the focus of the registry committee this year will be selecting a vendor to administrate the registry and then working with that vendor to set the groundwork for a successful roll out down the road. Our subcommittees are working hard to streamline the final product, from setting up logical defaults to save time, to developing mechanisms that will allow us to capture data without every patient having to return to the office for follow-up.”

Dr. Howard Rogers, vice chair of the NRO Committee, added that since the last update to the membership “there have been significant developments that may affect our registry process. The requirements for a Qualified Clinical Data Registry (QCDR) have been defined and are being continually refined by CMS. The ACMS remains confident that over time the Mohs registry will allow members to fully participate in the quality reporting portion of the Merit-based Incentive Payment System (MIPS) and be of great value to members.” 

Read the full, detailed National Registry and Outcomes Update here. (member login required)


HIGHLIGHTS FROM THE LITERATURE

Sterile vs. Nonsterile Gloves in Outpatient Surgical Procedures:
Any Difference in Surgical Site Infections?

By Joshua Spanogle, MD, FACMS

“Comparison of Sterile vs Nonsterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures: A Systematic Review and Meta-analysis”
- Brewer JD, Gonzalez AB, et al. JAMA Dermatol. 2016;152(9):1008-1014.

During my training, I used both sterile and non-sterile gloves to take Mohs layers, depending on my supervising surgeon’s preference. Invariably, we used sterile gloves for closure. In practice, I use non-sterile gloves to take my Mohs layers and sterile gloves for closure. The thinking behind the use of sterile gloves in outpatient surgery (particularly for closures, which are more invasive and take more time) is that they prevent surgical site infections (SSIs). However, in a climate where judicious use of healthcare resources is increasingly important, is the use of more expensive sterile gloves warranted? 

Though some studies found an increase in SSIs from the use of non-sterile vs. sterile gloves in dermatologic surgery,[1],[2]  others found no increase. [3],[4],[5],[6] To make sense of such conflicting conclusions, Jerry Brewer and colleagues at the Mayo Clinic, Rochester, performed a systematic review and meta-analysis of the literature regarding the use of non-sterile vs sterile gloves in common outpatient procedures.

The authors initially considered 512 publications for inclusion in the review and meta-analysis. After eliminating a number of publications (for irrelevance, differences in study design, or discordance between independent reviewers) a total of 14 articles were selected for analysis. The group of 14 included both observational studies and randomized clinical trials, and were considered high-quality with minimal risk of bias. Both skin surgery and dental procedures were included, but the heterogeneity among all studies was low. (The authors performed sub-group analysis for the cutaneous reconstruction studies, which did not change the results). A total of 11,071 patients were pooled in the meta-analysis. In light of the large number of patients, the low heterogeneity among studies, and the high quality of the pooled studies themselves, this study should be considered high quality as well. 

The authors found no difference in the rates of postoperative SSIs when either sterile or non-sterile gloves are used. Though the authors acknowledge there may have been subtle practice differences among studies (hand washing, for example), the low heterogeneity and large number of patients mean this is unlikely to have affected outcome. The possibility of publication bias exists for the observational studies, but these studies showed similar outcomes to one another and were in line with the randomized clinical trials included in the meta-analysis. Overall, the authors note, “given the thoroughness of original research strategy and systematic review, the data in this study would be considered complete.”

Dr. Brewer and his colleagues present us with very compelling data that using non-sterile gloves in dermatologic surgery (including Mohs and reconstruction) does not result in increased SSIs. They note that, practically, there are other considerations vis-à-vis the use of sterile gloves: patient perception of “sterility,” sterile gloves’ snug fit and increased dexterity, and the medicolegal ramifications of deviating from accepted sterile-glove practice.

So, what to do? Using non-sterile or sterile gloves is obviously the surgeon’s choice, based on his or her preference for “feel,” patient expectations, risk aversion, cost, etc. However, this study is invaluable for making an informed decision. For those considering an intermediate risk-benefit protocol, non-sterile gloves for the clean, non-sterile Mohs layer and sterile gloves for the quasi-sterile reconstruction procedures is strongly supported in the literature and makes practical sense. For those who choose to use non-sterile gloves for all aspects of Mohs surgery, this paper provides data-driven, high-quality evidence that such a choice is (or should be) well within the standard of practice.

[1] Martin JE, Speyer LA, et al. Heightened infection-control practices are associated with significantly lower infection rates in office-based Mohs surgery. Dermatol Surg. 2010;36(10):1529-1536.

[2] Rogues AM, Lasheras A, et al. Infection control practices and infectious complications in dermatological surgery. J Hosp Infect. 2007;65(3):258-263.

[3] Mehta D, Chambers N, et al. Comparison of the prevalence of surgical site infection with use of sterile versus nonsterile gloves for resection and reconstruction during Mohs surgery. Dermatol Surg. 2014;40(3):234-239.

[4] Rhinehart MB, Murphy MM, et al. Sterile versus nonsterile gloves during Mohs micrographic surgery: infection rate is not affected. Dermatol Surg. 2006;32(2):170-176.

[5] Xia Y, Cho S, et al. Infection rates of wound repairs during Mohs micrographic surgery using sterile versus nonsterile gloves: a prospective randomized pilot study. Dermatol Surg. 2011;37(5):651-656.

[6] Lilly E, Schmults CD. A comparison of high- and low-cost infection-control practices in dermatologic surgery. Arch Dermatol. 2012;148(7):859-861


FELLOW-IN-TRAINING PERSPECTIVES

By Adele Haimovic, MD

I was privileged to attend the recent Board of Directors meeting at the ACMS headquarters in Milwaukee, Wis. as your FIT representative, and have prepared this report from my experiences there. As fellows-in-training (FITs) during a challenging time for Mohs surgery, we have multiple charges. First, and foremost, we are developing skills so we can provide our patients with the highest standard of care. In addition, we have to learn about the way medicine works in 2016 and beyond. While many of us put this on the backburner during our schooling, we have to gain a better understanding of the committees the ACMS has established to support our specialty, the requirements physicians must meet, and the changing reimbursement and regulatory climate.

As a co-fellow-in-training, I wanted to use this opportunity to review the important resources and networking and educational tools available to us as FITs of the Mohs College:

Regulations and documentation: Due to the changing reimbursement climate and the numerous documentation requirements imposed on us as physicians, we must make sure to provide our patients with the best treatment, practice in a cost-conscientious manner, and understand the upcoming changes to our system. Many terms such as the RUC (Relative Value Scale Update Committee), MACRA (Medicare Access and CHIP Reauthorization Act), MIPS (Merit-based Incentive Payment System), and APM (Alternative Payment Model) are being referenced by practicing dermatologists. While these terms sound like alphabet soup, it is important to understand what they are and how they function. The RUC is an advisory board to the Centers for Medicare and Medicaid Services (CMS) that determines prices for current procedural terminology (CPT) codes. They essentially review and recommend values for all of our E and M visits and procedures. If selected to participate in a RUC survey, it is critically important to fill those out correctly and seek out help for any questions you may have. Keep in mind all of the time it takes before and after any procedure. MACRA, which is set to start in January 2017, plans to move Medicare payment from a volume paid system to a system that rewards both quality and cost savings. Dermatologists have the choice of participating in the MIPS or the APM model. Although these regulations may seem overwhelming initially, there are many resources available to us to better understand them. The ACMS recently hosted a free webinar explaining MACRA and highlighting the important changes for Mohs surgeons.

Coding and billing: At the ACMS as well as other dermatology organizations’ annual meetings there are sessions geared toward understanding coding and payment structures. The AAD releases a quarterly Derm Coding Consult newsletter and on its website under the Advocacy tab there are numerous articles and a presentation explaining the most up-to-date rulings.

Case logs: The ACMS promotes the highest standard of patient care by requiring its members to have completed a fellowship in Mohs surgery, dermatopathology and reconstructive surgery. As media efforts to promote skin cancer awareness and the effectiveness of Mohs surgery increase, many patients will request a surgeon that is fellowship trained. To join the ACMS, a completed case log with 500 cases must be submitted. Be sure to do this during your fellowship. The ACGME case log should be used to record your cases. At least 50 of the Mohs cases and 50 of the reconstructions submitted must qualify as complex.

Career search: The process of a job search can be overwhelming and frustrating. Earlier this year, the ACMS launched the online Mohs Surgery Career Center at careers.mohscollege.org, and it allows Mohs surgeons to search and apply for open Mohs-related positions. It’s free to search for jobs, set up alerts, and upload your CV for potential employers to search. This online job board is a great resource that young surgeons should take advantage of.

Webinars: On the ACMS website there are two anatomy courses available to fellows-in-training and ACMS members. Both “Navigating Superficial Anatomy of the Face for Mohs Surgeons” and “Upper Limb and Nail Bed Anatomy for Mohs Surgeons” are outstanding educational resources available for purchase at a discounted rate of $75 for fellows-in-training.

Research and presentation opportunities: As part of the ACGME requirements, all Micrographic Surgery and Dermatologic Oncology fellows-in-training must complete an original research project. The ACMS Annual Meeting has two opportunities for FITs to participate in research:

  • Scientific Abstracts: Research that addresses the needs of our patients and the ACMS may be submitted. The fellow-in training will be eligible for the Tromovitch Award Competition. The deadline for submission is Thursday, January 12, 2017.
  • Clinicopathologic Case Competition: Fellows are invited to submit a case that has either rare histopathology or that presents a diagnostic challenge. The deadline for submission is February 15, 2017.
  • Flap Workshop: A hands-on cutaneous flap workshop designed for fellows-in-training will take place the day before the ACMS Annual Meeting begins in San Francisco at the Hilton Union Square. More information will be made available soon.

SURVEY RESPONSES REQUESTED

The following short surveys are being distributed at the request of ACMS members in good standing for the purposes of research/data collection, and have been reviewed and approved for distribution by the Executive Committee of the ACMS Board of Directors. Your responses are appreciated. Survey submission guidelines are available here.

Treatment of squamous cell carcinoma in solid organ transplant patients

The Division of Dermatology at Washington University School of Medicine invites you to participate in a short survey regarding the treatment of squamous cell carcinoma in transplant and non-transplant patients. This is a follow-up survey based on the feedback received from our first survey sent out earlier this year. The survey will only take a few minutes to complete, and we appreciate your participation whether or not you participated in our first survey. This study was approved by the Washington University in St. Louis Institutional Review Board (IRB ID #201506014).

Sincerely,

Principal Investigator: Eva Hurst, MD, FACMS
Washington University School of Medicine

Prophylactic orolabial HSV treatment for patients undergoing photodynamic therapy for facial actinic keratoses

We invite you to participate in a survey on prophylactic orolabial HSV treatment for patients undergoing photodynamic therapy for facial actinic keratoses. Currently, there are no evidence-based guidelines and we hope to better understand clinical practice amongst dermatologists and dermatologic surgeons. Please help us by completing the short (<5 min.) and voluntary online questionnaire. Please note that the survey will be used for research purposes only and all information will be confidential, with no identifiable personal information collected. There will be no compensation provided for completion of survey. You may contact Jordan Slutsky, MD, Principal Investigator at (631) 444-4200 if you have questions about the research. Thank you for your time and assistance.

Sincerely,

Principal Investigator: Jordan Slutsky, MD, FACMS
Co-Investigators: Tara Kaufmann, MD, Lea Bellomo, MD, Kyle Radack, MD, Elizabeth Cusick, BS
Department of Dermatology, Stony Brook University

Management of anticoagulant and antiplatelet agents in dermatologic surgery

At the Laser & Skin Surgery Center of New York, we are studying how dermatologic surgeons manage anticoagulants and antithrombotic agents during the perioperative period. We would greatly appreciate your input by completing this short (<5 min.) survey. All responses are confidential and cannot be traced to a particular respondent or practice. The results of this survey will be submitted for publication in a peer-reviewed journal. Thank you for your time.

Sincerely,

Principal Investigator: Roy Geronemus, MD, FACMS
Co Investigators: Yoon-Soo Cindy Bae, MD; Joshua Farhadian, MD
Ronald O. Perelman Department of Dermatology, New York University School of Medicine


SAVE THE DATE


Mohs Surgery Career Center

Visit careers.mohscollege.org to search, apply for, and post open Mohs-related positions

The ACMS and ASMH recently launched the new Mohs Surgery Career Center for surgeons and histotechs. Physician assistants, dermatopathologists, practice managers, administrative staff and others can also search for job openings, post resumes, and connect with employers. This new resource was launched in conjunction with the Annual Meeting in Orlando, and replaces the free online Job Board on the ACMS website. The new Career Center adds features and functionality that were not possible before, including more positions in more categories, expanded national reach, and the ability to search by position type, work setting, and state.


The Cutting Edge provides the latest news relevant to Mohs surgeons. Delivered biweekly via email, this news brief includes scannable summaries of content available on the ACMS website and elsewhere.

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