Summer 2016 e-Newsletter
Dear Colleagues –
As I continue to develop the habit of offering these monthly updates, I’m grateful to be reminded how much work is done on a regular basis by the College’s Board, committees, volunteer leaders, members at large and staff. It is evident in this election season that consensus and cooperation are vital to success. At the Mohs College we are fortunate to experience these characteristics daily.
With the election quickly approaching, we must remain attuned to the ever-changing healthcare landscape in Washington, DC, and be prepared to make our voices heard when the value and importance of dermatology and Mohs surgery is called into question.
You are likely aware that the U.S. Preventive Services Task Force (USPSTF) recently declined to recommend full-body screenings for skin cancer, citing insufficient evidence of benefit or harm. As dermatologists who see patients every day, we understand the value of these preventive measures and deal with the consequences of patients not seeking early care. We also know that other similar decisions by the USPSTF have contradicted established clinical guidelines based on medical literature. Unfortunately, the USPSTF has little accountability and does not meet with relevant stakeholders during its review process. In addition, medical specialists in subjects under review do not serve on the Task Force.
This USPSTF decision sends a mixed message to the public and general practitioners that while skin cancer incidence continues to rise, screenings aren’t proven to be worth having. As several ACMS members pointed out when this decision was covered in the news media at the end of July, perhaps the most valuable element of a skin screening exam is the education of patients regarding skin cancer prevention that would not otherwise take place—discussion of risk factors, skin self-examination, appropriate sun protection, and more. Individuals should be encouraged not to delay such potentially life-saving visits.
Given the importance of ensuring public understanding of the importance of these screenings, a letter to the editor was drafted by the ACMS on behalf of The Alliance of Specialty Medicine in response to the New York Times story about the USPSTF decision. In addition, the ACMS joined the AAD, ASDS, and ASMS in submitting an OpEd to the NYT that further outlines the skin cancer epidemic and reasons why skin screenings remain a critical component of regular health examinations. I am grateful to our fellow dermatology organizations for their shared leadership and commitment to making our voice heard on issues that affect us all.
It goes without saying that writing letters is hardly the only advocacy in which the College is engaged. We recently participated in the 2016 Alliance of Specialty Medicine Annual Advocacy Conference fly-in in Washington, DC. The event was a great success, with nearly 150 specialty physicians, practice administrators and specialty society staff interacting with Congressional leaders and their staff, as well as senior agency officials. A summary of the fly-in can be found here.
I am very pleased to inform you that the College will offer its second member education webinar, Upper Limb Anatomy for Mohs Surgeons, on Wednesday, October 5, 2016 at 7:00 pm CDT. It will feature expert instruction on the anatomy of the shoulder, arm, forearm, hand, fingers and fingernails by Nirusha Lachman, PhD, associate professor in the Department of Anatomy, College of Medicine with joint appointment in the Department of Surgery, Division of Plastic Surgery at Mayo Clinic. Dr. Lachman understands Mohs surgery and reconstruction and will focus on helping us understand the anatomical features that are important to our procedures.
The first webinar led this past February by Dr. Lachman, Navigating Superficial Anatomy of the Face for Mohs Surgeons, exceeded registration expectations and was very well received. Registration for the Upper Limb Anatomy webinar will be limited by the technical capacity of the webinar site. It will be recorded for later review by participants and purchase by those who can’t attend the live session. Further information on learning objectives and registration is forthcoming.
I mentioned it last month, but by now you should have received a postcard inviting you to submit an abstract for the Annual Meeting in San Francisco taking place April 27-30, 2017. The abstract submission period isn ow open, and submissions can be made via the meeting website, where you will find all necessary criteria and submission guidelines. Please consider how your experiences might be shared through a Scientific or Rapid Pearl abstract, and encourage your fellows-in-training to submit an abstract for the Tromovitch Award and/or a case for the Clinicopathologic Case Competition.
After having described to you how hard all of the ACMS committees and staff are working, I will tell you that I am taking some time to relax. With my wife, MaryAnn, I am enjoying a tour of Russia, including a river cruise between Moscow and St. Petersburg. I always find that getting outside everyday life to enjoy different experiences and cultures provides me with new vigor on my return. I hope you are able to take some time to enjoy the fruits of summer and your labor with family and friends.
На здоровье (Nostrovia)
Thomas Stasko, MD, FACMS
ACMS President, 2016-17
2017 Annual Meeting Call for Abstracts
We cordially invite you to 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:
- 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.
- 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.
The Scientific Program Committee has broadened abstract submission opportunities with the goals of involving more members in the Annual Meeting and encouraging the highest quality of presentations. To learn more about each of these opportunities, please see the full Call for Abstracts for details:
Your participation is crucial to ensure the continued success of our specialty’s premier meeting. Please encourage fellows-in-training to submit an abstract for the Tromovitch Award and/or a case for the Clinicopathologic Case Competition.
If you have questions about a proposed abstract or the submission process, please contact email@example.com. We look forward to your contribution and hope to see you in San Francisco!
Thomas Stasko, MD, FACMS Michel A. McDonald, MD, FACMS
2016-17 ACMS President 2017 Scientific Program Chair
Highlights from the 2016 Annual Meeting
By John G. Albertini, MD, FACMS, Immediate Past President
ACMS members gathered in warm, sunny Orlando from April 28 through May 1 for the 48th Annual Meeting held at the Rosen Shingle Creek. In addition to its numerous amenities, restaurants, recreation options and proximity to theme parks, the venue proved to be an ideal one for learning and sharing.
Dr. Chris Miller and the Scientific Program Committee—Drs. Michel McDonald, Tom Stasko, Allison Vidimos, and Jerry Brewer—put together an excellent and comprehensive program with sessions for every level of experience. I even heard personally from many senior members that they learned numerous new pearls and tips, me included.
A big reason for this high level of quality was the expertise of our guest speakers. Dr. Marty Makary’s Keynote Address proved highly entertaining and inspiring. He noted the significant opportunities for improving healthcare quality by reducing clinical practice variation when feasible. This served as a compelling introduction to his research group’s partnership with the Mohs College on our Improving Wisely program. In addition, Dr. Rosalie Elenitsas' recommendations on collaborating with dermpath, as well as her insights on the pathology of specialty tumors, were invaluable; Dr. Ben Chang and Dr. Stephen Kovach's expertise on surgical outcomes for the hand and foot was top-notch; and Dr. Wendy Lee's discussion of eyelid anatomy and periocular reconstruction was highly instructive. Dr. Peter Toensing's session on How Insurers Measure the Cost-Effectiveness of Mohs Surgeons was definitely illuminating for all those who wonder how and why we’re economically profiled.
Many colleagues were also motivated and inspired to more confidently address their patients' nail unit cancers, including melanoma. Dr. Chris Miller’s session included meticulous step-by-step video instruction that is relevant to all Mohs surgeons. Attendees were particularly impressed by the other sessions incorporating video, especially for Advanced and Staged Reconstruction. Another highlight of the program was the outstanding Strategies to Achieve Perfect Mohs Frozen Sections, as members have been citing the need for more practical education on technical lab issues.
Finally, the pre-meeting Hands-On Skin Flap Workshop was incredibly well-organized and taught by a who’s who faculty of senior Mohs surgeons imparting pearls of wisdom to a small group of enthusiastic attendees that ran the gamut from new fellowship graduates to those in practice for decades. The ratings were off the chart for the quality of instruction and ability to engage with mentors during hands on surgical instruction.
During this year’s Tromovitch abstract session, where fellows presented the top research projects of the year, Dr. Renato Goreshi won the award for an abstract on Matrilin-2 as an Invasion Marker to Distinguish Basal Cell Carcinoma from Benign Adnexal Tumors.
As always, there was ample opportunity for networking and reconnecting with old friends and colleagues, from Thursday’s welcome reception, luncheons for the Women’s Dermatologic Society and VA Mohs surgeons, Saturday’s Fellows-in-Training reception, and the Blade and Light reception.
A special thanks to Board members whose terms ended at the meeting, Drs. Chris Arpey, Liz Billingsley and Tim Flynn; and to the new Board members whose terms began, Drs. Jerry Brewer, Scott Collins, and Howard Rogers. Congratulations to the recipients of the Distinguished Service Award, Drs. Sarah Arron, Deb MacFarlane, and Oliver Wisco, and congratulations especially to Dr. Len Goldberg, recipient of this year's Frederic E. Mohs Award for his outstanding career as a surgeon, mentor and true pioneer in our field.
By now I shouldn’t be, but each year I’m more impressed by the quality and value of the Annual Meeting than the year before. I hope you’ll join your Mohs colleagues for next year’s Annual Meeting in San Francisco from April 27-30, 2017. I look forward to seeing you there.
Mohs Surgeons Head to Capitol Hill on MACRA, Compounding
By Emily L. Graham, RHIA, CCS-P, Vice President, Regulatory Affairs, Hart Health Strategies
Addressing unique challenges faced by specialty medicine providers and their patients, as well as ensuring a smooth transition to new payment models established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, were among the primary messages specialty physicians, including Mohs surgeons, emphasized to lawmakers and staff during the Alliance of Specialty Medicine’s Advocacy Conference on July 12-13, 2016.
Just under 150 specialty physicians, practice administrators and specialty society staff engaged in the conference, hearing from a variety of Congressional leaders and their staff, as well as senior agency officials. ACMS members Howard Rogers, Brent Moody, Allison Vidimos, Barry Leshin, Erin Gardner, Pat Davey and ACMS Executive Director Rebecca Brandt were in attendance.
Guest speakers included Representative Marsha Blackburn (R-TN), Representative G.K. Butterfield (D-NC), Representative Larry Bucshon (R-IN), Senator Rand Paul (R-KY) and Senator Chris Murphy (D-CT). A panel of bipartisan Congressional staff from the House of Representatives Energy and Commerce, Ways and Means and Senate Finance Committees, discussed Hill efforts to see through repeal of the flawed Sustainable Growth Rate (SGR) formula and implement a new payment system as part of MACRA, followed by a presentation from the Kate Goodrich, MD, of the Centers for Medicare and Medicaid Services (CMS), on the agency’s plans for implementing the law. Charlie Cook (center, above) spoke about the 2016 Presidential election, making predictions for who may succeed President Obama in November.
Specialty physicians made 142 visits to Capitol Hill offices to discuss MACRA implementation; concerns with the United States Preventative Services Task Force (USPSTF) and garner support for a bill that would make the USPSTF process more transparent and inclusive of specialty physicians; and show support for the House-passed 21st Century Cures legislation and encourage the Senate to continue moving forward on its Senate Innovations Package.
Focus on MACRA
Since the passage of MACRA last Spring, the Alliance and the American College of Mohs Surgery have engaged in multiple pre-rulemaking and rulemaking comment opportunities aimed at helping the Centers for Medicare and Medicaid Services (CMS) implement the new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs), collectively known as the Quality Payment Program (QPP). Despite our best efforts, several of the proposals did not adequately capture the needs specialty and subspecialty physicians, including Mohs surgeons. For example, benchmarks and thresholds used to reward and penalize physicians are based on an assessment of the broader specialty, making true peer-to-peer comparisons in the various subspecialties, such as Mohs surgeons, impossible. In addition, proposed changes to the “meaningful use” program under MIPS did not offer a true departure from the current “all-or-nothing” approach, making this part of the performance program more difficult for specialty physicians when it comes to objectives and measures of meaningful use of electronic health records (EHRs) more difficult for specialists.
To ensure a smooth transition, and to give CMS more time to address some of the other challenges with how quality and resource use will be assessed, the Alliance and the ACMS called on Congress to encourage a delay in the initial start date for MIPS, which is currently set to begin on January 1, 2017. A six-month delay would give physicians more time to prepare for the biggest change in Medicare physician payments since the implementation of the Resource-Based Relative Value Scale (RBRVS).
When the opportunity presented, and in the context of 21st Century Cures and the Innovations package, Mohs surgeons also raised concerns about challenges with compounding regulations, urging the Congress to ensure US Food and Drug Administration (FDA) requirements are not onerous for physicians or unduly limit patient access to important skin cancer care and services.
The ACMS continues to engage on Capitol Hill and with agency officials on these and other issues of interest to Mohs surgeons.
ACMS Receives ACCME Reaccreditation Through 2020
At the end of July, the ACMS received reaccreditation through 2020 from the Accreditation Council for Continuing Medical Education (ACCME) to continue to offer continuing medical education for physicians at events such as the Annual Meeting.
Through joint leadership initiatives, the ACCME and member organizations identify and implement strategies for improving physicians’ continuing professional development and patient care.
“This important step affirms our ability to offer CME, and proves the value of our scientific programs,” said ACMS President Thomas Stasko, MD, FACMS. “A huge thank you to the CME & Education Committee led by Dr. Jeremy Bordeaux, and to ACMS education manager Susan Sadowski, who coordinated this effort from the staff side. Their work was critical to achieving this milestone.”
The ACCME’s seven member and founding organizations are the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, the Association for Hospital Medical Education, the Council of Medical Specialty Societies, and the Federation of State Medical Boards of the United States.
Rogers to Serve on CMS’ MACRA Clinical Committee
ACMS Board member and Chair of the ACMS Private Payer Task Force, Howard W. Rogers, MD, PhD, FACMS, has been selected to serve on the Centers for Medicare & Medicaid Services (CMS) MACRA Episode-Based Resource Use Measures Clinical Committee, which will develop measures for the Medicare Access & CHIP Reauthorization Act (MACRA) of 2015.
Clinical Committee members will convene to discuss and provide input on the development of the care episode and patient condition groups that will be used as the basis of resource use measures.
“We received a large number of nominations and have worked with the Centers for Medicare & Medicaid Services (CMS) to finalize Clinical Committee members,” read Rogers’ appointment letter. “We believe that your perspective, experience, and expertise would provide valuable input to the development of episode-based resource use measures and we look forward to your participation on the Clinical Committee.”
According to CMS, MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries:
- Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
- Making a new framework for rewarding health care providers for giving better care.
- Combining existing quality reporting programs into one new system.
These proposed changes, named the Quality Payment Program (QPP), replace a patchwork system of Medicare reporting programs with a flexible system that allows physicians to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). For more on MACRA, QPP, MIPS and APMs, visit the CMS website.
Help Your Histotechnician Improve His/Her Skills
This October, the American Society for Mohs Histotechnology is offering a new, customized, hands-on training program through its Mohs Technician Quality Assurance (MTQA) Training Initiative. Offered exclusively to technicians currently working for ACMS member surgeons, this training will take place October 6-7, 2016 at the Avantik Training Campus in Springfield, New Jersey.
Topics covered during this two-day training will include mapping and inking, embedding, cryosectioning, staining, CLIA regulations and troubleshooting. 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.
It should be noted that this training is not an official Histotech Certification program, nor is it intended to substitute training for techs with no experience. The MTQA Training initiative is designed to further enhance the performance and quality of work to established Mohs technicians.
Register your technician now, as space is limited. Discounted rates are available for practices registering more than one technician for the training. Click here for more information and to register.
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.
Recent ACMS Ads Yield Inquiries; Infographic Available Online
As part of a plan to gain exposure for and promote the effectiveness of Mohs surgery as performed by fellowship trained surgeons, the ACMS recently took advantage of two unique media placement opportunities.
The first was a banner ad that appeared on the cover of a Skin Cancer supplement in the USA Today on June 17 in the Los Angeles, New York, Philadelphia, Chicago, Seattle, Atlanta and Phoenix markets, totaling 450,000 copies and 1.3 million potential readers. The second was a full-page infographic ad created for a supplement on Skin Health that ran in the Chicago Tribune on June 30, totaling 411,000 copies and 1.2 million potential readers. View/download it here (member login required).
The infographic highlights the rising incidence of skin cancers in the U.S., what makes Mohs surgery so effective, and why fellowship training sets ACMS members apart. On the day the ad ran in Chicago, the ACMS office got half a dozen calls from readers who mentioned the ad and were seeking a Mohs surgeon. Other calls have come since the initial run date.
Because of the College’s prior work with Mediaplanet on similar supplements over the past five years, these ads made a sizable impact across a broad footprint for a very fair price. Consider how you might share this graphic via your websites, social media, or elsewhere.
Results of Recent Improving Wisely Survey Indicate Support
By John G. Albertini, MD, FACMS
Chair, Physician Engagement Council; Immediate Past President
As outlined in previous communications and highlighted in the 2016 Annual Meeting Keynote Address, the Mohs College has partnered with Dr. Marty Makary’s team at Johns Hopkins to develop its Improving Wisely initiative. As the name implies, the goal of this data transparency program is for Mohs surgeons to ‘improve wisely’ the quality and value of the care they provide. The Mohs College is piloting this unique opportunity for all of us, and our colleagues, to understand our personal practice patterns in relation to peers. Mohs surgeons will be able to benchmark themselves using quality metrics determined by senior leadership.
The initial measure for review is the average number of Mohs stages per case. Additional quality measures will be introduced in the future. All physicians who bill for Mohs surgery will be provided a confidential, personalized notification of their status relative to other Mohs surgeons nationally. Education and/or mentoring will be available for those interested in strategies to improve. The Johns Hopkins team is collaborating with CMS to obtain early privileged access to their datasets, thus reducing the long delays that can limit the applicability and utility of the reporting. Ongoing evaluation of the updated datasets will afford the opportunity for timely re-assessment of personal changes in practice.
We want to share with the Mohs College membership the results of the recent Improving Wisely survey distributed at the Annual Meeting and in follow up emails. It provides strong confirmation that our membership appreciates this opportunity to demonstrate that the Mohs College is the premier society for Mohs surgery and dermatologic oncology, and that we value high-quality, cost-effective patient care and ongoing quality improvement.
Nearly 400 members responded to the survey, another testament to the high engagement of our membership in this Improving Wisely initiative. I am very gratified to report that 90% are interested in learning how their practice patterns compare to peers, and only 2% disagree that it would be beneficial to see performance data for the initial quality metric of mean Mohs stages per case. Eighty percent somewhat or strongly agree that on a national level, sharing a physician’s personal data with the physician can result in higher quality medical care. Dr. Makary is also successfully working with like-minded cardiologists and gastroenterologists in similar programs.
Some reservations do exist, and 17% of survey respondents express concern that the data report could negatively affect them. This is clearly not the intention; the goal is education and quality improvement. In fact, the notification process is intentionally centralized at Johns Hopkins and reports are confidential, non-punitive, and legally non-discoverable in order to address these concerns. We agree with the vast majority (70%) who believe that valid physician performance data should be kept confidential and not publicly reported. Unfortunately, society has entered an era of transparency (WikiLeaks, the Panama Papers and police body cameras), and CMS did the same two years ago when making its claims data publicly available. Now one must assume that all data will be scrutinized, just as the Wall Street Journal scoured the CMS data for a Pulitzer Prize and other media sources continue to mine it today. We believe that by understanding one’s own practice patterns in relation to peers, a positive clinical change can be made that benefits patients and avoids a potentially negative impact. Only 4% disagree with this statement. Additionally, more than two thirds of respondents believe that such a data transparency program can reduce unnecessary health care costs. Such a reduction would add significant value to the high-quality care we provide and help transform an impression held by many that Mohs surgery is too costly and of low overall value.
I hope this update on the Improving Wisely program and the recent survey results improves your understanding of the initiative and its goals and timeline. We hope to provide the notification reports in the near future as data analysis is finalized and verified. Please feel free to send inquiries or questions to the Mohs College.
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. According to NRO Vice Chair Dr. Howard Rogers, “the overall goal of the ACMS National Registry is to clinically characterize and define the practice of Mohs surgery by Mohs College members. The registry will collect data regarding patient and tumor characteristics, surgical services, as well as outcomes and complications tracking, providing the richest, most detailed picture of how Mohs surgery is performed. This information will facilitate creation of sophisticated and fully risk-stratified performance measures that will allow ACMS members to demonstrate their value and cost effectiveness to insurers as well as to participate and thrive in the world of health care reform.”
Since 2014, the NRO has grown to include six subcommittees and dozens of active ACMS members dedicated to designing and implementing the registry in a way that is beneficial for patients and ACMS members. We’ve reached out to the Chairs of the respective subcommittees to provide a sneak peek at what’s to come over the next year in Q&A format below:
Read the full, detailed Update on National Registry and Outcomes Committee here. (member login required)
Billing a Frozen Section on the Same Day as Mohs
By Joshua Spanogle, MD, FACMS
There has been some confusion about billing 88331 (pathology consultation during surgery with frozen section) on the same day as 17311/17313 (Mohs Micrographic Surgery). Recently, there have been more reports of denials-of-claim when these codes are billed on the same day. Though it is relatively uncommon in our practice to perform a frozen section biopsy on the same day as Mohs, there are clinical situations in which doing so is of benefit to the patient.
Scenario: A patient comes in for Mohs surgery for a basal cell carcinoma on the cheek. During evaluation, the surgeon notices another suspicious lesion in the same vicinity, which would affect the repair if this lesion, too, were a cancer. The surgeon performs a biopsy and prepares a frozen section, which reveals another basal cell carcinoma. The results are discussed with the patient.
What should the surgeon do?
The National Correct Coding Initiative (NCCI) edits list CPT code pairs that CMS considers to be bundled together and cannot be billed together on the same date of service. The relevant section of the NCCI Policy Manual for Medicare Services states:
Mohs micrographic surgery (CPT codes 17311-17315) is performed to remove complex or ill-defined cutaneous malignancy. A single physician performs both the surgery and pathologic examination of the specimen(s). The Mohs micrographic surgery CPT codes include skin biopsy and excision services (CPT codes 11100-11101, 11600-11646, and 17260-17286) and pathology services (88300-88309, 88329-88332). Reporting these latter codes in addition to the Mohs micrographic surgery CPT codes is inappropriate.
This would seem to suggest that billing 88331 (frozen section) and 17311 (first stage Mohs) on the same day is not permissible. But the guidelines provide for an exception:
However, if a suspected skin cancer is biopsied for pathologic diagnosis prior to proceeding to Mohs micrographic surgery, the biopsy (e.g., CPT codes 11100-11101) and frozen section pathology (CPT code 88331) may be reported separately utilizing modifier 59 or 58 to distinguish the diagnostic biopsy from the definitive Mohs surgery.
In no uncertain terms, then, CMS allows for billing of 88331 on the same day as 17311. According to American Medical Association guidelines, criteria for billing a biopsy and pathology on the same day as Mohs surgery are as follows:
- when the lesion for which Mohs surgery is planned has not been biopsied within the previous 60 days; or
- when the surgeon cannot obtain a pathology report, with reasonable effort, from the referring physician; or
- when the biopsy is performed on a lesion that is not associated with the Mohs surgery.
Documentation is crucial, according to Karl Ellzey, president of Ellzey Coding Solutions. “It is recommended that the medical exam documentation and operative report clearly indicate the lesion was suspicious, a confirmation biopsy and frozen section were performed to validate the medical necessity of performing Mohs, and that the results were discussed with the patient prior to Mohs being performed.”
Scenario: The surgeon decides to treat both basal cell carcinomas with Mohs. The first clears in two stages, the second in one stage. Because of the proximity of the subsequent defects, the surgeon was able to close both with a single complex closure. The surgeon thoroughly documents her medical reasoning and bills the following:
17311 x 2 (first stage Mohs), modifier 59 (distinct procedure or service)
17312 (second stage Mohs, one site)
13132 (complex repair)
11100, modifier 59 (distinct procedure or service)
88331, modifier 59 (distinct procedure or service)
Many thanks to Karl Ellzey of Ellzey Coding Solutions for his insight and expertise, and to Drs. Brett Coldiron and Glenn Goldman for their review of this article.
Revisiting Policies on Anticoagulants during Cutaneous Surgery:
Is it Safe to Hold Warfarin?
By Todd V. Cartee, MD, FACMS
“Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation”
Douketis JD, Spyropoulos AC, Kaatz S, et al. N Engl J Med 2015;373:823-33
Throughout my training and first five years in practice the mantra has consistently been espoused to continue all anticoagulation throughout Mohs procedures and reconstructions, despite their complexity. The plastic surgeons we work with at our institution have always felt quite differently. This has occasionally created interdepartmental tensions and has complicated the reconstructive timing when an unexpectedly complex defect requires an immediate unplanned referral to plastics. However, we have firmly adhered to the literature that has supported the safety of Mohs surgery in the anticoagulated patient and cited the reports of disastrous repercussions when anticoagulation is held[1-3]. A 2008 meta-analysis in Dermatologic Surgery and a 2011 prospective study in JAAD demonstrate a 7- and 10-fold, respectively, increased risk of moderate-to-severe bleeding complications in warfarin-treated patients undergoing cutaneous surgery. Nevertheless, this bleeding risk seems insignificant when juxtaposed with the anecdotal reports of life threatening thrombotic complications when anticoagulants have been held.
A recent paradigm-shifting study has now demonstrated the safety of continuing anticoagulation during surgery at least for some patients. Anticoagulants are prescribed for a wide variety of indications. Therefore, patients’ individual bleeding risk as well as their risk for a thrombotic event also varies widely. Prior reports in dermatology or plastic surgery of vascular complications after cutaneous surgery have involved a range of patients most of whom had high-risk indications, e.g., artificial heart valves or high-risk regimens of potent antiplatelet inhibitors or combinations of anticoagulants. However, the most common anticoagulated patient we encounter is the subject of this very carefully controlled trial, namely, patients with atrial fibrillation on warfarin.
The Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE) trial was a double-blind, randomized controlled trial of 1884 patients with atrial fibrillation on warfarin who underwent a variety of surgical procedures. Patients with artificial valves were excluded. Warfarin was held in all subjects for five days prior to the procedure and generally started back the night after. Subjects were randomly assigned to receive bridging anticoagulation therapy with doxeparin (low-molecular-weight heparin) or a matching placebo from three days before the procedure until 24 hours before the procedure. All anticoagulation was held for 24 hours prior to the procedure and then the doxeparin was resumed postoperatively for 5-10 days (see study design below). Only about 4% of patients underwent dermatologic surgery. But, this is by far the largest prospective study of the risk of thrombotic complications during a brief cessation of warfarin. The incidence of arterial thromboembolism was remarkably low and not statistically different between the group that received bridging anticoagulation and the control (0.4 vs. 0.3%; P = 0.01 for noninferiority). However, major bleeding complications were much more common in those who received doxeparin bridging (3.2% vs. 1.3%; P = 0.005 for superiority).
While postoperative thrombotic events can and do occur in patients with AFib, this study would indicate that they are rare and not increased by brief interludes off warfarin. As stated by the authors, “the premise that warfarin interruption leads to rebound hypercoagulability and that the milieu of the procedure confers a prothrombotic state … is not supported by the results of this trial.”
This study is not directly applicable to Mohs surgery, for which multiple studies have demonstrated safety with continuing warfarin. For the average Mohs procedure, warfarin poses minimal challenges. But we have all also experienced lengthy operative times, drained postoperative hematomas in the middle of the night, and felt compelled to perform suboptimal repairs due to bleeding diatheses. Since reviewing this study, when a patient has experienced prior bleeding complications and strongly wishes to stop warfarin, I find myself less willing to argue for its continuance. I have not yet proactively pursued this strategy, but if a large flap or graft is anticipated, will you also find yourself tempted to briefly interrupt warfarin therapy? This randomized controlled trial would provide some support to what has previously been considered antithetical to evidence-based surgical practice.
- Alam, M. and L.H. Goldberg, Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy. Dermatol Surg, 2002. 28(11): p. 992-8; discussion 998.
- Khalifeh, M.R. and R.J. Redett, The management of patients on anticoagulants prior to cutaneous surgery: case report of a thromboembolic complication, review of the literature, and evidence-based recommendations. Plast Reconstr Surg, 2006. 118(5): p. 110e-117e.
- Schanbacher, C.F. and R.G. Bennett, Postoperative stroke after stopping warfarin for cutaneous surgery. Dermatol Surg, 2000. 26(8): p. 785-9.
- Lewis, K.G. and R.G. Dufresne, Jr., A meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery. Dermatol Surg, 2008. 34(2): p. 160-4; discussion 164-5.
- Bordeaux, J.S., et al., Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol, 2011. 65(3): p. 576-83.
The following short survey is being distributed at the request of ACMS members in good standing for the purposes of research/data collection, and has been reviewed and approved for distribution by the Executive Committee of the ACMS Board of Directors. Your responses are appreciated.
Survey on Attitudes Regarding Electrosurgical Smoke
At the University of Missouri Dermatology and Skin Surgery Center we are studying surgeon and staff attitudes regarding electrosurgical smoke produced during outpatient dermatologic surgery. We would greatly appreciate your feedback via a quick (< 5 min) survey. We hope to have both you and your clinical staff that assist you with surgery complete this survey. Please forward the survey link in this e-mail to your clinical staff so that they may participate in this study as well.
We know you are presented with many surveys throughout the year, and we thank you very much for taking this time to help advance our field. All responses to this survey are confidential and cannot be traced back to a particular respondent or practice.
Please see our consent below:
- I would like to ask you to participate in a study that involves research.
- Participation is voluntary and your decision not to participate will not involve any penalty or loss of benefits
- For this study, we have designed a short survey that should take <10 minutes.
- The purpose of our study is gather information regarding your experiences with electrosurgical smoke produced during outpatient dermatologic surgery.
- You may expect to benefit from taking part in this research to the extent that you are contributing to medical knowledge.
- If you choose to participate, your survey data will be anonymous and in no way identifiable to you.
- You will not be compensated for participation in this study.
- If you have any questions about this survey, you many contact Brandon Merrill, MD or Nicholas Golda, MD at (573) 882-4800.
- I would be happy to answer any questions that you may have.
Brandon Merrill, MD; Nicholas Golda, MD
University of Missouri Department of Dermatology
Who is the Fool? A Review of Nobody’s Fool by Richard Russo
By David P. Clark, MD, MFA, FACMS
I confess my allergy to political rhetoric—it gives me an intellectual rash. And, this year’s presidential election campaign has proved to be the most contentious in recent memory. Much of the verbiage concerns the chasm between older blue-collar sorts and the connected, educated no-collar millennials. Of course, each political faction is sure they’ve identified the responsible fools, a fool identification program that has become an epidemic. Disclosure: I tolerate little of this mindless rhetoric before retreating into a good book. So, if you are in need of an antidote to politics, allow me to suggest Nobody’s Fool by Richard Russo, an author who does know a thing or two about fools.
Richard Russo is a master storyteller and a writer who understands the long tradition of literary and religious “fools.” These “fools” often became the speakers of truth. Russo’s specialty: the people thought foolish because they carry on pedestrian lives in dying small towns. His characters are ordinary. These are the people struggling to support families and maintain communities. A difficult life in upstate New York or the rust belt or rural New England where the exit of business, jobs, and hope occurred years before NAFTA was an idea.
Lucky for us, Russo hasn’t given in to the temptation to write a political rant in the guise of fiction. Rather, the author has crafted a story about the nuanced and zany citizens living in North Bath, New York. The main protagonist, Donald “Sully” Sullivan is street-tested World War II veteran who arrives at age 60 divorced, with a bum knee, an estranged son, and precious few prospects.
Russo’s particular talent is his intense observation of ordinary life—the divorces, stultifying menial jobs, misspent opportunities, and loneliness. He observes the citizens of North Bath traverse tragic circumstances, bouts of personal selfishness, and much bad luck. But, the author also allows us to see their small mercies and kindnesses. Russo writes a prose that holds humor and hope.
Sully is no hero; by his admission, he has spent a lifetime making bad decisions. But, just as Russo enumerates Sully’s warts, the reader laughs with Sully as he lists his numerous contradictions and peccadillos. Russo refuses to allow Sully, or any of the characters, to become stereotypes.
Reading Nobody’s Fool reminds me—in ways our current politics do not—most of my fellow humans are fundamentally decent folks trying to do what is right. And, Russo suggests, avoiding stereotyping requires we must first learn to laugh at our foibles.
Nobody’s Fool is on the extremely short list of novels made into a good movie. The 1994 film Nobody's Fool starred Paul Newman, Melanie Griffith, Bruce Willis, and Jessica Tandy, but won no Oscars. However, with the passage of time, critics now regard the work as a classic and an example of superb acting.
Is the movie or the book better?
Movies and books are disparate animals with different strengths and weaknesses. No film can hope to convey the character development possible in a 450-page novel. And, it is a rare book that provides the vivid visual images found on the big screen. However, in the case of Nobody’s Fool, both are well worth your time.
Russo has recently written a sort-of sequel (no spoilers here). Everybody’s Fool was released last Spring. But, before reading the new novel, I strongly recommend reading or re-reading the original Nobody’s Fool.
My wish for all the readers of this column: watch less CNN this fall and read more good novels. Your imagination and empathy will be the better for it. Honest.
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