Spring 2019 e-Newsletter
In This Issue:
- President’s Message
- ACMS Happenings
- Ask Glenn: Answers to Your Mohs Coding & Billing Questions
- Viewpoint: Avoiding and Managing Medicare Fraud and Abuse Investigations
- Hot Topic: Observation Should be the New Standard for Moderately Dysplastic Nevi
- Practice Tips and Efficacy: Mohs Surgeons’ Favorites
- Highlights from the Literature: Dermatopathology Appropriate Use Criteria
- Fellow-in-Training Perspectives: Patient-Reported Outcome Measures
Dear Colleagues –
April brings great anticipation for all. This is especially true for our members as we look forward to a few days in May when we can refine our surgical skills, enhance our body of knowledge, reengage with the important and timely issues facing our specialty, and reconnect with colleagues.
A three-peat! I am delighted to report that for the third time in our organization’s history, more than 1,000 physicians will attend our Annual Meeting. We first broke the 1,000-attendee threshold in San Francisco in 2017, and hit this milestone again last year in Chicago. This achievement is a testament to the educational value of our Annual Meeting, to the thoughtful planning of the Scientific Program Committee under Dr. Sarah Arron, and to the assembly of an extraordinary roster of faculty and guest speakers. A record number of 169 abstracts were submitted for the scientific session, and there were 35 entries to the Fellow-in-Training Clinicopathologic Case Competition. I would also like to acknowledge the essential role of the CME & Education committee, and of our staff in Milwaukee, who spend many months attending to hundreds of details. While there is much about the meeting to look forward to, I would like to call your attention to a few items in particular:
- We are fortunate to have Dr. Leonard D'Avolio as our keynote speaker. Dr. D’Avolio is the founder of Cyft, an organization that uses data and artificial intelligence to develop learning healthcare systems. We will also hear guest speakers Drs. Petr Hausner, Nirusha Lachman, Nicholas Mahoney, Scott Strome, Mohan Suntha, and Reza Vagefi; their respective areas of expertise are detailed in the Final Program.
- Please be sure to attend the Business Meeting at noon on Friday, May 3. In addition to the presentation of the Frederic Mohs Award and the Distinguished Service Awards, there will be important updates and information about the state of the College, and on advocacy and regulatory issues that affect all of us. Also, please join your colleagues and me for the President’s Reception at 6:30 pm on Saturday night, May 4 at the Four Seasons. This elegant event will feature fabulous live music, great food and drinks, and celebration.
- Download the Annual Meeting mobile app for the meeting schedule, the audience response system, and for completion of session evaluations. Your feedback is vital for ACCME accreditation purposes and for planning next year’s meeting in Nashville.
Please take a few moments to read through this issue of the Membership Bulletin e-Newsletter for updates on ACMS Happenings, as well as articles on topics such as Appropriate Use Criteria, management of moderately dysplastic nevi, avoiding and managing Medicare fraud/abuse investigations, patient-reported outcome measures, Mohs surgeons’ favorite resources and tips, and more. Many thanks to all involved for their work on another invaluable issue of the Newsletter.
The sixth episode of the Conversations in Mohs Surgery podcast is now available at www.mohscollege.org/podcast. Dr. Shlomo Koyfman, a radiation oncologist at the Cleveland Clinic who was a blockbuster guest speaker at last year’s Annual Meeting, discusses his recent study, Suboptimal Outcomes in Cutaneous Squamous Cell Cancer of the Head and Neck with Nodal Metastasis. Subscribe via iTunes/Apple Podcasts, Google Play, or RSS, and please take a moment to rate and review the podcast.
Reflections on 2018-19
Serving as College President has been the greatest honor of my career. As I reflect on the past year, I am pleased to recount some of our milestones and accomplishments:
The American Board of Medical Specialties (ABMS) approved the American Board of Dermatology’s application for subspecialty certification in Micrographic Dermatologic Surgery (MDS). In anticipation of the initial exam in 2021, a Task Force chaired by Dr. Sumaira Aasi has been established to assist members with exam preparation.
A committee of the Board, chaired Dr. Liz Billingsley. has been working vigilantly to update the Strategic Plan. The new plan will be presented at the Business Meeting next month.
In-Office Physician Compounding
ACMS immediate Past President, Allison Vidimos, MD, RPh has meaningfully engaged the massive bureaucracies of the FDA and CDC, and the USP Compounding Workgroup. Through her efforts, we can be hopeful that the impact of new regulations impinging on the use of buffered lidocaine is mitigated.
The Physician Education Council/Improving Wisely workgroup has continued its important collaboration with researchers at the Robert Wood Johnson Foundation and Johns Hopkins on data transparency to reduce overuse of Mohs surgery. Initial reports were distributed to members last summer on their percentage of total Mohs cases performed on the trunk and extremity, and the impact of this report on utilization will be forthcoming.
Advocacy and Public Policy
The Private Sector Advocacy Committee mailed an informational letter to Insurance Medical Directors around the country detailing the cost-effectiveness and quality of Mohs surgery. The ACMS participated in two fly-ins during the summer of 2018 in Washington, DC. The first focused on the College’s advocacy agenda, engaging with Congressional staff, and regulatory agency leaders on myriad issues relevant to our members. Energized from the morning sessions and with talking points in hand, our members spent the afternoon on Capitol Hill meeting with members of Congress and their legislative aides. College members also joined colleagues from other specialties for the Alliance for Specialty Medicine annual meeting, with a similar format and a lobbying agenda focused on issues facing specialty healthcare. A comprehensive update of 2018-19 advocacy and regulatory efforts prepared by Hart Health Strategies is available here.
As of April 1, 2019, $1.5 Million has been pledged to the ACMS Foundation, representing 60% our goal of $2.5 million. The 2019 Annual Meeting in Baltimore features the first Foundation-supported event—a gift from a generous and grateful patient will be funding the Friday Keynote Speaker, Dr. Leonard D’Avolio. The Foundation is on track to grant $200,000 awards in 2020 in the areas of research, lectureships, travel and patient education. Applications for awards will be available later this year. The Governance and Policy Committee chaired by Dr. Tom Stasko developed the Foundation’s gift acceptance and spending policies, and grant review committee structure, all subject to approval by the Board of Directors at its upcoming meeting.
National Registry and Outcomes
The clinical database for the ACMS National Registry, MohsAIQ (Mohs Advancing and Improving Quality), was launched on August 1. MohsAIQ received CMS recognition as a Qualified Clinical Data Registry (QCDR) that will enable data to be transmitted for 2019 Merit-based Incentive Program (MIPS). Four Mohs-specific measures were approved by CMS for inclusion in the QCDR reporting for 2019—read more here. There are 73 members who have enrolled to date.
A new policy approved by the Board of Directors at its October meeting eliminates exemptions from fellowship training programs match participation. We anticipate this new policy will substantively enhance the application and interview process for fellowship applicants and program directors. The slide review program has been rebooted and revamped under Dr. Fred Fish’s leadership. Members and fellowship programs will again have the opportunity to have a sample of their Mohs frozen section slides critiqued by a team of colleagues and histotechnicians. To facilitate this initiative, a platform was added to the College website permitting review teams to more efficiently access slide submissions.
The College launched a podcast series, Conversations in Mohs Surgery, hosted by Dr. Thomas Knackstedt, to more closely examine the micrographic dermatologic surgery literature and to hear interviews with colleagues in Mohs surgery, dermatology and related specialties. The Cutting Edge biweekly news brief continued to see strong open and click rates that beat industry averages by up to 35%. This year also saw the launch of an animated Mohs surgery patient education video produced by Dr. Kenny Omlin that has garnered 20,000 views in its first five months online.
All of the above would not have been possible without the inspired leadership and dedication shown by our Board of Directors, committees, task forces, and staff. I am confident that our colleagues Drs. Liz Billingsley, Glenn Goldman and Clark Otley will build upon these successes and lead us ably into the future.
I look forward to seeing you in Baltimore next week.
Barry Leshin, MD, FACMS
ACMS President, 2018-19
See the 2019 Annual Meeting Final Program
View highlights and information to be aware of as the meeting approaches:
- Registration Desk hours
- How to check in and pick up your registration materials
- Speaker bios
- Special events
- Professional headshots
- How to get the meeting app
Click the cover image to view the Final Program PDF >
MohsAIQ Registry Approved for 2019 MIPS Reporting
The MohsAIQ registry has been approved as a Qualified Clinical Data Registry by the Centers for Medicare and Medicaid Services for the 2019 reporting year under the Merit-based Incentive Payment System. MohsAIQ is the only reporting solution designed exclusively for Mohs surgeons to fulfill MIPS requirements.
Surgeons and institutions who participate in MohsAIQ can maximize their MIPS performance in 2019 and, thus, optimize reimbursement payments in 2021. MohsAIQ supports the Quality, Improvement Activities, and Promoting Interoperability categories of MIPS. ACMS members now have four new Mohs surgery-specific QCDR measures available to report to CMS through MohsAIQ along with any combination of the eight general Quality measures.
The specialty-specific measures unique to MohsAIQ include:
- Adherence to Mohs Micrographic Surgery Appropriate Use Criteria
- Closing the Mohs Surgery Referral Loop: Transmission of Surgical Report
- Surgical Site Infection Rate – Mohs Micrographic Surgery
- Antibiotic Prophylaxis for High Risk Cardiac / Orthopedic Cases prior to Mohs micrographic surgery – Prevention of Overuse
With the assistance and expertise of Hart Health Strategies, the ACMS undertook significant efforts to engage lawmakers and regulators in Washington, DC and beyond on issues of importance to Mohs surgeons and specialty physicians. These efforts spanned five key areas:
- Protect access to skin cancer care
- Preserve physician-office compounding
- Maintain the in-office ancillary services exception of the Stark Law
- Drive meaningful quality improvement and efficient resource use
- Increase awareness of the growing skin cancer epidemic
Updated Fellowship Match Policy and new SLOR
The College's Fellowship Match program is a service provided solely by Fellowship Matching Programs of San Francisco, California and is sponsored by the ACMS for the benefit of applicants and directors of fellowship programs approved by the ACMS or the ACGME. All programs participating in the match must be approved for such participation either by ACMS or the ACGME and no program may accept a match for a fellowship candidate without having obtained such approval.
In late 2018, the ACMS Board of Directors approved a new policy that eliminates exemptions for MSDO Fellowship programs, with the exception of applicants on active military duty or International (non-Canadian) applicants. All MSDO Fellowship training programs and directors are expected to participate in the 2019 match (for fellowships that begin in July 2020) in order for participants to be considered for membership in the ACMS, unless one of the two exceptions noted above applies. All other aspects/deadlines for the SF Match remain unchanged.
There is also an updated Standardized Letter of Recommendation (SLOR) for Micrographic Surgery and Dermatologic Oncology (MSDO) fellows participating in the Match program, available here.
Send Your Tech to Mohs Technician Training
Do your histotechs need help in reaching a higher level of slide preparation or reinforcing their skills? The American Society for Mohs Histotechnology offers customized, hands-on instruction through its ongoing Mohs Technician Training Training Program. Offered exclusively to technicians currently working for ACMS member surgeons, registration is open for the next training session taking place June 27-28, 2019 at Sakura Finetek USA, Inc., in Torrance, CA. Topics include mapping and inking, embedding, staining, cryosectioning, CLIA regulations and troubleshooting.
Non-member registration will include ASMH membership through 2019. Upon completion, trainees can claim 12 CEUs through the National Society for Histotechnology and will receive a certificate of completion from the ASMH/ACMS.
Click an image to learn more:
Answers to Your Mohs Coding & Billing Questions
Responses provided by Glenn D. Goldman, MD, FACMS
Many ACMS members have questions about proper coding and billing for Mohs surgery. This reinforces a need for ongoing education to ensure the College meets its goal of integrity and ethics in all aspects of Mohs practice. Dr. Glenn Goldman answers these coding and billing questions submitted to firstname.lastname@example.org. Responses are included in the e-Newsletter for the benefit of all members.
Avoiding and Managing Medicare Fraud and Abuse Investigations
by Willam Henghold, MD, FACMS
In their recent article in JAMA Dermatology, Wolfson, et al succinctly describe a growing area of concern for us Mohs surgeons: the threat of a government investigation into our practice.(1) Big brother is watching, and not just big brother, but our patients, colleagues, and medical organizations as well. And that is as it should be. Transparency is a good thing.
The subtitle of the article is “Mohs in the Crosshairs.” I don’t think this is a new problem. Mohs has been in the “crosshairs” for the entire time I’ve been in private practice (going on 15 years). And why is that? The answer is simple: the procedure is well reimbursed relative to other treatments for skin cancer specifically, and to other procedures across all specialties generally, and its use is increasing exponentially. I had one year in practice before the multiple surgery reduction rule hit Mohs surgery. And then there were the Mohs codes changes and other attempts to find ways to reduce reimbursement. This leads to a fear of the unknown for the future of the specialty. But I am proud to be a fellow of the American College of Mohs Surgery. It is an organization guided by smart, forward thinking, and fearless individuals who have always “leaned forward in the foxhole” and faced challenges head on.
Approximately 6 years ago I was asked by the Federal Bureau of Investigation (FBI) to help with a fraud investigation of a dermatology practice. This practice had become notorious in our community for a variety of reasons...
Observation Should be the New Standard for Moderately Dysplastic Nevi
by Todd V. Cartee, MD, FACMS
The management of moderately dysplastic nevi (DN) remains a vexing quandary in clinical practice. Little consensus exists even among experts resulting in a large number of excisions that are potentially unnecessary. Recent surveys demonstrate that a majority of dermatologists choose to re-excise moderately DN with a positive margin on the biopsy. This occurs because there has essentially been no substantial longitudinal data to guide management decisions.
To address this knowledge gap, 9 institutions participating in the Melanoma Prevention Working Group conducted a retrospective cohort study of cases of moderately DN with positive histologic margins, who were managed with observation and had at least 3 years of follow-up. For eligible cases, the intent of the biopsy had to be complete sampling of the nevus so cases of incisional or partial biopsies were excluded. 467 nevi in 438 patients met inclusion criteria. Remarkably, no cases of melanoma occurred at the site of biopsy. The cohort however was at markedly increased risk of developing a new melanoma at a separate site (22.8%!). Given that the lifetime risk of melanoma in white Americans is 2.6%, this almost 9 fold higher incidence over an average follow-up of only 6.9 years represents an astoundingly increased melanoma risk. Furthermore, the researchers found that subjects who had a prior melanoma (OR, 11.74; P < .001) or a prior DN (OR, 2.55; P = .01) were at an even higher risk for subsequent melanoma than the overall cohort despite controlling for age, sex, and family history in a multivariate model.
One potential criticism of this study is the absence of homogeneity in grading dysplasia among pathologists...
Click an image to learn more:
Mohs Surgeons’ Favorites
by Mark Russell, MD FACMS
During their career medical professionals learn from multiple sources based on a variety of exposures including formal and informal training, conferences, independent study, and experience. Education by colleagues represents another learning resource.1 The purpose of this article is to collect favorite practice tips from our experienced colleagues. A survey addressing practice style and practice management was sent to a limited number of Mohs surgeons in private and academic practice.
I would like to thank those 20 Mohs surgeons who were willing to share their wisdom and respond to the survey. They represent over 500 years of collective practice experience. The first of this two-part report is linked below.
Dermatopathology Appropriate Use Criteria
by Alok Vij, MD
Nearly every person agrees that health care should be delivered with the highest quality and high value, offering patients increasingly effective, safe, and cost-conscious care. With an ever-expanding knowledge base about the pathophysiology of disease states comes an expanding litany of diagnostic and therapeutic tools, some of which have a hefty price tag. Knowing that every procedure, diagnostic or therapeutic, has benefits and risks as well as cost, appropriate use criteria have been developed in many specialties, synthesizing scientific evidence and the collective judgement of experts to guide the use of procedures in everyday practice. Studies have shown that qualifying appropriateness is correlated with addressing cost-effectiveness .
Due to a rise in the incidence of skin cancer as well as an increase in the number of Mohs surgeons, the use of Mohs surgery increased by 400% between 1995 and 2009. In 2012, appropriate use criteria (AUC) were developed for the application of Mohs surgery to treat cutaneous malignancies, taking location, size, histologic findings, and patient-specific factors into account to optimize the use of Mohs surgery in which the potential clinical benefits are expected to be greatest .
In a first for pathology-based subspecialties, the American Society of Dermatopathology, in concert with the American Association of Dermatology and the College of American Pathologists, released AUC for dermatopathology ...
Patient-Reported Outcome Measures
By Thomas Bander, MD • 2018-19 FIT Board Observer
What defines a successful Mohs case? Clear surgical margins? An excellent aesthetic outcome? A lack of infection, bleeding, or numbness? A thankful patient? The definition of success in the literature has traditionally been based on oncologic outcomes (rates of cure, recurrence, and mortality), objective complications (bleeding, infection, and neurologic symptoms), or aesthetic results—usually from the physician’s perspective. Ultimately, we care most that patients are pleased with their surgical outcome, but we know that objective assessments of outcomes like scar appearance may not correlate with the degree of psychosocial distress.1 Thankfully, we now have several instruments to quantify skin cancer treatment outcomes from the patient’s perspective.1,2 How do we evaluate this new body of literature, and how can it be used in our daily clinical practice?
A patient-reported outcome measure (PROM) is a questionnaire given to patients to assess a variety of psychosocial outcomes, such as health-related quality of life, cancer worry, appearance-related distress, and patient satisfaction. PROMs must be carefully developed and tested to ensure three key characteristics: validity, reliability, and responsiveness.3 Importantly, these instruments cannot be merged or edited from their validated forms, as effective PROMs are rigorously tested to target the intended patient population and detect differences before and after intervention...
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Mohs Surgery Career Center
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The ACMS/ASMH Mohs Surgery Career Center is a resource for surgeons, histotechs, physician assistants, dermatopathologists, practice managers, administrative staff and others to search for job openings, post resumes, and connect with employers. The Career Center includes positions in multiple categories, expanded national reach, and the ability to search by position type, work setting, and state.
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