D ermatology has evolved through different paradigms over time. Prior to the founding of the American Academy of Dermatology, general surgeons often were found on the membership roles of dermatology societies. It wasn’t until 1932 that the American Board of Medical Specialties approved a certifying exam in dermatology and syphilogy. After World War II, dermatology became more oriented toward medical dermatology. With the founding of the American College of Mohs Micrographic Surgery and Cutaneous Oncology by Dr. Fred Mohs in 1967 and the American Society for Derma-tologic Surgery in 1970, dermatology as a medical, surgical and cosmetic hybrid was born. Throughout the ’70s and ’80s the concept of dermatologists as purveyors of cosmetic services continued to expand. Today, surgery is an integral part of a dermatology resident’s education. The Residency Review Committee (RRC), operating under the Accreditation Council for Graduate Medical Education (ACGMC), requires emphasis on dermatologic surgery in the organization and implementation of any dermatology-training program. Yet, dermatologic surgery as a subspecialty is still developing. Training Many residencies offer an immersion in medical, as well as surgical, dermatology in the first year of training. Proper care of the surgical patient involves knowledge and expertise in pre-operative assessment, intra-operative technique and managing post-operative care and complications. Familiarity with surgical complications with an understanding of issues in prevention and correction is crucial for success. Those with a particular interest in advanced training may wish to spend a portion of their residency with the program’s surgeon in a defined elective. There are many options for further training. Fellowship training in dermatologic surgery has gone through significant changes in the past few years. The ACGME recently approved a 1-year fellowship in procedural dermatology, which incorporates all the aspects of Mohs fellowships with 500 Mohs cases and a total of 1,000 surgical procedures within the year fellowship. Also, the planned fellowship encourages training in cosmetic procedures, though there are no numerical targets set. These procedures include sclerotherapy, chemical peels, hair transplantation, dermabrasion, small-volume liposuction, cutaneous soft tissue augmentation with injectable filler materials, rhinophyma correction and laser surgery. There are currently very few procedural dermatology fellowships in operation, although it’s expected there might be a trend for the current Mohs fellowships to convert into procedural dermatology fellowships. This change would involve a detailed program application process. History of Mohs Fellowships To get a sense of what procedural dermatology fellowships may look like in the future, it’s important to know more about the current Mohs fellowships, which are not ACGME accredited. The American College of Mohs Micrographic Surgery and Cutaneous Oncology approves Mohs fellowships. The organization was established to safeguard the standards of Mohs micrographic surgery and provide a means for recognition and approval of those who have become proficient and experienced in Mohs. The current Mohs fellowships can be 1 or 2 years in length. One-year programs require 500 cases, and 2-year programs require 300 cases per year. The ultimate result of the newly approved procedural dermatology fellowships remains to be seen, yet it’s certain that residents interested in dermatologic surgery will have an opportunity for further training. Until then, all residents should keep surgical logs of the procedures they perform during residency and fellowship training. As the office setting will likely become more regulated, these logs will provide proof to authorities of a dermatologist’s qualifications and ability to perform surgical procedures. Clinic Operations Once you’re ready to start a surgical practice, there are many aspects to setting it up such as the number of surgeons using the facility, the types of cases planned, and the volume of cases planned for the space. A typical surgical room should have good lighting and a mechanical table. The lighting can be done inexpensively with simple fluorescent lights or with more expensive ceiling-mounted and articulated surgical lighting equipment. A mechanical table costs $7,000 to $10,000. The space itself should be at least 160 sq. feet. If more than one surgical suite is needed, design each room as copies to simplify the task of locating equipment. For layout, incorporate efficiency in distance. C-shaped or U-shaped designs may be preferable to long halls if they incorporate cut-through halls for offices, lab or storage spaces out of the view of patients. This may be the best place for a break room or nurse’s station. Spaces for dirty and clean utilities (cleaning instruments and packing surgical packs in preparation for sterilization) are mandatory. The office lab can usually fit into 500 sq. feet. This area is for making frozen sections and for placing cryostats. The space can also be used for preparation, packing and sterilization of equipment. For storage, double the space you initially think you need. Bathrooms for patients and staff and a well-appointed waiting room are also a must. The waiting room is an important part of a patient’s experience in a physician’s office. Adequate restrooms equipped with features to assist patients in wheelchairs or walkers are recommended. Proper signs are also important. Staff When it comes to personnel, well-trained staff can be the most important factor in terms of efficiency. Usually the nurses in a practice have one of the following degrees: R.N., C.N.A., or L.P.N., although their expertise in dermatologic surgery is usually developed on the job. Mohs surgeons will need a histopathologist on staff. Equipment Good instruments are key with surgical trays costing $1,000 to $1,200 per tray. You’ll need at least 5 to 10 trays. Besides instruments, you’ll need sutures, bandaging materials and skin preparation clean-sers. Sutures can be expensive ($5 to $10 per pack), so buy in bulk to save money. You’ll also need antibiotic soaps and cleansers, emergency medicine kits, inventory control, technology and templates. The emergency kits need to have an automated defibrillator and a code cart with medicines that aren’t expired. Inventory control systems are important as supplies are apt to be lost, diverted or expired, which add to practice expense. Templates can be very useful for history and physical exam forms. Decide early if you want automation of templates so you can purchase appropriate software. Some simple equipment purchases can be useful. Physicians can use portable phones while in surgery. Centrally located eraser boards with patient information (new or return visit, reason for visit) and on supply needs in the different rooms are helpful. Quality assurance (QA) is another important aspect of a well-run office. This job should be facilitated by the designation of a single employee. Tracking “no shows,” biopsy reports, return visits after cancer, infection rates and a number of other issues fall under the umbrella of QA. Reimbursement Issues The most important factor in ensuring proper reimbursement is proper documentation. Record the reason for the visit using diagnosis codes from the International Classification of Disease 9th Edition (ICD-9) system, and use current procedural terminology (CPT) codes. One issue with reimbursement in dermatologic surgery has to do with procedures considered medically unnecessary, which usually receive an ICD-9 code of V50.9. Payers expect physicians to acknowledge those instances where medical necessity is not achieved, while providers expect payment for procedures done in good faith with documentation of medical need. A medical record should clearly define which procedure was done and why a particular method of closure was chosen if several are available. Understanding multiple surgical reduction rules, where they apply and how they may be misapplied, can generate significant revenue. The correct use of modifiers to code for evaluation and management visits within global post-operative periods that are unrelated to the surgical procedure is crucial. Know that follow-up visits for procedures with zero post-operative days can be billed as additions to the bottom line. Utilization of the 59 modifier to designate separate surgical procedures can reduce the risk of inappropriate bundling. Understanding the appropriate use of the modifier 25 to ensure appropriate payment for evaluation and management services rendered in conjunction with surgical services is necessary. You also need to recognize definitions of what constitutes a complex repair or tissue rearrangement and understand the nuances of choosing a particular code among those and documenting what was done and why in order to earn appropriate payment. Finally, you must remain up-to-date on changes within the coding lexicon to maintain fiscal viability and avoid complaints of abuse or unbundling. Close attention to documentation of necessity, procedures, and evaluation and management issues is crucial for the smooth functioning of any practice. Setting up a Surgery Practice In order to run a successful and profitable surgery practice, it’s essential to run an efficient office. Close attention must be paid to the design and layout of office space, to the equipment needed and to hiring the right staff.
Adding a Subspecialty with EaseSpotlight on: Derm Surgery
D ermatology has evolved through different paradigms over time. Prior to the founding of the American Academy of Dermatology, general surgeons often were found on the membership roles of dermatology societies. It wasn’t until 1932 that the American Board of Medical Specialties approved a certifying exam in dermatology and syphilogy. After World War II, dermatology became more oriented toward medical dermatology. With the founding of the American College of Mohs Micrographic Surgery and Cutaneous Oncology by Dr. Fred Mohs in 1967 and the American Society for Derma-tologic Surgery in 1970, dermatology as a medical, surgical and cosmetic hybrid was born. Throughout the ’70s and ’80s the concept of dermatologists as purveyors of cosmetic services continued to expand. Today, surgery is an integral part of a dermatology resident’s education. The Residency Review Committee (RRC), operating under the Accreditation Council for Graduate Medical Education (ACGMC), requires emphasis on dermatologic surgery in the organization and implementation of any dermatology-training program. Yet, dermatologic surgery as a subspecialty is still developing. Training Many residencies offer an immersion in medical, as well as surgical, dermatology in the first year of training. Proper care of the surgical patient involves knowledge and expertise in pre-operative assessment, intra-operative technique and managing post-operative care and complications. Familiarity with surgical complications with an understanding of issues in prevention and correction is crucial for success. Those with a particular interest in advanced training may wish to spend a portion of their residency with the program’s surgeon in a defined elective. There are many options for further training. Fellowship training in dermatologic surgery has gone through significant changes in the past few years. The ACGME recently approved a 1-year fellowship in procedural dermatology, which incorporates all the aspects of Mohs fellowships with 500 Mohs cases and a total of 1,000 surgical procedures within the year fellowship. Also, the planned fellowship encourages training in cosmetic procedures, though there are no numerical targets set. These procedures include sclerotherapy, chemical peels, hair transplantation, dermabrasion, small-volume liposuction, cutaneous soft tissue augmentation with injectable filler materials, rhinophyma correction and laser surgery. There are currently very few procedural dermatology fellowships in operation, although it’s expected there might be a trend for the current Mohs fellowships to convert into procedural dermatology fellowships. This change would involve a detailed program application process. History of Mohs Fellowships To get a sense of what procedural dermatology fellowships may look like in the future, it’s important to know more about the current Mohs fellowships, which are not ACGME accredited. The American College of Mohs Micrographic Surgery and Cutaneous Oncology approves Mohs fellowships. The organization was established to safeguard the standards of Mohs micrographic surgery and provide a means for recognition and approval of those who have become proficient and experienced in Mohs. The current Mohs fellowships can be 1 or 2 years in length. One-year programs require 500 cases, and 2-year programs require 300 cases per year. The ultimate result of the newly approved procedural dermatology fellowships remains to be seen, yet it’s certain that residents interested in dermatologic surgery will have an opportunity for further training. Until then, all residents should keep surgical logs of the procedures they perform during residency and fellowship training. As the office setting will likely become more regulated, these logs will provide proof to authorities of a dermatologist’s qualifications and ability to perform surgical procedures. Clinic Operations Once you’re ready to start a surgical practice, there are many aspects to setting it up such as the number of surgeons using the facility, the types of cases planned, and the volume of cases planned for the space. A typical surgical room should have good lighting and a mechanical table. The lighting can be done inexpensively with simple fluorescent lights or with more expensive ceiling-mounted and articulated surgical lighting equipment. A mechanical table costs $7,000 to $10,000. The space itself should be at least 160 sq. feet. If more than one surgical suite is needed, design each room as copies to simplify the task of locating equipment. For layout, incorporate efficiency in distance. C-shaped or U-shaped designs may be preferable to long halls if they incorporate cut-through halls for offices, lab or storage spaces out of the view of patients. This may be the best place for a break room or nurse’s station. Spaces for dirty and clean utilities (cleaning instruments and packing surgical packs in preparation for sterilization) are mandatory. The office lab can usually fit into 500 sq. feet. This area is for making frozen sections and for placing cryostats. The space can also be used for preparation, packing and sterilization of equipment. For storage, double the space you initially think you need. Bathrooms for patients and staff and a well-appointed waiting room are also a must. The waiting room is an important part of a patient’s experience in a physician’s office. Adequate restrooms equipped with features to assist patients in wheelchairs or walkers are recommended. Proper signs are also important. Staff When it comes to personnel, well-trained staff can be the most important factor in terms of efficiency. Usually the nurses in a practice have one of the following degrees: R.N., C.N.A., or L.P.N., although their expertise in dermatologic surgery is usually developed on the job. Mohs surgeons will need a histopathologist on staff. Equipment Good instruments are key with surgical trays costing $1,000 to $1,200 per tray. You’ll need at least 5 to 10 trays. Besides instruments, you’ll need sutures, bandaging materials and skin preparation clean-sers. Sutures can be expensive ($5 to $10 per pack), so buy in bulk to save money. You’ll also need antibiotic soaps and cleansers, emergency medicine kits, inventory control, technology and templates. The emergency kits need to have an automated defibrillator and a code cart with medicines that aren’t expired. Inventory control systems are important as supplies are apt to be lost, diverted or expired, which add to practice expense. Templates can be very useful for history and physical exam forms. Decide early if you want automation of templates so you can purchase appropriate software. Some simple equipment purchases can be useful. Physicians can use portable phones while in surgery. Centrally located eraser boards with patient information (new or return visit, reason for visit) and on supply needs in the different rooms are helpful. Quality assurance (QA) is another important aspect of a well-run office. This job should be facilitated by the designation of a single employee. Tracking “no shows,” biopsy reports, return visits after cancer, infection rates and a number of other issues fall under the umbrella of QA. Reimbursement Issues The most important factor in ensuring proper reimbursement is proper documentation. Record the reason for the visit using diagnosis codes from the International Classification of Disease 9th Edition (ICD-9) system, and use current procedural terminology (CPT) codes. One issue with reimbursement in dermatologic surgery has to do with procedures considered medically unnecessary, which usually receive an ICD-9 code of V50.9. Payers expect physicians to acknowledge those instances where medical necessity is not achieved, while providers expect payment for procedures done in good faith with documentation of medical need. A medical record should clearly define which procedure was done and why a particular method of closure was chosen if several are available. Understanding multiple surgical reduction rules, where they apply and how they may be misapplied, can generate significant revenue. The correct use of modifiers to code for evaluation and management visits within global post-operative periods that are unrelated to the surgical procedure is crucial. Know that follow-up visits for procedures with zero post-operative days can be billed as additions to the bottom line. Utilization of the 59 modifier to designate separate surgical procedures can reduce the risk of inappropriate bundling. Understanding the appropriate use of the modifier 25 to ensure appropriate payment for evaluation and management services rendered in conjunction with surgical services is necessary. You also need to recognize definitions of what constitutes a complex repair or tissue rearrangement and understand the nuances of choosing a particular code among those and documenting what was done and why in order to earn appropriate payment. Finally, you must remain up-to-date on changes within the coding lexicon to maintain fiscal viability and avoid complaints of abuse or unbundling. Close attention to documentation of necessity, procedures, and evaluation and management issues is crucial for the smooth functioning of any practice. Setting up a Surgery Practice In order to run a successful and profitable surgery practice, it’s essential to run an efficient office. Close attention must be paid to the design and layout of office space, to the equipment needed and to hiring the right staff.
D ermatology has evolved through different paradigms over time. Prior to the founding of the American Academy of Dermatology, general surgeons often were found on the membership roles of dermatology societies. It wasn’t until 1932 that the American Board of Medical Specialties approved a certifying exam in dermatology and syphilogy. After World War II, dermatology became more oriented toward medical dermatology. With the founding of the American College of Mohs Micrographic Surgery and Cutaneous Oncology by Dr. Fred Mohs in 1967 and the American Society for Derma-tologic Surgery in 1970, dermatology as a medical, surgical and cosmetic hybrid was born. Throughout the ’70s and ’80s the concept of dermatologists as purveyors of cosmetic services continued to expand. Today, surgery is an integral part of a dermatology resident’s education. The Residency Review Committee (RRC), operating under the Accreditation Council for Graduate Medical Education (ACGMC), requires emphasis on dermatologic surgery in the organization and implementation of any dermatology-training program. Yet, dermatologic surgery as a subspecialty is still developing. Training Many residencies offer an immersion in medical, as well as surgical, dermatology in the first year of training. Proper care of the surgical patient involves knowledge and expertise in pre-operative assessment, intra-operative technique and managing post-operative care and complications. Familiarity with surgical complications with an understanding of issues in prevention and correction is crucial for success. Those with a particular interest in advanced training may wish to spend a portion of their residency with the program’s surgeon in a defined elective. There are many options for further training. Fellowship training in dermatologic surgery has gone through significant changes in the past few years. The ACGME recently approved a 1-year fellowship in procedural dermatology, which incorporates all the aspects of Mohs fellowships with 500 Mohs cases and a total of 1,000 surgical procedures within the year fellowship. Also, the planned fellowship encourages training in cosmetic procedures, though there are no numerical targets set. These procedures include sclerotherapy, chemical peels, hair transplantation, dermabrasion, small-volume liposuction, cutaneous soft tissue augmentation with injectable filler materials, rhinophyma correction and laser surgery. There are currently very few procedural dermatology fellowships in operation, although it’s expected there might be a trend for the current Mohs fellowships to convert into procedural dermatology fellowships. This change would involve a detailed program application process. History of Mohs Fellowships To get a sense of what procedural dermatology fellowships may look like in the future, it’s important to know more about the current Mohs fellowships, which are not ACGME accredited. The American College of Mohs Micrographic Surgery and Cutaneous Oncology approves Mohs fellowships. The organization was established to safeguard the standards of Mohs micrographic surgery and provide a means for recognition and approval of those who have become proficient and experienced in Mohs. The current Mohs fellowships can be 1 or 2 years in length. One-year programs require 500 cases, and 2-year programs require 300 cases per year. The ultimate result of the newly approved procedural dermatology fellowships remains to be seen, yet it’s certain that residents interested in dermatologic surgery will have an opportunity for further training. Until then, all residents should keep surgical logs of the procedures they perform during residency and fellowship training. As the office setting will likely become more regulated, these logs will provide proof to authorities of a dermatologist’s qualifications and ability to perform surgical procedures. Clinic Operations Once you’re ready to start a surgical practice, there are many aspects to setting it up such as the number of surgeons using the facility, the types of cases planned, and the volume of cases planned for the space. A typical surgical room should have good lighting and a mechanical table. The lighting can be done inexpensively with simple fluorescent lights or with more expensive ceiling-mounted and articulated surgical lighting equipment. A mechanical table costs $7,000 to $10,000. The space itself should be at least 160 sq. feet. If more than one surgical suite is needed, design each room as copies to simplify the task of locating equipment. For layout, incorporate efficiency in distance. C-shaped or U-shaped designs may be preferable to long halls if they incorporate cut-through halls for offices, lab or storage spaces out of the view of patients. This may be the best place for a break room or nurse’s station. Spaces for dirty and clean utilities (cleaning instruments and packing surgical packs in preparation for sterilization) are mandatory. The office lab can usually fit into 500 sq. feet. This area is for making frozen sections and for placing cryostats. The space can also be used for preparation, packing and sterilization of equipment. For storage, double the space you initially think you need. Bathrooms for patients and staff and a well-appointed waiting room are also a must. The waiting room is an important part of a patient’s experience in a physician’s office. Adequate restrooms equipped with features to assist patients in wheelchairs or walkers are recommended. Proper signs are also important. Staff When it comes to personnel, well-trained staff can be the most important factor in terms of efficiency. Usually the nurses in a practice have one of the following degrees: R.N., C.N.A., or L.P.N., although their expertise in dermatologic surgery is usually developed on the job. Mohs surgeons will need a histopathologist on staff. Equipment Good instruments are key with surgical trays costing $1,000 to $1,200 per tray. You’ll need at least 5 to 10 trays. Besides instruments, you’ll need sutures, bandaging materials and skin preparation clean-sers. Sutures can be expensive ($5 to $10 per pack), so buy in bulk to save money. You’ll also need antibiotic soaps and cleansers, emergency medicine kits, inventory control, technology and templates. The emergency kits need to have an automated defibrillator and a code cart with medicines that aren’t expired. Inventory control systems are important as supplies are apt to be lost, diverted or expired, which add to practice expense. Templates can be very useful for history and physical exam forms. Decide early if you want automation of templates so you can purchase appropriate software. Some simple equipment purchases can be useful. Physicians can use portable phones while in surgery. Centrally located eraser boards with patient information (new or return visit, reason for visit) and on supply needs in the different rooms are helpful. Quality assurance (QA) is another important aspect of a well-run office. This job should be facilitated by the designation of a single employee. Tracking “no shows,” biopsy reports, return visits after cancer, infection rates and a number of other issues fall under the umbrella of QA. Reimbursement Issues The most important factor in ensuring proper reimbursement is proper documentation. Record the reason for the visit using diagnosis codes from the International Classification of Disease 9th Edition (ICD-9) system, and use current procedural terminology (CPT) codes. One issue with reimbursement in dermatologic surgery has to do with procedures considered medically unnecessary, which usually receive an ICD-9 code of V50.9. Payers expect physicians to acknowledge those instances where medical necessity is not achieved, while providers expect payment for procedures done in good faith with documentation of medical need. A medical record should clearly define which procedure was done and why a particular method of closure was chosen if several are available. Understanding multiple surgical reduction rules, where they apply and how they may be misapplied, can generate significant revenue. The correct use of modifiers to code for evaluation and management visits within global post-operative periods that are unrelated to the surgical procedure is crucial. Know that follow-up visits for procedures with zero post-operative days can be billed as additions to the bottom line. Utilization of the 59 modifier to designate separate surgical procedures can reduce the risk of inappropriate bundling. Understanding the appropriate use of the modifier 25 to ensure appropriate payment for evaluation and management services rendered in conjunction with surgical services is necessary. You also need to recognize definitions of what constitutes a complex repair or tissue rearrangement and understand the nuances of choosing a particular code among those and documenting what was done and why in order to earn appropriate payment. Finally, you must remain up-to-date on changes within the coding lexicon to maintain fiscal viability and avoid complaints of abuse or unbundling. Close attention to documentation of necessity, procedures, and evaluation and management issues is crucial for the smooth functioning of any practice. Setting up a Surgery Practice In order to run a successful and profitable surgery practice, it’s essential to run an efficient office. Close attention must be paid to the design and layout of office space, to the equipment needed and to hiring the right staff.
