E arly detection of melanoma can be the difference between life and death. Of the three major types of skin cancer — basal cell carcinoma, squamous cell carcinoma and melanoma — melanoma is the least common, but the most lethal. But, since melanoma is highly curable if detected early, dermatologic subspecialty clinics for pigmented lesions have been established to facilitate early melanoma detection. This is critical because the outlook for patients with advanced melanoma remains dismal. However, early melanomas are hard to detect and are relatively rare compared to non-malignant moles. The challenge is to identify early melanomas while avoiding unnecessary removal of benign lesions. Pigmented lesion clinic patients include those with congenital melanocytic lesions, a personal history of melanoma, numerous moles, atypical (dysplastic moles), and/or a family history of melanoma. This subspecialty area is unique because the dermatologist has a chance to markedly reduce the life-threatening potential of developing melanomas. Attention to detail, tolerance for risk, interest in dermatopathology, and the ability to manage anxious patients are important attributes of a dermatologist who is interested in opening a pigmented lesion clinic. Training Tips For those interested in pigmented lesions, training begins with a residency in dermatology. Selection of a residency program with a subspecialty pigmented lesion clinic is optimal, but for those residents who do not have facilities at their own program, attending dermoscopy courses at the American Academy of Dermatology (AAD) meetings or at international meetings is a realistic option. Managing Patient Anxieties In pigmented lesion clinics there are four main skills that should be mastered. The first involves patient-doctor interaction. You must be willing to listen to the patient and pay attention to a patient’s focus on particular moles. Patients may be focused on a particular lesion and their questions and anxieties about that lesion must be addressed. Sometimes the cause of the patient’s concern is obvious — for example, a lesion that clinically appears to be consistent with an intradermal nevus, but is rubbing on clothing. Clinically, the patient’s concern is easy to understand and often the concern for melanoma is minimal. Sometimes it is not so obvious why the patient has noted the lesion, for example, a small macular lesion that the patient states is just something they have recently noticed and about which they are worried. While these lesions may not display the ABCDs of melanoma (asymmetry, border irregularity, color variation and diameter greater than 6 mm) the patient’s suspicion is a significant factor to consider when making the decision as to whether excision is necessary. Sometimes these lesions prove to be early melanomas, sometimes not. However, one of the wonderful things about your position as a dermatologist in these cases is that if the patient has a lot of anxiety wrapped up in a particular mole, you have the ability to remove the anxiety and put it in a jar. If only the psychiatrists could be so lucky. Another part of this interaction is educating the patient. Patients often feel that they are a walking pre-cancer. We need to provide them with a strategy that they can understand and then help them put the plan into action. Recognizing Melanoma A second skill you’ll need is recognizing and detecting melanomas in a background of benign nevi (possibly 20,000 to 200,000:1 on an annual basis). The dermatologist must find the mole(s) that does not match the patient’s normal nevus pattern. The theory is that benign nevi are caused by common mild genetic defects in growth regulation, while melanoma lesions have rare malignant genetic defects in growth regulation. These genetic defects result in different growth patterns on the skin surface with the common mild defects appearing as the baseline nevus pattern and the rare malignant defect appearing as a mole pattern that is dissimilar from the others (this is known as the “ugly duckling sign”). Furthermore, benign nevi tend to demonstrate uniform growth with eventual stabilization, but malignant melanomas will eventually demonstrate a non-uniform pattern and will fail to stabilize growth. So, the mole(s) that is dissimilar from the patient’s other moles is potentially worrisome for melanoma particularly if it also has non-uniform features and has demonstrated growth. Using The Dermoscope The third skill you need to master is use of the dermoscope. The dermoscope simply allows a closer look at the skin’s surface by providing magnification (often 10x) and reducing surface reflection either with cross-polarized light or fluid-surface contact. Dermoscopy is particularly helpful in discriminating non-melanocytic lesions (seborrheic keratoses, hemangiomas, pigmented basal cell carcinomas, and lichen planus-like keratoses) from melanocytic lesions. The patterns for benign lesions can often be readily identified. The lesions that don’t display clearly benign patterns require further attention. The use of dermoscopy requires training, but the value delivered to the practitioner is well worth it. Resources to learn more about dermoscopy are available on the Web (dermoscopy.org), through the AAD, in print form (dermoscopy atlases) and at courses given at regional and international meetings. Total Body Photography The fourth skill needed is the ability to use total body photography (TBP). TBP allows for an assessment of change by providing a baseline of the patient’s total visible skin surface. Unlike dermoscopic images of a particular mole or snapshots of individual moles, TBP can be used to assess change for any lesion(s) anywhere on the patient’s body that might be of concern. TBP is especially critical for new lesions because documentation of skin where no moles are present is unlikely to exist in normal medical records. It is important to keep in mind that all acquired nevi are new at some point. TBP should also be used as an adjunct tool during the follow-up examination. If a lesion(s) is of concern to the patient, and/or is dissimilar to the other moles, and/or is lacking clearly benign dermoscopic features and also demonstrates change compared to TBP, then that lesion should be considered for excision. This tool can help significantly with the main focus of pigmented lesion clinic, which is to identify and excise potentially malignant lesions while minimizing unnecessary biopsies. Without TBP, the common approach is to remove the worst looking lesions at every visit. Once the worst looking lesions have been removed, the focus tends to move on to the next set of lesions. This approach, potentially resulting in multiple unnecessary excisions on every visit, is neither optimal for the patient nor for the physician. Certainly, any lesions worrisome for melanoma should be removed on the patient’s first visit, but lesions that are not thought to be a melanoma on the first visit and are stable over time are unlikely to be melanoma. Dermatologists who regularly use total body photography should feel more confident in their assessment of the benign or malignant nature of a particular mole, theoretically allowing for improved detection of early melanomas at the same time as reducing unnecessary excisions. In an effort to expedite patient flow, the nurses should explain the need to have the patients fully disrobe and put on a gown in an effort to facilitate the total body skin examination. A nurse must be available to chaperone the full body skin exams. Ultimately, these four approaches can help improve melanoma detection. The use of these approaches during regular surveillance of patients every 3 to 12 months facilitates the early detection of melanoma. If you’re interested in pigmented lesions, you should seek to be proficient in all these key skills. The Cost of Personnel for Running Clinic Operations A sole focus on pigmented lesions is a possible option for academic dermatologists, but the private practitioner interested in pigmented lesions will probably find that they may want to only dedicate a half-day to a full-day per week to this area. The general dermatology clinic personnel in terms of nurses, billing and check-in can be used for the pigmented lesion clinic. In the end, personnel expenses are similar to those involved with running a general dermatology clinic. Equipment Needs and Associated Costs Equipment needs are minimal for a pigmented lesion clinic, especially if all patient rooms are already outfitted with computers. A hand-held dermoscope, manufactured by many companies including, Heine, Welch Allyn and 3-Gen, can cost between $200 and $1,000. Dermoscopy cameras are also available and may cost around $1,000 to $4,000. There are a number of approaches for total body photos. At Duke, we developed and use the MoleMapCD system. (This service is marketed nationally by DigtialDerm, Inc.) If you use this system, you refer patients to a medical photographer trained in obtaining a high-quality standardized set of total body photos. You receive the images in the form of a CD, which includes display software and the patient’s photos. A second CD is included for distribution to the patient. There are no costs to the physician for this service. However, you must have a laptop or desktop computer in the patient’s room to display the photos. Currently the patient is responsible for the cost, generally less than the total cost of one to two excisions, and a growing number of insurance companies are covering this service. Other approaches include the use of slides, print images or digital images, either taken in house or by local photographers. TBP hardware systems are also available. Even though the goal of these efforts is to minimize unnecessary biopsies, these patients are prone to developing skin cancer and still require a fair number of excisions. Therefore, the equipment for standard excisions is also required. Overall, the costs associated with starting a pigmented lesion clinic are not burdensome and depending on the approach taken could run just a little more than $1,000. Reimbursement Issues The common diagnosis codes used in pigmented lesion clinic include: • V10.82 (history of melanoma) • V10.83 (history of other non-melanoma skin cancer) • 216.9 (benign neoplasm skin) • 238.2 (skin neoplasm of uncertain behavior) • 172.9 (melanoma). Billing is usually for an office visit and excision(s) if required. A new patient visit, especially for patients with a history of melanoma, will usually require the time and complexity of a level 3 or 4 visit. A follow-up patient with photos, but no prior melanoma is often a level 3 visit, and with prior melanoma is often a level 4 visit. Two CPT category III codes exist for a physician request for total body photography of patients at high risk for developing primary melanoma, 0044t (dysplastic nevus syndrome, familial melanoma) and 0045t (personal history melanoma, dysplastic nevi). Reimbursement for these codes has not been firmly established and if using an outside service this charge would be generated by the outside provider. Excision codes 11400, 11401, and 11402 are commonly used. For some excisions, billing for closure may also be needed. Choosing This Area of Practice Specializing in pigmented lesions within dermatology fulfills a critical patient need and can be rewarding. This area is one of the few areas in dermatology and oncology where the physician-patient collaboration has the capacity to stop a potentially life-threatening cancer at a readily curable stage. Pigmented lesions also are an area of intense basic and clinical science research and can be attractive to those with an interest in research. An interest in dermatopathology helps when interpreting and discussing the pathology reports. Moreover, those dermatologists who are apt at visual exam of skin lesions should find early melanoma detection a suitable challenge for which patients are extremely grateful. Disclosure: The Center for Dermatology Research is funded by a grant from Galderma. Dr. Grichnik is a major shareholder in DigitalDerm, Inc.
Adding a Subspecialty with Ease: Spotlight on: Pigmented Lesions
E arly detection of melanoma can be the difference between life and death. Of the three major types of skin cancer — basal cell carcinoma, squamous cell carcinoma and melanoma — melanoma is the least common, but the most lethal. But, since melanoma is highly curable if detected early, dermatologic subspecialty clinics for pigmented lesions have been established to facilitate early melanoma detection. This is critical because the outlook for patients with advanced melanoma remains dismal. However, early melanomas are hard to detect and are relatively rare compared to non-malignant moles. The challenge is to identify early melanomas while avoiding unnecessary removal of benign lesions. Pigmented lesion clinic patients include those with congenital melanocytic lesions, a personal history of melanoma, numerous moles, atypical (dysplastic moles), and/or a family history of melanoma. This subspecialty area is unique because the dermatologist has a chance to markedly reduce the life-threatening potential of developing melanomas. Attention to detail, tolerance for risk, interest in dermatopathology, and the ability to manage anxious patients are important attributes of a dermatologist who is interested in opening a pigmented lesion clinic. Training Tips For those interested in pigmented lesions, training begins with a residency in dermatology. Selection of a residency program with a subspecialty pigmented lesion clinic is optimal, but for those residents who do not have facilities at their own program, attending dermoscopy courses at the American Academy of Dermatology (AAD) meetings or at international meetings is a realistic option. Managing Patient Anxieties In pigmented lesion clinics there are four main skills that should be mastered. The first involves patient-doctor interaction. You must be willing to listen to the patient and pay attention to a patient’s focus on particular moles. Patients may be focused on a particular lesion and their questions and anxieties about that lesion must be addressed. Sometimes the cause of the patient’s concern is obvious — for example, a lesion that clinically appears to be consistent with an intradermal nevus, but is rubbing on clothing. Clinically, the patient’s concern is easy to understand and often the concern for melanoma is minimal. Sometimes it is not so obvious why the patient has noted the lesion, for example, a small macular lesion that the patient states is just something they have recently noticed and about which they are worried. While these lesions may not display the ABCDs of melanoma (asymmetry, border irregularity, color variation and diameter greater than 6 mm) the patient’s suspicion is a significant factor to consider when making the decision as to whether excision is necessary. Sometimes these lesions prove to be early melanomas, sometimes not. However, one of the wonderful things about your position as a dermatologist in these cases is that if the patient has a lot of anxiety wrapped up in a particular mole, you have the ability to remove the anxiety and put it in a jar. If only the psychiatrists could be so lucky. Another part of this interaction is educating the patient. Patients often feel that they are a walking pre-cancer. We need to provide them with a strategy that they can understand and then help them put the plan into action. Recognizing Melanoma A second skill you’ll need is recognizing and detecting melanomas in a background of benign nevi (possibly 20,000 to 200,000:1 on an annual basis). The dermatologist must find the mole(s) that does not match the patient’s normal nevus pattern. The theory is that benign nevi are caused by common mild genetic defects in growth regulation, while melanoma lesions have rare malignant genetic defects in growth regulation. These genetic defects result in different growth patterns on the skin surface with the common mild defects appearing as the baseline nevus pattern and the rare malignant defect appearing as a mole pattern that is dissimilar from the others (this is known as the “ugly duckling sign”). Furthermore, benign nevi tend to demonstrate uniform growth with eventual stabilization, but malignant melanomas will eventually demonstrate a non-uniform pattern and will fail to stabilize growth. So, the mole(s) that is dissimilar from the patient’s other moles is potentially worrisome for melanoma particularly if it also has non-uniform features and has demonstrated growth. Using The Dermoscope The third skill you need to master is use of the dermoscope. The dermoscope simply allows a closer look at the skin’s surface by providing magnification (often 10x) and reducing surface reflection either with cross-polarized light or fluid-surface contact. Dermoscopy is particularly helpful in discriminating non-melanocytic lesions (seborrheic keratoses, hemangiomas, pigmented basal cell carcinomas, and lichen planus-like keratoses) from melanocytic lesions. The patterns for benign lesions can often be readily identified. The lesions that don’t display clearly benign patterns require further attention. The use of dermoscopy requires training, but the value delivered to the practitioner is well worth it. Resources to learn more about dermoscopy are available on the Web (dermoscopy.org), through the AAD, in print form (dermoscopy atlases) and at courses given at regional and international meetings. Total Body Photography The fourth skill needed is the ability to use total body photography (TBP). TBP allows for an assessment of change by providing a baseline of the patient’s total visible skin surface. Unlike dermoscopic images of a particular mole or snapshots of individual moles, TBP can be used to assess change for any lesion(s) anywhere on the patient’s body that might be of concern. TBP is especially critical for new lesions because documentation of skin where no moles are present is unlikely to exist in normal medical records. It is important to keep in mind that all acquired nevi are new at some point. TBP should also be used as an adjunct tool during the follow-up examination. If a lesion(s) is of concern to the patient, and/or is dissimilar to the other moles, and/or is lacking clearly benign dermoscopic features and also demonstrates change compared to TBP, then that lesion should be considered for excision. This tool can help significantly with the main focus of pigmented lesion clinic, which is to identify and excise potentially malignant lesions while minimizing unnecessary biopsies. Without TBP, the common approach is to remove the worst looking lesions at every visit. Once the worst looking lesions have been removed, the focus tends to move on to the next set of lesions. This approach, potentially resulting in multiple unnecessary excisions on every visit, is neither optimal for the patient nor for the physician. Certainly, any lesions worrisome for melanoma should be removed on the patient’s first visit, but lesions that are not thought to be a melanoma on the first visit and are stable over time are unlikely to be melanoma. Dermatologists who regularly use total body photography should feel more confident in their assessment of the benign or malignant nature of a particular mole, theoretically allowing for improved detection of early melanomas at the same time as reducing unnecessary excisions. In an effort to expedite patient flow, the nurses should explain the need to have the patients fully disrobe and put on a gown in an effort to facilitate the total body skin examination. A nurse must be available to chaperone the full body skin exams. Ultimately, these four approaches can help improve melanoma detection. The use of these approaches during regular surveillance of patients every 3 to 12 months facilitates the early detection of melanoma. If you’re interested in pigmented lesions, you should seek to be proficient in all these key skills. The Cost of Personnel for Running Clinic Operations A sole focus on pigmented lesions is a possible option for academic dermatologists, but the private practitioner interested in pigmented lesions will probably find that they may want to only dedicate a half-day to a full-day per week to this area. The general dermatology clinic personnel in terms of nurses, billing and check-in can be used for the pigmented lesion clinic. In the end, personnel expenses are similar to those involved with running a general dermatology clinic. Equipment Needs and Associated Costs Equipment needs are minimal for a pigmented lesion clinic, especially if all patient rooms are already outfitted with computers. A hand-held dermoscope, manufactured by many companies including, Heine, Welch Allyn and 3-Gen, can cost between $200 and $1,000. Dermoscopy cameras are also available and may cost around $1,000 to $4,000. There are a number of approaches for total body photos. At Duke, we developed and use the MoleMapCD system. (This service is marketed nationally by DigtialDerm, Inc.) If you use this system, you refer patients to a medical photographer trained in obtaining a high-quality standardized set of total body photos. You receive the images in the form of a CD, which includes display software and the patient’s photos. A second CD is included for distribution to the patient. There are no costs to the physician for this service. However, you must have a laptop or desktop computer in the patient’s room to display the photos. Currently the patient is responsible for the cost, generally less than the total cost of one to two excisions, and a growing number of insurance companies are covering this service. Other approaches include the use of slides, print images or digital images, either taken in house or by local photographers. TBP hardware systems are also available. Even though the goal of these efforts is to minimize unnecessary biopsies, these patients are prone to developing skin cancer and still require a fair number of excisions. Therefore, the equipment for standard excisions is also required. Overall, the costs associated with starting a pigmented lesion clinic are not burdensome and depending on the approach taken could run just a little more than $1,000. Reimbursement Issues The common diagnosis codes used in pigmented lesion clinic include: • V10.82 (history of melanoma) • V10.83 (history of other non-melanoma skin cancer) • 216.9 (benign neoplasm skin) • 238.2 (skin neoplasm of uncertain behavior) • 172.9 (melanoma). Billing is usually for an office visit and excision(s) if required. A new patient visit, especially for patients with a history of melanoma, will usually require the time and complexity of a level 3 or 4 visit. A follow-up patient with photos, but no prior melanoma is often a level 3 visit, and with prior melanoma is often a level 4 visit. Two CPT category III codes exist for a physician request for total body photography of patients at high risk for developing primary melanoma, 0044t (dysplastic nevus syndrome, familial melanoma) and 0045t (personal history melanoma, dysplastic nevi). Reimbursement for these codes has not been firmly established and if using an outside service this charge would be generated by the outside provider. Excision codes 11400, 11401, and 11402 are commonly used. For some excisions, billing for closure may also be needed. Choosing This Area of Practice Specializing in pigmented lesions within dermatology fulfills a critical patient need and can be rewarding. This area is one of the few areas in dermatology and oncology where the physician-patient collaboration has the capacity to stop a potentially life-threatening cancer at a readily curable stage. Pigmented lesions also are an area of intense basic and clinical science research and can be attractive to those with an interest in research. An interest in dermatopathology helps when interpreting and discussing the pathology reports. Moreover, those dermatologists who are apt at visual exam of skin lesions should find early melanoma detection a suitable challenge for which patients are extremely grateful. Disclosure: The Center for Dermatology Research is funded by a grant from Galderma. Dr. Grichnik is a major shareholder in DigitalDerm, Inc.
E arly detection of melanoma can be the difference between life and death. Of the three major types of skin cancer — basal cell carcinoma, squamous cell carcinoma and melanoma — melanoma is the least common, but the most lethal. But, since melanoma is highly curable if detected early, dermatologic subspecialty clinics for pigmented lesions have been established to facilitate early melanoma detection. This is critical because the outlook for patients with advanced melanoma remains dismal. However, early melanomas are hard to detect and are relatively rare compared to non-malignant moles. The challenge is to identify early melanomas while avoiding unnecessary removal of benign lesions. Pigmented lesion clinic patients include those with congenital melanocytic lesions, a personal history of melanoma, numerous moles, atypical (dysplastic moles), and/or a family history of melanoma. This subspecialty area is unique because the dermatologist has a chance to markedly reduce the life-threatening potential of developing melanomas. Attention to detail, tolerance for risk, interest in dermatopathology, and the ability to manage anxious patients are important attributes of a dermatologist who is interested in opening a pigmented lesion clinic. Training Tips For those interested in pigmented lesions, training begins with a residency in dermatology. Selection of a residency program with a subspecialty pigmented lesion clinic is optimal, but for those residents who do not have facilities at their own program, attending dermoscopy courses at the American Academy of Dermatology (AAD) meetings or at international meetings is a realistic option. Managing Patient Anxieties In pigmented lesion clinics there are four main skills that should be mastered. The first involves patient-doctor interaction. You must be willing to listen to the patient and pay attention to a patient’s focus on particular moles. Patients may be focused on a particular lesion and their questions and anxieties about that lesion must be addressed. Sometimes the cause of the patient’s concern is obvious — for example, a lesion that clinically appears to be consistent with an intradermal nevus, but is rubbing on clothing. Clinically, the patient’s concern is easy to understand and often the concern for melanoma is minimal. Sometimes it is not so obvious why the patient has noted the lesion, for example, a small macular lesion that the patient states is just something they have recently noticed and about which they are worried. While these lesions may not display the ABCDs of melanoma (asymmetry, border irregularity, color variation and diameter greater than 6 mm) the patient’s suspicion is a significant factor to consider when making the decision as to whether excision is necessary. Sometimes these lesions prove to be early melanomas, sometimes not. However, one of the wonderful things about your position as a dermatologist in these cases is that if the patient has a lot of anxiety wrapped up in a particular mole, you have the ability to remove the anxiety and put it in a jar. If only the psychiatrists could be so lucky. Another part of this interaction is educating the patient. Patients often feel that they are a walking pre-cancer. We need to provide them with a strategy that they can understand and then help them put the plan into action. Recognizing Melanoma A second skill you’ll need is recognizing and detecting melanomas in a background of benign nevi (possibly 20,000 to 200,000:1 on an annual basis). The dermatologist must find the mole(s) that does not match the patient’s normal nevus pattern. The theory is that benign nevi are caused by common mild genetic defects in growth regulation, while melanoma lesions have rare malignant genetic defects in growth regulation. These genetic defects result in different growth patterns on the skin surface with the common mild defects appearing as the baseline nevus pattern and the rare malignant defect appearing as a mole pattern that is dissimilar from the others (this is known as the “ugly duckling sign”). Furthermore, benign nevi tend to demonstrate uniform growth with eventual stabilization, but malignant melanomas will eventually demonstrate a non-uniform pattern and will fail to stabilize growth. So, the mole(s) that is dissimilar from the patient’s other moles is potentially worrisome for melanoma particularly if it also has non-uniform features and has demonstrated growth. Using The Dermoscope The third skill you need to master is use of the dermoscope. The dermoscope simply allows a closer look at the skin’s surface by providing magnification (often 10x) and reducing surface reflection either with cross-polarized light or fluid-surface contact. Dermoscopy is particularly helpful in discriminating non-melanocytic lesions (seborrheic keratoses, hemangiomas, pigmented basal cell carcinomas, and lichen planus-like keratoses) from melanocytic lesions. The patterns for benign lesions can often be readily identified. The lesions that don’t display clearly benign patterns require further attention. The use of dermoscopy requires training, but the value delivered to the practitioner is well worth it. Resources to learn more about dermoscopy are available on the Web (dermoscopy.org), through the AAD, in print form (dermoscopy atlases) and at courses given at regional and international meetings. Total Body Photography The fourth skill needed is the ability to use total body photography (TBP). TBP allows for an assessment of change by providing a baseline of the patient’s total visible skin surface. Unlike dermoscopic images of a particular mole or snapshots of individual moles, TBP can be used to assess change for any lesion(s) anywhere on the patient’s body that might be of concern. TBP is especially critical for new lesions because documentation of skin where no moles are present is unlikely to exist in normal medical records. It is important to keep in mind that all acquired nevi are new at some point. TBP should also be used as an adjunct tool during the follow-up examination. If a lesion(s) is of concern to the patient, and/or is dissimilar to the other moles, and/or is lacking clearly benign dermoscopic features and also demonstrates change compared to TBP, then that lesion should be considered for excision. This tool can help significantly with the main focus of pigmented lesion clinic, which is to identify and excise potentially malignant lesions while minimizing unnecessary biopsies. Without TBP, the common approach is to remove the worst looking lesions at every visit. Once the worst looking lesions have been removed, the focus tends to move on to the next set of lesions. This approach, potentially resulting in multiple unnecessary excisions on every visit, is neither optimal for the patient nor for the physician. Certainly, any lesions worrisome for melanoma should be removed on the patient’s first visit, but lesions that are not thought to be a melanoma on the first visit and are stable over time are unlikely to be melanoma. Dermatologists who regularly use total body photography should feel more confident in their assessment of the benign or malignant nature of a particular mole, theoretically allowing for improved detection of early melanomas at the same time as reducing unnecessary excisions. In an effort to expedite patient flow, the nurses should explain the need to have the patients fully disrobe and put on a gown in an effort to facilitate the total body skin examination. A nurse must be available to chaperone the full body skin exams. Ultimately, these four approaches can help improve melanoma detection. The use of these approaches during regular surveillance of patients every 3 to 12 months facilitates the early detection of melanoma. If you’re interested in pigmented lesions, you should seek to be proficient in all these key skills. The Cost of Personnel for Running Clinic Operations A sole focus on pigmented lesions is a possible option for academic dermatologists, but the private practitioner interested in pigmented lesions will probably find that they may want to only dedicate a half-day to a full-day per week to this area. The general dermatology clinic personnel in terms of nurses, billing and check-in can be used for the pigmented lesion clinic. In the end, personnel expenses are similar to those involved with running a general dermatology clinic. Equipment Needs and Associated Costs Equipment needs are minimal for a pigmented lesion clinic, especially if all patient rooms are already outfitted with computers. A hand-held dermoscope, manufactured by many companies including, Heine, Welch Allyn and 3-Gen, can cost between $200 and $1,000. Dermoscopy cameras are also available and may cost around $1,000 to $4,000. There are a number of approaches for total body photos. At Duke, we developed and use the MoleMapCD system. (This service is marketed nationally by DigtialDerm, Inc.) If you use this system, you refer patients to a medical photographer trained in obtaining a high-quality standardized set of total body photos. You receive the images in the form of a CD, which includes display software and the patient’s photos. A second CD is included for distribution to the patient. There are no costs to the physician for this service. However, you must have a laptop or desktop computer in the patient’s room to display the photos. Currently the patient is responsible for the cost, generally less than the total cost of one to two excisions, and a growing number of insurance companies are covering this service. Other approaches include the use of slides, print images or digital images, either taken in house or by local photographers. TBP hardware systems are also available. Even though the goal of these efforts is to minimize unnecessary biopsies, these patients are prone to developing skin cancer and still require a fair number of excisions. Therefore, the equipment for standard excisions is also required. Overall, the costs associated with starting a pigmented lesion clinic are not burdensome and depending on the approach taken could run just a little more than $1,000. Reimbursement Issues The common diagnosis codes used in pigmented lesion clinic include: • V10.82 (history of melanoma) • V10.83 (history of other non-melanoma skin cancer) • 216.9 (benign neoplasm skin) • 238.2 (skin neoplasm of uncertain behavior) • 172.9 (melanoma). Billing is usually for an office visit and excision(s) if required. A new patient visit, especially for patients with a history of melanoma, will usually require the time and complexity of a level 3 or 4 visit. A follow-up patient with photos, but no prior melanoma is often a level 3 visit, and with prior melanoma is often a level 4 visit. Two CPT category III codes exist for a physician request for total body photography of patients at high risk for developing primary melanoma, 0044t (dysplastic nevus syndrome, familial melanoma) and 0045t (personal history melanoma, dysplastic nevi). Reimbursement for these codes has not been firmly established and if using an outside service this charge would be generated by the outside provider. Excision codes 11400, 11401, and 11402 are commonly used. For some excisions, billing for closure may also be needed. Choosing This Area of Practice Specializing in pigmented lesions within dermatology fulfills a critical patient need and can be rewarding. This area is one of the few areas in dermatology and oncology where the physician-patient collaboration has the capacity to stop a potentially life-threatening cancer at a readily curable stage. Pigmented lesions also are an area of intense basic and clinical science research and can be attractive to those with an interest in research. An interest in dermatopathology helps when interpreting and discussing the pathology reports. Moreover, those dermatologists who are apt at visual exam of skin lesions should find early melanoma detection a suitable challenge for which patients are extremely grateful. Disclosure: The Center for Dermatology Research is funded by a grant from Galderma. Dr. Grichnik is a major shareholder in DigitalDerm, Inc.
