Coding Changes: Interview with Dr Mark Kaufmann

Mark Kaufmann, MD, and Larry Green, MD, discuss the 2021 bill code changes and what dermatologists need to know for the new year.

Dr Green is section editor of The Dermatologist’s Psoriasis Center of Excellence and clinical professor of dermatology at George Washington School of Medicine in Washington, DC

Dr Kaufmann is the chief medical officer of Advanced Dermatology and Cosmetic Surgery and a clinical associate professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City.

Transcript

Dr Larry Green: Hi, everyone. Welcome to another podcast. My name’s Larry Green. I’m section editor of The Dermatologist’s Psoriasis Center of Excellence and clinical professor of dermatology at George Washington School of Medicine in Washington, DC.

We’re really lucky to have with us today Dr Mark Kaufmann, who’s Clinical Associate Professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City.

Mark has served as the Deputy Chair of the American Academy of Dermatology Patient Access and Payer Relations Committee, the PAPR Committee -- I like the acronym -- and is past member of the AAD’s Council on Government Affairs and Health Policy and Practice.

Currently, Mark serves as an adviser to the AAD’s delegation of the American Medical Association Relative Value Scale Update Committee, better known as the RUC, and is President-elect of the American Academy of Dermatology. Mark, thanks for being here and thanks...

Dr Mark Kaufmann: Pleasure, Larry.

Dr Green: ...all the coding changes. A lot’s going to change January 1st. Right now, we have seen that CMS is not going to change their budget neutrality, from what we’ve heard. All these coding changes are very relevant to us.

I think it’s important for us to know what to do because things are really going to change. Mark, thanks for coming. First, let’s go over what specifically is changing, in a broad sense, in January.

Dr Kaufmann: Thanks very much, Larry. It’s a pleasure to be here. It’s not so much a coding number change. There is one code, 99201, that’s being deleted. Really, the change is not in the code but the way we choose the code.

We’ve all gotten used to this pesky way of counting bullets or having our EHRs count bullets to determine what level EM we choose. That is going out the window on January 1. As you said, it’s really important to understand that on December 31, you’re going to be coding with the current paradigm.

On the next day, on January 1, if you’re seeing patients, you’re going to be coding with the new paradigm. There’s no grace period. There’s no transition. It’s a hard stop. Really, it’s a different paradigm of how we choose the codes.

Dr Green: Let’s go over how things are going to change. We’re going more towards -- we were talking before -- towards elements that are changing so that counseling is being devalued and prescription-writing or even mentioning over-the-counter products is being more valued. How are things going to change to qualify for each level of code in a broad sense?

Dr Kaufmann: I’ll just step back just one level and tell you that there are going to be two choices. You have two ways of coding starting in January. One is to choose time, which doesn’t really work in a dermatologist’s favor. The times are pretty significant.

The other paradigm is to choose medical decision-making. What you’re referring to with the valuation and devaluation in medical decision-making is unfortunately true. Counseling a patient, basically telling a patient, “You’re OK. Go home,” basically it is straightforward medical decision-making.

A co-chair of the committee that rewrote the code said that straightforward medical decision-making is akin to something that you may want to have called your mother about rather than go to the doctor.

Basically, if your patient comes in and says, “I have this lesion on my arm. I saw you for a total body six months ago. I just don’t know if you saw this,” and you say, “You’re OK. Go home,” that’s straightforward medical decision-making.

If you say, “You’re OK. Go home, but before we do that, let’s see what you’re doing for sun protection. Let’s talk about sunscreens. Let’s talk about polypodium leucotomos,” if you’re going to go there, then that actually is more than just counseling. That’s discussion of OTC medications. That actually gets you to a level 3, which is low medical decision-making.

It really matters how you’re going to deal with the patient. It’s a different way to think than the current way we think. I think it’s just going to take muscle memory to get there.

Dr Green: It’s interesting. We occasionally have time. It’s very rare, like you said, for us dermatologists. Once in a while, we’ll get those patients who, I’ll say, end up with an hour visit or 55-minute visit, who come in, say, for Botox.

Then they say while they’re here, they want a full body skin exam, treatment for their acne. They have hair loss. They want a few spots removed. That happens every now and then but rare for us. Time is going to be unusual.

Dr Kaufmann: Just remember though, if you’re going to use time, you have to subtract the procedures. Time is only for cognitive work.

Dr Green: Let me ask about hair loss, for example. That’s an interesting diagnosis that we see quite a bit. That’s something that is time-consuming but not necessarily time-consuming enough to make up the time.

That involves a lot of counseling. Counseling, like we talked about, is being devalued. A hair pull is a procedure, I guess that can count as time because that’s not something that we can get paid for separately, if we do an examination of hair.

What would you say when someone comes in for hair loss? Beyond counseling or the type of counseling that we can say to them, if we don’t prescribe, say, spironolactone...You could recommend PRP, but that’s part of counseling, in a way. If we don’t prescribe something like spironolactone.

Dr Kaufmann: There is over-the-counter solutions you might recommend, which would get you to a level 3, like minoxidil. Certainly, if you’re going to go to spironolactone or to finasteride or to another prescription medication, then you certainly can potentially get to a moderate.

There are three columns on the medical decision-making chart. You have to check off two out of three in order to use that level of medical decision-making. You have to look at androgenetic alopecia probably as a chronic illness, which it is. It doesn’t just last a year.

Is it stable, or is it progressing? If it’s progressing, then actually that does justifies putting it in the moderate MDM category. If you have progressing androgenetic alopecia and you’re going to prescribe a Rx medication, that is a level 4 visit.

If you’re going to recommend topical minoxidil, that’s a level 3 visit. If you’re going to just tell them that “This is a fact of life. Get married quickly...”

Dr Green: [laughs]

Dr Kaufmann: ...then that’s going to be a straightforward medical decision-making.

Dr Green: That’s something your mother could do. There, you’re back onto level 2.

Dr Kaufmann: [laughs]

Dr Green: We want to be more than that. That’s for sure, but that’s, I think, well said. That really breaks down androgenetic alopecia and how we can code for it with three levels. That’s something commonly we see.

Let me go to something that’s probably the most common thing that dermatologists do, and that’s a routine skin check. Actually, before I do that, Mark, is there anything in a broader sense that I’m missing, that you wanted to mention? I mean...

Dr Kaufmann: I would just make mention of the fact that unlike the past, where there were really differentiating factors between established patient codes and new patient codes, one of the major changes in January is that it’s the same rules whether the patient is new or established.

It’s medical decision-making gets you to either a level 3 established visit, 99213, or a level 3 new patient visit, 99203. Same rules regardless whether the patient is new or established.

Dr Green: Actually, that’s a really good point. Like you mentioned, we’re used to coding, say, a 99202 is equivalent to a 99213. That’s no longer the case.

Dr Kaufmann: No longer the case.

Dr Green: 202 is equivalent to 212, 303 to 13, etc. That’s a big distinguishing factor I think it’s important for us to know because it’s very unlike what we’re used to doing and will change as of January 1.

Let me go back and then ask about the most common thing that we do, is a routine skin exam. Routine skin exams involve a lot of counseling. What are ways that we can make that routine skin exam, right now which is a 99203, 99214-type visit to threes and fours and not level 2 in the new rules?

Dr Kaufmann: This is one of the areas where we do see the devaluation of counseling. Let me first say that I believe a total body skin exam that reveals benign diagnosis is going to be a level 3 visit, again, regardless whether it’s a new patient or an established patient.

Having said that, we typically would get to a level 3 on a new patient in today’s paradigm. You do mention the fact that some people are coding level 4 for the established patients, and that’s where the devaluation will occur because I don’t think that you will get to a level 4, starting in January, on a total body skin exam where there are only benign diagnoses.

You’re not going to get there. That’s where the devaluation occurs, but I do think...I know that there’s been a lot of conflicting information that’s been published, even by AAD, about a total body skin exam. Here’s my opinion. Again, there’s a lot of opinion in the new paradigms, but here’s mine.

You have seborrheic keratosis on a patient and angiomas and benign nevi. Those are more than two, even if you call them minor problems, so that gets you to a low level in column one. If you’re a good dermatologist, you’re going to review the use of OTC sunscreen in column three. If you do those two things, you qualify for a level 3 visit, and it should be a level 3 visit every time.

The one thing I do want to mention–and this has been brought up in a recent example in some of the AAD stuff–is that screening examinations are not covered by CMS. History of diagnoses, like history of melanoma, actually doesn’t count in medical decision-making because once you use history of codes, you’re dealing with problems that are considered by CMS to be closed and not active, even though we know that that’s a very active patient for us.

A lot of coding experts have advised to use the active code, to actually use the melanoma code, when coding for a visit, but it’s not necessary because it won’t get you to a higher level. You have to basically understand that a total body skin exam is going to be a level 3 visit.

Just as an aside, a lot of people make a big point that screening exams aren’t covered, and they’re not. That’s the problem with the US task force that deals with screening examinations, the whole another topic.

Suffice it to say that when my scribes hear from a patient, “I’m here for my skin cancer check” or “I’m here for my screening exam,” they usually try to clarify with the patient. “You mean you have spots on your body that you want evaluated, right?”

They’ll typically say, “Yes.” That’s usually the chief complaint that we use, is “I have spots on my body I would like evaluated.” It solves a lot of problems.

Dr Green: Some people might be thinking that history of melanoma or basal cell qualifies as a chronic illness, but that’s not the case.

Dr Kaufmann: It is not the case. You could try and make the case that you want to use the diagnosis of melanoma because you’re actively surveilling. You might get called out on this if you’re going to use it once or twice a year on a regular basis.

I make this point in a lot of coding sessions. There are coding rules, and there’s coding common sense. While you might want to be able to live on the edge, you’re going to probably pay the price for that. You really should follow the golden rule of document what you do and bill accordingly for medical necessity for what you’re documenting.

Dr Green: The Z codes, you were saying that’s the history of, Z85.820 and 828, melanoma and basal cell, don’t add anything. You still think it’s OK to put them, but it doesn’t add to our level 3.

Dr Kaufmann: Yeah. If you have seborrheic keratoses and angiomas and benign nevi as your diagnoses, you don’t need the history of for billing. Now, obviously, you’re going to want to put that in your chart because that’s really important. Not everything that’s important is necessary for billing anymore.

Just like the way that the history and physical aren’t parts of the billing paradigm, they’re certainly a good part of what we do and certainly really important to continue to do appropriately.

Dr Green: Thanks. We went over skin examinations, and we talked about hair loss. Let’s talk about one other common code that dermatologists use, and that’s acne, acne psoriasis.

Let’s start with acne, and then we can talk about psoriasis and atopic dermatitis. Those are sort of all the same in terms of how we’re going to code for them, but those are all chronic illnesses. That, from what you’re saying, brings us right to a level 3 right away.

Dr Kaufmann: Yeah, that’s correct. The language is really important in the new paradigm. Exacerbation of a chronic illness, and we deal with a lot of chronic inflammatory disease. We deal with dermatitis. We deal with acne vulgaris. We deal with psoriasis.

These are all chronic diseases that flare. If you have an exacerbation of any of those chronic inflammatory dermatoses, you are in the moderate level of medical decision-making. There are going to be a lot more level 4 visits next year in dermatology because they tend to flare. Patients come in when they have a flare of atopic dermatitis.

If an atop patient comes in with a flare and you prescribe topical halobetasol cream, that is a level 4 visit in the new paradigm. That’s just the way it’s set up. You have a exacerbation of a chronic illness, and you’ve done prescription drug management.

Dr Green: Yeah, that’s something we’re going to be happy to get used to doing, but that is one of the rules. Then acne is a chronic illness, we consider it, because it usually lasts more than a year, so that makes it that. What about something that is a flare but is not a chronic illness, say, poison ivy or an allergic contact. How would that fit in?

Dr Kaufmann: There actually is a category for that. It’s in the low medical decision-making. It’s one acute uncomplicated illness or injury. If you have an acute rhus dermatitis, that would qualify only for low because it’s not a chronic illness. This is just an acute episode. That would be a level 3 visit because of...

Dr Green: With a prescription?

Dr Kaufmann: Actually, even with OTCs, it would. Remember, you’re only at the low level. Even if you do a prescription, it doesn’t bring you up to a level 4 visit. It just confirms the level 3 visit.

Dr Green: Right. An allergic contact is the same visit, say, as best we’re going to get for a full body skin check, which is sort of sad.

Dr Kaufmann: It’s just the way it is. It’s going to take a lot of muscle memory. I think one of the more important things to take out of this conversation also is the concept of prescription drug management. A lot of people are asking questions. What if a patient comes in for refills?

I think this is one of the places where you really should use your judgment. I think there’s a big difference between refilling isotretinoin and a biologic versus refilling triamcinolone or Epiduo. I think we should be judicious with coding high-level visits for refilling a medication that’s not isotretinoin or a biologic.

Certainly, obviously, when you’re refilling isotretinoin and a biologic, you’re doing more than checking off a box in an EHR. You’re talking to the patient about the seriousness of this medication and about the potential toxicity of these medications. I think that’s important to get credit for.

If the patient comes in and goes, “You know, that triamcinolone you gave me last year for my eczema, I need a refill,” I really would hesitate to consider that prescription drug management.

Dr Green: With those, even that refill, triamcinolone as opposed to isotretinoin, would you code the refill triamcinolone as a level 99203, or it’d be 13?

[crosstalk]

Dr Kaufmann: Yes. That’s exactly the way I think of it. A typical well-controlled patient that’s coming in for a topical medicine refill on standing order, I would consider that a level 3 visit, whereas isotretinoin and biologics, I would consider in the level 4 area.

Dr Green: There’s actually a Z code for long-term biologic monitoring. I don’t know how many insurers take note of that, but I tend to use that as well to help show that I’m really doing a lot of...

I don’t want to use the word counseling, but it’s a lot to talk about with a medication that could have a lot of potential adverse events. I don’t know if you’d encourage people to continue using that or not.

Dr Kaufmann: For CMS, the Z codes aren’t going to be helpful.

Dr Green: For other insurers. Any other thoughts you want to add, Mark, before we finish up, or summarize for everybody who’s listening to get them ready for January 1st?

Dr Kaufmann: My main message would be we will get to level 4s much more than we used to under the new paradigm. There are going to be people who are going to look at this medical decision-making grid and say, “I can get to level 5s.” My message would be really be careful about that, OK?

My example, in my head, of what a level 5 visit in dermatology is an erythrodermic psoriatic patient walking into your office and you having to go through giving them prescriptions for a biologic and maybe cyclosporine or something else. That would be a level 5 visit.

Anything short of that, I would hesitate to try and stretch something because you think you can qualify by checking off a box. The bell curve of the coding distribution of dermatology is going to change in January, but I still would try and recommend to people you don’t want to be at the edge of that curve.

Dr Green: Don’t forget people who are doing more EM services are getting a bump-starting January 1st as well.

Dr Kaufmann: The return visits. Actually, the new visits couldn’t overcome the conversion factor cut that CMS came up with. The new visit codes actually go down, which is ironic because the whole idea was to give it a raise.

Dr Green: Exactly.

Dr Kaufmann: In order to pay for the raise for the return visits, they had to even cut the new visits.

Dr Green: [laughs] OK. There you go. Unfortunately, those of us who are doing procedures are going to suffer a little bit more with the cuts.

Dr Kaufmann: Yeah. Without a legislative fix, it looks like a 5 to 8% cut for non-EM codes. That’s going to be surgery. That’s going to be pathology. Unless they’re seeing clinical patients, dermatopathologists are going to take a big hit too.

Dr Green: Surgery, just to remind everyone, that includes freezing of things. That’s considered surgery.

Dr Kaufmann: Freezing.

[crosstalk]

Dr Green: ...or freezing an SK or freezing a wart, that’s...

[crosstalk]

Dr Kaufmann: Taking a biopsy is going to go down.

Dr Green: That’s also considered surgery. All that, we count on the EM return visits to try and make up for as much as we can.

Thank you, Mark, for going over all these new coding initiatives and our new coding rules–I should say that’s going to happen in less than a month–and helping get us prepared. I know you’re doing this all over, and I appreciate everything you’re doing on behalf of us dermatologists and on behalf of the AAD.

Dr Kaufmann: My pleasure, Larry. Thanks for having me.