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POSTED DECEMBER 23, 2009

From Alex Gross, MD | GSD Advocacy Committee Chair

Despite overwhelming support from the state House and Senate, the Laser Bill that was passed during the 2009 legislative session remains unfunded.  In a greater effort to trim the state budget, the line item for funds to administrate the granting of laser licenses was "red lined" from the Medical Board's 2010 budget proposal.  We are currently working with Rep. Ben Harbin, chairman of the Appropriations Committee, to secure funding for bill.  The Medical Board is eager to begin granting laser licenses to those who qualify under the law, and to have a mechanism to police laser practitioners.  If you are interested in serving on the GSD Legislative Committee, please contact Dr. Alex Gross.

POSTED OCTOBER 22, 2007

From Billie L. Jackson, MD:

The pathology bill hearing to oppose direct billing for Dermatologist will be heard this Friday, October 26 at 1:00 p.m. in Atlanta (at the Capitol).  We need several dermatologists to testify in opposition to the proposed bill.  Please send out an email to all members and ask for volunteers. Especially anyone performing direct billing that is showing a savings to patients for doing so.

Explanation of bill and the GSD's position - Rhonda Rogers, MD:

The GSD echoes the AAD's policy of permitting both direct billing and client billing.  Most of the members of GSD direct bill; ie, they bill the patient for the biopsy but do not bill the patient for the reading of the slide...they have their designated pathologist read the slide and bill the patient directly.  In this scenario, both the dermatologist and the pathologist "direct bill."  If this present bill were to pass, this would be the only scenario that would be legal.  

A minority of dermatologists in Georgia offer their patients "client billing" and bill their patients both for the service they themselves provide as well as for the cost of the pathology service.  These dermatologists have contracted with a pathology lab (actually vice versa), and the pathologist pays the dermatologist a certain amount for each slide read.  This scenario is what the pathology group is trying to make illegal - ironic since they initiate the contract in the first place.

The term "direct billing" is notoriously confusing.  The pathologists are wanting direct billing so they can bill the patient directly for the service that they provide, ie, reading the slide.  Client billing involves dermatologists charging patients for pathologists’ services that were performed by pathologists.  So as I understand it, "client billing" and "pass through billing" are the same and differ from direct billing. 

At this website, http://www.skinandaging.com/article/4239,Inga Ellzey in 2005 makes the distinction this way:

Billing Scenarios
Basically, four scenarios represent how dermatology practices bill with respect to pathology services. They are:

1. No billing for pathology services. In this scenario, the practice sends tissue specimens to an outside reference lab that performs both the technical and professional services (referred to as the global service) and bills the insurance carriers or patients directly.

In this scenario, there is no “pass-through” billing. Pass-through billing means that the dermatology practice buys the service(s) from a lab at a discounted price, marks up the cost of the service(s), and then passes the increased charge on to the patient or insurance carrier through direct billing from the practice.

2. Pass-through billing. Here, the practice makes money by purchasing the technical component, the professional component, or both. The practice marks up the cost of the purchased service and passes the increase on to the patient or insurance company by billing the pathology service(s) directly to the insurance company.

Some carriers are now establishing up policies that prohibit practices from pass-through billing. Some states have anti-mark up legislation in effect prohibiting physicians from making money by marking up purchased laboratory and/or pathology service. Medicare does not allow pass-through billing.

3. Purchased service billing. Medicare allows the physician to purchase the technical component of the pathology services from an outside reference laboratory. The purchasing of the technical component is only allowed if the practice reads its own slides. In this scenario, there are two options:
        a. The technical component is billed by the laboratory and the practice only bills for the professional component.
        b. The technical component is billed by the physician who purchases it. In this scenario, the physician can bill Medicare only the exact amount charged to the practice for the technical component by the outside lab. In other words, if the laboratory charges $10 for the slide prep, then the practice can only bill Medicare $10 for the technical component.
                • No mark-ups are allowed.
               •The technical component must be billed on a separate claim form. It can’t be billed on the same claim form that contains the billing for the professional component.
                • No global billing is allowed if either component is purchased. Global billing refers to billing the pathology service with no modifiers.

4. Global billing. In this scenario, the practice has its own in-house laboratory, a High-Complexity CLIA certification, and not only employs physicians who read the slides, they also make their own slides. No portion of the pathology service is purchased.

Billing is done directly from the practice and no modifiers are needed when billing for pathology services.

Billing Myths and Musts
In this section, some billing myths and musts are covered that should guide billers to quality billing for these types of services.

1. Myth: The codes are subject to the multiple surgery reduction rule. This is incorrect. These are laboratory services and are not subject to any reductions. Each service will be paid at 100% of the allowed amount regardless of the number of services billed.

2. Myth: The codes have an associated post-op period. There is no global period associated with these services. Therefore, no global modifiers are required. If other services are billed (such as surgery or E/M visits) and these are billed during the postoperative period, a -24 or -79 modifier is required. Pathology services are not subject to global periods and therefore do not require post-op modifiers.

3. Must: These codes are billed in units if multiple services are performed on the same date of service.

Example: Four slides are read; the diagnoses are 702.0, 173.3, 173.2, and 216.5. The practice bills globally. You would bill:
88305 x 4 units (only one of the four diagnoses needs to be listed in block 24E regardless that not all four share the identical diagnosis).

4. Myths about the difference between CPT codes 88304 and 88305. Some practices have misunderstood the application of these codes. These misapplications include:
  a. Using 88304 when the diagnoses are benign and 88305 when the diagnosis is malignant. Wrong! The diagnosis has nothing to do with the code selection.
  b. Using 88304 when only one slide is ordered and using 88305 when more than one are ordered for the same patient for the same date of service. Wrong! The number of slides obtained has nothing to do with code selection.
  c. Using 88304 when the service is purchased and 88305 when the service is performed solely in-house. Wrong! How services are billed, whether purchased or not, have already been covered earlier in the article.

5. Myth: You must bill the purchased service in the geographic payment locality where the service was performed. Effective Oct. 22, 2004, Medicare has implemented a temporary change in carrier jurisdictional pricing rules of purchased diagnostic services. The change allows physicians purchasing out-of-jurisdiction tests and interpretations to bill their local carrier for these services. They no longer have to bill the service based on the point of service.

6. Myth: You can bill for consultations performed by outside consultants. It is not uncommon for physicians who read their own slides to occasionally have a second opinion ordered on a challenging or questionable slide. Frequently, these dermatopathologist consultants are in another state and are usually not signed up with the carriers with which the group has contracts. The consulting physician usually does not want to get involved in billing the patient or the patient’s insurance carrier. Consequently, they just send a bill to the physician who ordered the consultation.

The consults are usually expensive and so the ordering physician wants to get reimbursed for the cost of the dermpath consultation. So he/she just bills the consultation using his name and provider number. This is not allowed by Medicare whatsoever.

Other carriers consider it pass-through billing while others even consider this practice fraud because the provider doing the billing for the service did not actually perform the service and is misrepresenting the services by billing for it under his/her name and provider number.

POSTED OCTOBER 10, 2007

Update letter to GSD Membership from GSD President Rhonda Rogers emailed and mailed

CLICK HERE IF YOU MISSED IT

POSTED MARCH 13, 2006

Subject: AAD Synergy Summit

Reported by: Stuart M. Goldsmith, M.D., GSD President 

The AAD Synergy Summit, held February 3-4 in Orlando, brought together state society presidents with national leaders to discuss issues in the areas of quality of care initiatives, scope of practice, and ethics in medical care.  My impression of some high points includes:

Quality of Care: Be on the lookout for performance requirements, e.g., documentation of total skin exam and lymph node exam in patients with a history of melanoma. Some type of “pay for performance” requirements are going to be implemented, and it could only be in our interest to be involved in the development of these requirements. 

I urge everyone to read Dr. Hood’s review, in the Feb., 2006 American Board of Dermatology newsletter, of the changes on the horizon for dermatologists’ maintenance of certification, including a closed book examination beginning in 2006. Many changes are mandated from the national specialty certification body.

Continuum/Scope of Practice: Whether in regards to PA training and scope of practice or non-dermatologists, including non-physicians, performing dermatology procedures, dermatologists must set high standards of patient care and educate the public about our training and expertise. Other societies, e.g. physician assistant societies, are organized and aggressively promoting their agendas. The AAD logo, for example, can be utilized more in offices, advertisements, communications, and educational settings as a means of differentiating our qualifications.

Ethics in Medical Care: Guidelines may be developed in regards to patient notification of conflicts of interest as well as pathology billing mark-up. More disclosure regarding ghost writers was also recommended. In addition, the AAD policy already in place regarding physician assistant supervision should be re-emphasized. This policy states that the supervising physician should see each new patient and each established patient with a significant new problem. A PA to physician ratio maximum of 2:1 was also supported.

This summit emphasized the importance of involvement at the state level, as much of the legislation that directly affects our patients and our practices is created and enforced at the state level. There has been Georgia legislation discussed this year involving tanning bed regulation, pathology billing, laser supervision, and scope of practice/prescribing privileges. Though the pathology issue saw physicians in disagreement, with the other issues there are non-physicians, with their own agendas, lobbying hard for positions that may not be in our patients’ interests. If there is not an organized response, our patients and our specialty will suffer. Whether through the Medical Association of Georgia, the Atlanta Dermatology Society, and, hopefully, to an increasing extent this society, I encourage every dermatologist in Georgia to become informed, get involved and to get others involved. 

POSTED MARCH 9, 2006

Subject: Tanning Bed Legislation

Tanning bed legislation providing structure and regulation that the GSD supports went before a House committee hearing on Wednesday, March 8, 2006.  Dr. Stuart Goldsmith, GSD President, was in attendance and presented in favor of the bill. 

The bill was tabled.  

Comments from Dr. Goldsmith: There were, I think, some legitimate concerns about administration and funding (though I may be giving the committee an undeserved benefit of the doubt, concerning the politics involved). Rep. Drenner is committed to getting this legislation passed and she has done a lot of research, including review of each state’s legislation.  She had, apparently, kept asking MAG to get dermatology input.  I only became involved after I contacted her office to find out about the status of the legislation, which was introduced last March.  I wish I had asked months ago.  Nonetheless, each step may get us closer to getting something worthwhile passed.  I hope getting some legislation passed is a major goal for next year.  We, obviously, need to get others involved, particularly AAD and MAG. I will try to talk soon with Larry Lanier at AAD.  Other organizations, e.g., Pediatrics and Family Practice, would also, I would think, support a more effective legislation.  Currently, the only requirement is that consent must be obtained for those under 18, and I think that requirement is often ignored.

POSTED FEBRUARY 9, 2006

Subject: American Society for Dermatologic Surgery (ASDS) Non-Physician Practice of Medicine Campaign

To Georgia Society of Dermatologists

Due to the proliferation of spas, salons and walk-in clinics,the American Society for Dermatologic Surgery has noted an increase in legislation across the country allowing certain cosmetic procedures to be performed by non-physicians.  This email is being sent to you to raise your level of awareness of this growing trend and to let you know the ASDS can be a resource to you should you need to respond to legislation proposed in your state.  The ASDS has launched a campaign warning legislators that cosmetic treatments, such as those using lasers, high-tech light devices, chemical peels, soft tissue fillers, botulinum toxin are medical/surgical procedures that should be performed by a fully qualified physician or under the direct supervision of the physician.

One example of a bill threatening patient safety is Virginia House Bill 1399. The bill would add a "laser light technician" to the Board for Barbers and Cosmetology. The bill states that the regulation of laser or light therapy technicians will be approved by the Board for Barbers and Cosmetology. The bill further defines laser or light therapy as the "nonabrasive photo-rejuvenation of the skin or the removal of hair by selective photothermolysis, using laser or light therapy devices."   Fortunately, the bill was sent back to committee and will be carried over until next year.

Not only is ASDS involved in tracking legislation on this issue but we are also pursuing cases where non-physicians are performing medical procedures illegally. In California ASDS established a working relationship with the Medical Board of California to jointly pursue enforcement actions against non-physicians performing these illegal procedures. ASDS is also compiling evidence it has received in California and submitting these records to the state regulatory agencies and local public attorney civil-consumer protection units for pursuit.

It is ASDS’s position that under the appropriate circumstances, a physician may delegate certain procedures to certified or licensed non-physician office personnel (e.g. RN, CMA, LPN, PA, NP, CORT). Specifically, the physician must directly supervise the non-physician office personnel to protect the best interests and welfare of each patient. The supervising physician shall be physically present on-site, immediately available, and able to respond promptly to any question or problem that may occur while the procedure is being performed. It is the physician’s obligation to ensure that, with respect to each procedure performed, the non-physician office personnel possess the proper training in cutaneous medicine, the indications for the procedure, and the pre- and post-operative care involved.

Please note that legislation delegating cosmetic procedures to non-physicians could be underway in your state. As you know, the best way to defeat these bills is to have your association respond quickly to your state legislators voicing your opposition to the bill. 

Do not hesitate to contact Ted Thurn, Advocacy and Socioeconomic Affairs Manager at tthurn@asds.net with any questions you may have.

Sincerely,

Darrell S. Rigel, MD

ASDS Scope of Practice Work Group

POSTED JANUARY 24, 2006

Subject: Proposed Laser Rules

There is an important issue on which the GSD needs to get active. The Composite State Board of Medical Examiners has issued a "Notice of Intent to Amend and Adopt Rules" regarding who can operate laser equipment and the definition of "physician supervision".  The Atlanta Dermatological Association has officially responded and will be present at the public hearing on February 2.

The hearing will begin at 8:30 a.m. on Thursday, February 2, 2006 at the DCH Board Room, 40th Floor, 2 Peachtree Street, NW, Atlanta, Georgia  30303, to provide the public an opportunity to comment upon and provide input into the proposed rules.  The Board will consider at this meeting, whether the formulation and adoption of this proposed rule amendment imposes excessive regulatory costs on any licensee or entity and whether any cost to comply with the proposed rule amendment could be reduced by a less expensive alternative that accomplishes the objectives of the statutes which are the basis of the proposed rule.

It is requested that GSD members, in particular, those also members of the Atlanta Dermatological Association, attend the hearing as representatives of the GSD.  Of course, all GSD members are encouraged to attend the hearing.  Harold Brody, MD, Scott Karempelis, MD, Alex Gross, MD and Mack Rachal, MD will speak at the public forum.  The AAD representative Rob Bohannon will also speak on the behalf of the AAD.

Find the Proposed Laser Rule at the following link: Proposed Laser Rules

Find the Atlanta Dermatological Association's response to the proposed laser rules and position statement at the following link: Atlanta Dermatological Association Response

Please make every effort to attend the hearing!