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Brace yourself. The Centers for Medicare and Medicaid Services (CMS) released its proposed 2019 Medicare Physician Fee Schedule rule, which also includes changes to policies for the 2019 Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act (MACRA), and it’s a pretty dense 1,440 page document.

The proposals have yet to be approved, but here I will attempt to drill down some of the details and highlight what they may mean for our specialty.


The Gist. CMS is proposing a payment reduction for Evaluation/Management (E/M) visits billed with a procedure. This is similar to the recent attempts by the private payers to reduce E/M visits appended with a modifier 25, which the American Academy of Dermatology Association (AADA) has been aggressively and, in many cases, successfully fighting. In addition, and in tandem, the proposal seeks to institute “blended” payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits. They are taking things slowly, revising only the E/M guidelines for the Office/Outpatient Evaluation and Management (E/M) codes (99201-99215) to test the waters. CMS proposes simplifying E/M coding by blending CPT codes 99202-99205—codes that cover new patient office visits levels 2 through 5—into a single payment of $135, and assigning E/M codes 99212–99215 a single payment of $93.

What it Means for Dermatologists. Most dermatologists live in the level 2 or 3 E/M range, so having a blended E/M payment could potentially benefit many of us. However, dermatologists who see more complex patients—level 4 and 5 E/M visits—will be more dramatically affected by these changes than those who typically see levels 1, 2, and 3. The 50 percent reduction of E/M billed with a modifier 25 will effectively erase any benefit the blended E/M codes would provide and is estimated to lead to a net four percent loss to the specialty.

The Big Picture. You can expect the AADA to write a strong comment letter. We will also fight hard to allow our members who perform complex medical dermatology to utilize the add-on codes for complicated visits should CMS choose to move forward with their proposals. The dermatologists seeing our most complex patients would clearly be the losers in a blended E/M system.

New Biopsy Codes

The Gist. We can expect significant changes to our skin biopsy codes. CMS has proposed values for six new biopsy codes that would replace the current CPT codes 11100 and 11101. These will go into effect January 1, 2019.

What it Means for Dermatologists. This part of the proposed rule is the only part that will definitely happen.

A Mixed Bag

In general, the proposed changes offer a mixed bag for dermatologists. AADA staff will continue analyzing the proposed rule and plans to submit comments to CMS by September 10, 2018. You should also consider sending in your own comment letter, and the Academy should be providing us more information on how to do so soon. The future of Global Period Codes is also at stake, and this is the overriding, potentially most devastating issue to us in the entire rule. We must push back hard and start planning to lobby for another legislative fix—similar to what MACRA was able to do.

Mark D. Kaufmann, MD is an associate Clinical Professor of Dermatology, Dept of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.

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