Day 1: Highlights

Thursday, February 9, 2017

Confocal Microscopy

Harold Rabinovitz, MD

Confocal microscopy is a high-resolution imaging device that allows visualization of individual cells in the skin. Unlike biopsy followed by histopathology, confocal microscopy can allow for noninvasive diagnosis using mosaic and stack imaging. Melanocytes and keratinocytes can be visualized. The images mimic what can be seen on histology but it is not invasive.

Confocal microscopy images can be read remotely or at the bedside. This imaging modality is especially useful in diagnosing lesions in cosmetically sensitive areas, such as facial melanomas on sun-damaged skin. A facial melanoma has two distinct features on confocal microscopy images: pagetoid cells and spindle-shaped cells. Harold Rabinovitz, MD, shared several cases of facial melanoma with clinical, dermoscopic, confocal, and histopathology images. Dr. Rabinovitz also reminds us that most facial melanomas are solitary pigmented lesions confined to a single area. Because of the cosmetic concerns associated with procedures on the face, confocal microscopy is a useful noninvasive imaging technique to diagnose facial melanomas on sun-damaged skin.

Dr. Rabinovitz also shared that other lesions, including basal cell carcinoma, can be diagnosed with confocal microscopy. Similar to features seen in histopathology, both tumor islands and clefting can be seen on confocal microscopy of basal cell carcinoma. Confocal microscopy is a noninvasive imaging tool to aid in the diagnosis of skin cancer.

MACRA Overview: The Future of Reimbursement

Mark Kaufmann, MD

Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in 2015. This act repealed the sustainable growth rate (SGR) formula, and allowed physicians to avoid a 21 percent pay cut in Medicare reimbursements. A new Quality Payment Program (QPP) has replaced the SGR.

Mark Kaufmann, MD, explained that the most important aspect of MACRA for dermatology is the postponed elimination of the global period. Also, now that MACRA has been signed into law, the interpretation and application is now the responsibility of Centers for Medicare and Medicaid Services (CMS). The revised payment system will be based on quality and performance, rather than on quantity. There will be two payment systems: Advanced Alternative Payment Method (APM) or Merit-based Incentive Payment System (MIPS). According to Dr. Kaufmann, the majority of physicians will be in MIPS. These systems will provide bonuses or penalties based on performance metrics.

These bonuses and penalties start at 4 percent in 2019 and rise to 9 percent by 2022.

Dr. Kaufmann also explained how SGR differs from MACRA. Cost replaces Value-Based Modifier, and Quality Measures replace the Physician Quality Reporting System (PQRS). Also, Advancing Care Information replaces Meaningful Use. These are new metric terms that will determine bonus or penalty payments.

Dr. Kaufmann concluded his talk by reminding us that there will be a 2-year lag time, meaning that performance in 2017 will determine reimbursements in 2019. Penalties are lessened in this new model. There are four options to participate in MIPS. No dermatologists should take Option Zero, which means to submit no quality information to CMS and automatically take a 4 percent payment cut in 2019. Dr. Kaufmann recommends that most dermatologists submit some information to CMS under the MIPS program in 2017 under Option One or Option Two in order to avoid penalties or receive a small bonus on reimbursement in 2019. Dr. Kaufmann concluded by reminding us that MACRA is a complex new system and that the interpretation of this new law is ongoing.

Charging for Self-Pay Procedures: Sebs, Tags, and Nevi

Mark S. Nestor, MD, PhD

In dermatology, most individuals have “spots and growths”, such as seborrheic keratosis, milia, nevi and cysts that are cosmetically bothersome. The removal of these spots and growths isn’t considered medically necessary and therefore is not covered by insurance providers. In addition, Mark Nestor, MD, PhD, explained that preventative treatments, such as photodynamic therapy (PDT) for photoaging and photodamage is not a covered procedure in most insurance plans.

Dr. Nestor continued his presentation by reviewing the specific definitions of medically necessary and non-medically necessary procedures. Medically necessary procedures and treatments meet accepted standards of medicine that are both medically reasonable and necessary to benefit or improve the specific condition.

Non-medically necessary procedures are sometimes in a gray area, because removal of certain benign lesions may also fall under either category based on symptoms or clinical presentation. Removal of benign cysts is one example of a procedure that could be either medically necessary or non-medically necessary.

Next, Dr. Nestor encouraged practitioners that perform non-covered procedures to document the procedures accurately and to also use additional consent, waiver, and ABN forms to explain to patients, prior to proceeding with the procedure, why these procedures are non-medically necessary and not covered by their insurance provider. He also recommends using the ICD-10 code Z41.1.

Dr. Nestor reviewed a gray area in the treatment of seborrheic keratosis, which may be medically necessary to treat if it is suspicious for malignancy, symptomatic, or inflamed. If these criteria are not met, patients with these lesions can either pay the Medicare allowable or a self-pay amount to receive treatment, and Dr. Nestor reminds us that these claims should not be submitted to the insurance provider. Light and laser treatments for acne and laser treatments for onychomycosis are examples of effective treatments that are not covered by most insurance providers at this time.

Dr. Nestor concluded his discussion by emphasizing that patient education and counseling of the patient are key aspects in the non-medically necessary treatment plan. He reminds us to document non-covered procedures adequately and to utilize a separate consenting process. These procedures can add significantly to a busy dermatology practice.

Role of Bioidentical Hormone Replacement in Skin Health

Sharon McQuillan, MD

An aging population provides the foundation of the aesthetic dermatology industry. More women live in a hormone-deprived state for a longer time period (~30 years) as the average female life expectancy is 80.4 years and the average onset of menopause is 50 years. Hormones impact skin aging and skin health in many ways as there are many hormone receptors located in the skin. With menopause and andropause, the body produces lower levels of hormones, and those hormones lose the ability to communicate. Every patient is individualized and requires testing.

Bioidentical Hormone Replacement (BHRT) is the use of hormones that are identical on a molecular level with endogenous hormones in Hormone Replacement Therapy (HRT). Steroids are ideal candidates for topical administration as they are low molecular weight, highly lipophyllic molecules, which allow for good absorption across the skin. Adipose tissue may act as a natural “reservoir” for hormones. Factors for consideration in the application include the amount, measurement of dosages, and sites of application (inside of arm, upper thigh, lower abdomen). Topical steroids should be rubbed in well for two minutes.

Dosing protocols of BHRT should be based on the individual’s goals and needs. These dosing protocols should only be used as a guideline to initiate therapy, and doses should be adjusted based on symptoms and side effects.

Bioidentical Hormone Replacement requires clinic time spent in discussion, but can be helpful for dermatology patients.

Use of Superficial Radiation Therapy in Treatment of Non-Melanoma Skin Cancers

David Goldberg, MD, JD

Modern superficial radiation therapy (SRT) devices utilize low energy photon X-rays to deliver planned, calibrated doses of radiation to target and treat designated lesions, while minimizing damage to healthy underlying tissue. This modality has proven very useful for treatment of non-melanoma skin cancer (NMSC) and keloids, with cure rates of NMSC as high as 98 percent.

The goal of SRT is to eradicate the tumor while maintaining quality of life. The ideal patient for SRT is elderly and a poor surgical candidate. Key factors to consider are patient history, clinical examination, and histopathology of the tumor. Older tumors can have hypoxic/anoxic tissue, and lesions with hard scabs are denser. Both factors alter dose selection and are more difficult to treat. It is also important to consider the anatomic location and number of tumors, perform proper illumination for margin delineation, utilize scouting biopsies for ill-defined borders, palpate for depth and mobility, and rule-out lymphadenopathy and metastasis. Histopathology must be determined. The histologic subtype and margins guide energy. High-risk lesions need higher energy for penetration, especially since biopsy reports sometimes contain inadequate depth data. Typical margins for basal cell carcinoma (BCC) are 8-10 mm and 10 mm for squamous cell carcinoma (SCC). Ill-defined and more aggressive tumors may warrant wider margins. A thorough exam from multiple angles and in various lighting should be conducted. Ultimately it is better to take wider-than-needed margins than not wide enough.

Indications for SRT are numerous. All skin surfaces can be treated, though the central face has higher risk of recurrence, and may be more amenable to Mohs surgery. Surfaces such as the scalp, eyelid, external ear canal and helix, and nasal ala are difficult areas for surgery, and better cosmetic results may be exhibited with SRT. SRT is ideal for areas prone to poor wound healing and in patients with contraindications to anesthesia or epinephrine, on anticoagulation or prone to bleeding, with poor functional status or disabilities, with a need for simultaneous treatment of multiple tumors, and those who lack the ability to perform necessary post-op wound care. Some patients may simply prefer not to be treated by surgery, decline surgical intervention, exhibit fear of surgery and scarring, or feel they can’t tolerate surgery. These patients are ideal candidates for SRT.

Contraindications to SRT include presence of pacemaker or defibrillator within the treatment area or previous SRT to the area. Any area that has previously been chemically or surgically treated has alteration of the dermis and may require more aggressive SRT parameters.

Clinical Applications: Keloids

Brian Berman, MD, PhD

Superficial radiation therapy (SRT) is FDA-approved for the treatment of post-keloidectomy surgical sites. According to the available literature, recurrence of keloids is greater than 70 percent after surgical excision alone. In one published study, 51 percent of keloids that were surgically excised recurred within one year and were often more extensive than the original keloid. Similarly, keloids that were excised and then treated with single or multiple injections of triamcinolone showed recurrence rates of 50 percent.

SRT is an excellent modality for treatment of post-keloidectomy surgical sites. Ionizing radiation directly damages the backbone of DNA and RNA, and indirectly breaks water into free radicals, further inducing single- and double-stranded breaks in RNA and DNA. These breaks render cells unable to proliferate. Furthermore, keloids exhibit mutations in p53 that cause an inhibition of apoptosis, leading to uncontrolled proliferation of keloid cells. SRT will reverse this inhibition and induce apoptosis by arresting the cell cycle of these uncontrolled proliferative cells.

Studies have shown that irradiation of keloidectomy sites in the first 24-48 hours post-operatively can significantly reduce recurrence of keloids. Published studies have typically used a biologically effective dose (BED) of 30 Gy divided into 1-3 fractions. More fractionation lead to less post-inflammatory hyperpigmentation. Recurrence rates were low and cosmetic outcome was favorable. The only report of malignancy post-SRT of a keloid occurred in 1963; however, it is unclear if this was a true malignant transformation due to the SRT.

In addition to DNA damage, another mechanism by which SRT limits keloid recurrence may be due to its inhibition of IL-6 and IL-17 positive cells. IL-6 has been shown to increase keloid size and inhibition of IL-6 leads to decreased keloid size. IL-17 and its role in inflammation may also contribute to keloid recurrence. These IL-6 and IL-17 cells are highly susceptible to SRT, further enhancing the inhibitory effects of SRT on recurrence of keloids.