- Email: [email protected]
Are dermatology residents adequately prepared for the business of medicine?
LETTERS RESEARCH Are dermatology residents adequately prepared for the business of medicine? To the Editor: Most physicians expend valuable time at the beginning of their careers learning the basics of practice management.1 Improper documentation and billing puts physicians, including residency programs, at risk for an audit from the Centers for Medicare and Medicaid Services, which could result in penalties, repayments, and potentially even jail time. The aim of this study was to assess current dermatology residents’ knowledge, education, exposure, and comfort level regarding billing and coding while assessing how important they believe this aspect of medicine is in residency training. A 16-question survey was administered to 313 attendees of the Residents’ Practice Management Symposium at the 70th Annual American Academy of Dermatology Meeting. In all, 184 surveys were returned (response rate of 58.8%). Table I represents the spectrum of responses to survey questions. Of 174 respondents, 49 (28.2%) reported not receiving any didactic sessions on how to code for dermatologic visits. An overwhelming majority (156 of 181 [86.2%]) reported no practice management component to their curriculum. In terms of billing, 117 of 179 (65.4%) residents complete their own billing approximately 75% to 100% of time; only 7 of 179 (3.9%) reported never completing their own billing. One quarter of residents (46 of 178) stated attendings never give feedback on billing and 64.5% (113 of 178) reported receiving feedback from their attendings less than 25% of the time. Most residents (149 of 181 [82.3%]) think learning billing and coding during residency is extremely important. Table II represents the percent of respondents who answered 5 commonly encountered knowledge questions correctly. Although residents often independently complete their own billing, many were unable to identify common diagnosis and procedure codes, reflecting a discrepancy in their perception of billing knowledge and their actual knowledge base. Interestingly, 134 of 182 (73.6%) respondents reported that their knowledge base in these topics would have some degree of influence on the type of job they would look for after residency. There are few studies that assess practice management curriculums in residency training programs; several authors have shown that residents think this topic is inadequately covered during residency training across multiple specialties.2-5 Of note, in a survey 340
FEBRUARY 2013
LETTERS Table I. Survey responses (P \ .0001) What is your current comfort level with coding for office visits/basic dermatologic procedures?
Extremely uncomfortable Somewhat uncomfortable Neutral Somewhat comfortable Extremely comfortable
n
%
16 29 38 85 14
8.8 15.9 19.8 46.7 7.7
How often do you (residents) complete your own billing for patients you see?
Never ;25% of patients you see ;50% of patients you see ;75% of patients you see Always
n
%
15 26 21 40 77
8.4 14.5 11.7 22.3 43.0
How often does an attending provide feedback on billing you (residents) complete?
Never ;25% of the time ;50% of the time ;75% of the time Always
n
%
46 68 37 18 9
25.8 38.2 20.8 10.1 5.1
Importance of learning billing and coding during residency
Not important at all Not very important Neutral Somewhat important Extremely important
n
%
0 4 3 25 149
0 2.2 1.7 13.8 82.3
Degree of impact knowledge base of coding/billing will influence type of job you look for immediately after residency
No impact at all Small impact Large impact Very significant impact
n
%
48 73 39 22
26.4 40.1 21.4 12.1
that assessed US dermatology residents’ satisfaction of 26 training components, residents were most dissatisfied with business management training.6 Our study results suggest that a more standardized curriculum as it relates to the coding and reimbursement aspect of practice is desired by current dermatology residents and is essential to guarantee a well-prepared dermatology resident. This curriculum can be structured with lectures on billing and J AM ACAD DERMATOL
J AM ACAD DERMATOL
Letters 341
VOLUME 68, NUMBER 2
Table II. Knowledge of dermatologic coding (P \ .0001) Survey question
Without looking this up, what does a J code represent? Without looking this up, what is the ICD-9 code for acne vulgaris? Without looking this up, what is the ICD-9 code for psoriasis without arthropathy? Without looking this up, what does CPT code 11100 stand for? You see a patient for acne vulgaris and seborrheic dermatitis and perform a biopsy on a concerning pigmented lesion. In addition to the E&M service, which of the following numbers is the most appropriate modifier to bill? 24, 25, 57, 59, I do not know without looking it up
E-mail: [email protected]
% Correct
19.3 36.8 29.3 51.4 74.7
CPT, Current procedural terminology; E&M, evaluation and management; ICD-9, International Classification of Diseases, Ninth Revision.
REFERENCES 1. Ridky J, Bennett T. Training surgery residents in group practice management. Med Group Manage J 1991;38:38-9. 2. Patel AT, Bohmer RM, Barbour JR, Fried MP. National assessment of business-of-medicine training and its implications for the development of a business-of-medicine curriculum. Laryngoscope 2005;115:51-5. 3. McDonnell PJ, Kirwan TJ, Brinton GS, Golnik KC, Melendez RF, Parke DW II, et al. Perceptions of recent ophthalmology residency graduates regarding preparation for practice. Ophthalmology 2007;114:387-91. 4. Lusco VC, Martinez SA, Polk HC Jr. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg 2005;189:11-3. 5. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg 2008;196:878-82. 6. Freeman SR, Greene RE, Kimball AB, Freiman A, Barzilai DA, Muller S, et al. US dermatology residents’ satisfaction with training and mentoring: survey results from the 2005 and 2006 Las Vegas dermatology seminars. Arch Dermatol 2008;144:896-900. http://dx.doi.org/10.1016/j.jaad.2012.07.017
coding, chart reviews to ensure proper documentation, problem-based learning sessions, conferences with the billing department, and active daily feedback on resident coding and documentation by attendings during clinics. Although teaching and learning these topics requires time and effort, improper coding and billing can lead to the downfall of a practice. Brief and repeated didactic sessions early in residency will likely leave a long-term impact by creating a foundation to build upon postresidency. More importantly, making sure residents understand documentation, coding, and billing will ensure that academic dermatology practices can be sustained. Rajiv I. Nijhawan, MD,a Lauren A. Smith, MD,b Thomas E. Rohrer, MD,c,d and Kavita Mariwalla, MDa,e Departments of Dermatology at St Luke’s-Roosevelt and Beth Israel Medical Centersa and New York University,b New York, New York; SkinCare Physicians, Chestnut Hill, Massachusettsc; Department of Dermatology, Brown University, Providence, Rhode Islandd; and Department of Dermatology, SUNY at Stony Brook, East Setauket, New Yorke Funding sources: None. Conflicts of interest: None declared. Correspondence to: Kavita Mariwalla, MD, Department of Dermatology, St Luke’s-Roosevelt and Beth Israel Medical Centers, 325 W 15 St, Area J, New York, NY 10011
Maintenance treatment of psoriasis with cyclosporine A: Comparison between continuous and weekend therapy To the Editor: Since its approval for the treatment of psoriasis in 1997, many trials have confirmed the effectiveness of cyclosporine A (CsA) as both induction and maintenance therapy for moderate to severe disease.1,2 Nevertheless, it may be associated with serious side effects. Intermittent short-course therapy is used to minimize the risks without a loss of clinical benefits.3 A 32-week prospective observational cohort study was conducted with 21 patients given the diagnosis of plaque psoriasis who had a Psoriasis Area and Severity Index (PASI) score above 12. Our aim was to compare 2 different CsA regimens for the maintenance therapy of psoriasis. The baseline assessment included a complete physical examination, blood pressure measurement, and laboratory studies. While on therapy, the patients were monitored at 6, 12, 22, and 32 weeks. We used 2 and t tests to compare the data. All patients gave their informed consent. Eleven patients were men (52.4%), the mean age was 44.3 6 9.9 years (range 27-60 years), the mean PASI score was 15.0 6 2.7 (range 12-23), and the mean body mass index was 26.9 6 3.5 kg/m2. Associated comorbidities were present in 42.8% of the patients. All patients without contraindications for the drug were treated with CsA 4 mg/kg/d for 12 weeks (induction treatment). PASI
FEBRUARY 2013
LETTERS Table I. Survey responses (P \ .0001) What is your current comfort level with coding for office visits/basic dermatologic procedures?
Extremely uncomfortable Somewhat uncomfortable Neutral Somewhat comfortable Extremely comfortable
n
%
16 29 38 85 14
8.8 15.9 19.8 46.7 7.7
How often do you (residents) complete your own billing for patients you see?
Never ;25% of patients you see ;50% of patients you see ;75% of patients you see Always
n
%
15 26 21 40 77
8.4 14.5 11.7 22.3 43.0
How often does an attending provide feedback on billing you (residents) complete?
Never ;25% of the time ;50% of the time ;75% of the time Always
n
%
46 68 37 18 9
25.8 38.2 20.8 10.1 5.1
Importance of learning billing and coding during residency
Not important at all Not very important Neutral Somewhat important Extremely important
n
%
0 4 3 25 149
0 2.2 1.7 13.8 82.3
Degree of impact knowledge base of coding/billing will influence type of job you look for immediately after residency
No impact at all Small impact Large impact Very significant impact
n
%
48 73 39 22
26.4 40.1 21.4 12.1
that assessed US dermatology residents’ satisfaction of 26 training components, residents were most dissatisfied with business management training.6 Our study results suggest that a more standardized curriculum as it relates to the coding and reimbursement aspect of practice is desired by current dermatology residents and is essential to guarantee a well-prepared dermatology resident. This curriculum can be structured with lectures on billing and J AM ACAD DERMATOL
J AM ACAD DERMATOL
Letters 341
VOLUME 68, NUMBER 2
Table II. Knowledge of dermatologic coding (P \ .0001) Survey question
Without looking this up, what does a J code represent? Without looking this up, what is the ICD-9 code for acne vulgaris? Without looking this up, what is the ICD-9 code for psoriasis without arthropathy? Without looking this up, what does CPT code 11100 stand for? You see a patient for acne vulgaris and seborrheic dermatitis and perform a biopsy on a concerning pigmented lesion. In addition to the E&M service, which of the following numbers is the most appropriate modifier to bill? 24, 25, 57, 59, I do not know without looking it up
E-mail: [email protected]
% Correct
19.3 36.8 29.3 51.4 74.7
CPT, Current procedural terminology; E&M, evaluation and management; ICD-9, International Classification of Diseases, Ninth Revision.
REFERENCES 1. Ridky J, Bennett T. Training surgery residents in group practice management. Med Group Manage J 1991;38:38-9. 2. Patel AT, Bohmer RM, Barbour JR, Fried MP. National assessment of business-of-medicine training and its implications for the development of a business-of-medicine curriculum. Laryngoscope 2005;115:51-5. 3. McDonnell PJ, Kirwan TJ, Brinton GS, Golnik KC, Melendez RF, Parke DW II, et al. Perceptions of recent ophthalmology residency graduates regarding preparation for practice. Ophthalmology 2007;114:387-91. 4. Lusco VC, Martinez SA, Polk HC Jr. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg 2005;189:11-3. 5. Jones K, Lebron RA, Mangram A, Dunn E. Practice management education during surgical residency. Am J Surg 2008;196:878-82. 6. Freeman SR, Greene RE, Kimball AB, Freiman A, Barzilai DA, Muller S, et al. US dermatology residents’ satisfaction with training and mentoring: survey results from the 2005 and 2006 Las Vegas dermatology seminars. Arch Dermatol 2008;144:896-900. http://dx.doi.org/10.1016/j.jaad.2012.07.017
coding, chart reviews to ensure proper documentation, problem-based learning sessions, conferences with the billing department, and active daily feedback on resident coding and documentation by attendings during clinics. Although teaching and learning these topics requires time and effort, improper coding and billing can lead to the downfall of a practice. Brief and repeated didactic sessions early in residency will likely leave a long-term impact by creating a foundation to build upon postresidency. More importantly, making sure residents understand documentation, coding, and billing will ensure that academic dermatology practices can be sustained. Rajiv I. Nijhawan, MD,a Lauren A. Smith, MD,b Thomas E. Rohrer, MD,c,d and Kavita Mariwalla, MDa,e Departments of Dermatology at St Luke’s-Roosevelt and Beth Israel Medical Centersa and New York University,b New York, New York; SkinCare Physicians, Chestnut Hill, Massachusettsc; Department of Dermatology, Brown University, Providence, Rhode Islandd; and Department of Dermatology, SUNY at Stony Brook, East Setauket, New Yorke Funding sources: None. Conflicts of interest: None declared. Correspondence to: Kavita Mariwalla, MD, Department of Dermatology, St Luke’s-Roosevelt and Beth Israel Medical Centers, 325 W 15 St, Area J, New York, NY 10011
Maintenance treatment of psoriasis with cyclosporine A: Comparison between continuous and weekend therapy To the Editor: Since its approval for the treatment of psoriasis in 1997, many trials have confirmed the effectiveness of cyclosporine A (CsA) as both induction and maintenance therapy for moderate to severe disease.1,2 Nevertheless, it may be associated with serious side effects. Intermittent short-course therapy is used to minimize the risks without a loss of clinical benefits.3 A 32-week prospective observational cohort study was conducted with 21 patients given the diagnosis of plaque psoriasis who had a Psoriasis Area and Severity Index (PASI) score above 12. Our aim was to compare 2 different CsA regimens for the maintenance therapy of psoriasis. The baseline assessment included a complete physical examination, blood pressure measurement, and laboratory studies. While on therapy, the patients were monitored at 6, 12, 22, and 32 weeks. We used 2 and t tests to compare the data. All patients gave their informed consent. Eleven patients were men (52.4%), the mean age was 44.3 6 9.9 years (range 27-60 years), the mean PASI score was 15.0 6 2.7 (range 12-23), and the mean body mass index was 26.9 6 3.5 kg/m2. Associated comorbidities were present in 42.8% of the patients. All patients without contraindications for the drug were treated with CsA 4 mg/kg/d for 12 weeks (induction treatment). PASI