This month’s news from across the specialty
What’s hot
July 1, 2023
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Need a refresher on optimizing CPT coding and documentation? At this year’s AAD Annual Meeting lecture on Coding and Office Management, Dr. Alexander Miller, the Academy’s primary advisor to the AMA-CPT Editorial Panel, provided dermatologists with up-to-date education on Medicare reimbursement.
If you are uncertain if a service to a Medicare patient is covered/payable, you can have the patient sign an Advance Beneficiary Notice of Non-coverage (ABN) prior to the service being performed. Submit the claim to Medicare with an appropriate modifier (GA, GX, GY) appended to the CPT code. It is very important that the modifier code is attached. Remember that documentation must be accurate and justify your procedures. For example, if seborrheic keratosis is inflamed and treated with LN2, documentation of clinical findings of inflammation must be present.
Some of the most common reasons for Medicare claim denials include incorrect patient information submitted (beneficiary’s name must be submitted exactly as printed on the Medicare ID card), ordering/referring physician’s name and/or NPI not specified on claim, and incorrect use of modifiers (i.e., 79 and 59).
Lastly if your Medicare claim is rejected, it is important that it is corrected, and not just resubmitted, as this costs Medicare to reprocess the claim. To access this and other 2023 AAD Annual Meeting lectures, visit the AAD store.
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Peristomal ulcers with hypergranulation can mimic peristomal pyoderma gangrenosum (PPG) and lead to the over-diagnosis of PPG. Several factors may increase the misdiagnosis of peristomal ulcers as PPG: The inconvenience of manipulating ostomy appliances discourages biopsy of suspected ulcers; thus, a large portion of PPG diagnoses are made clinically. Response to treatment is variable across literature reports, so treatment failure provides little reason for clinicians to suspect misdiagnosis. Time from ostomy placement to ulceration varies considerably across literature reports, which provides enough ambiguity for confirmation bias to support a misdiagnosis. Atypical presentations of common peristomal skin pathology, such as hypergranulation, can be a convincing mimic of PPG.
Many cases reported as PPG in the literature may not be truly PPG. (JAAD. 2019. 81(1): e15). These cases recapitulate the need for definitive diagnostic criteria for PPG. Before such diagnostic criteria become available, obtaining biopsies of suspected PPG is recommended, especially for ulcers around ileostomy and urostomy sites (JDCR. 2022. 29: 33-36). Ileostomies provide a particular enzyme and /or cytokine-rich output, which can lead to breakdown of the skin surrounding the ostomy. Ulcers not demonstrating neutrophilic infiltrates fail to meet the one major criterion for PG (JAMA Dermatol. 2018. 154(4): 461-466).
Is treatment with dupilumab associated with development of mycosis fungoides/Sezary syndrome? In the last few years, there have been scattered reports of this scenario. A recent study from the Journal of the American Academy of Dermatology (2023. 88(5): 1164-6) reported a systematic review of published data on atopic dermatitis patients who were treated with dupilumab and subsequently diagnosed with mycosis fungoides. The authors identified 23 such cases. Of these cases, 11 patients had advanced cutaneous T cell lymphoma. Some cases that had biopsy data available revealed that there was an increase in lymphoid atypia and epidermotropism of lymphocytes over time. The questions remain: Does dupilumab unmask subclinical mycosis fungoides? Does it induce mycosis fungoides or were these patients initially misdiagnosed? Because of the possible association, dermatologists should have a low threshold to biopsy atopic dermatitis patients before the initiation of the dupilumab therapy. In erythrodermic patients, peripheral blood analysis with flow cytometry should be considered. As there are limitations in these data, larger studies are necessary with long-term follow up to further investigate this possible association.
Dermatologists have become familiar with managing infections resistant to once-standard treatments, such as those occurring from methicillin-resistant S. aureus or acyclovir-resistant herpes simplex virus. A newer addition to the resistant-microorganism pantheon is Trichophyton indontineae.
Attributed to overuse and misuse of topical steroids and antifungals, T. indotineae has emerged as a cause of severe skin infections resistant to terbinafine and, in some cases, other antifungals. Initially identified in South Asia, T. indotineae infections have been reported in Asia, Europe, and Canada. CDC’s MMWR in May 2023 summarized the first two cases seen in the United States.
As in other T. indontineae infections, these cases demonstrated diffuse scaly annular pruritic plaques on the face, torso, and/or groin areas. One patient, who reported no travel history (suggesting local transmission), responded to itraconazole after failing terbinafine treatment. The other patient, who visited Bangladesh and reported that family members had pruritic rashes, improved with griseofulvin after failing terbinafine treatment; itraconazole is being considered.
The MMWR report raises two important points. First, dermatologists should be aware of the emergence, and clinical manifestations, of T. indontineae infections. As the MMWR report notes, dermatologists should contact their state or local health department for assistance with testing. Second, the U.S. cases were reported to public health officials by a dermatologist who cared for these patients. As in the early days of the HIV epidemic, and other outbreaks, dermatologists can be the first to encounter and report novel infections or other conditions not (yet) on lists of reportable conditions.
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Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup at the DermWorld homepage.
