Navigating immunosuppression during a pandemic: A guide for the dermatologist
Although the risk of infection with many commonly used immunosuppressive agents remains low, data evaluating their safety during the COVID-19 pandemic are scarce. In a recent JAAD study, the authors review and offer guidance based on currently available safety data and the most recent COVID-19 outcome data in patients with immune-mediated dermatologic disease. The experts emphasize a stepwise, shared decision-making approach in the management of immunosuppressive therapy.
In the study, the authors review data of risk infection and complications of immunosuppressive and immunomodulatory agents as well as therapeutic potential in COVID-19 for glucocorticoids, methotrexate, antimalarial drugs, oral small molecules (e.g., azathioprine, mycophenolate mofetil, and cyclosporine), apremilast, JAK inhibitors, anticytokine biologic therapy, rituximab, and dupilumab.
Review the Academy’s clinical guidance for COVID-19.
DW Insights and Inquiries: Topical tacrolimus topics
What were you doing in 2000? Worrying about counting chads in Florida? If you were a dermatologist, you were probably eagerly awaiting the release of topical tacrolimus (Protopic) and pimecrolimus (Elidel) two years later. These topical calcineurin inhibitors (TCIs) quickly became vital agents in dermatologists’ therapeutic repertoire for treating atopic dermatitis (AD) and other dermatoses off-label.
Hanna et al state: “Despite the demonstrated benefits of TCIs in treating atopic dermatitis (AD) in adult and pediatric populations, and notwithstanding the considerable evidence that had been collected on their safety and tolerability, use of TCIs decreased sharply in 2005, when national and international regulatory authorities, notably the U.S. FDA, took public action to inform patients and physicians of a potential risk for malignancy with TCIs as a result of postmarketing case reports of cancer (skin and lymphoma).”
According to Fiorillo et al: “Despite the large body of evidence and extensive clinical experience with these agents, there remain concerns among parents and clinicians regarding the long-term safety of this class of therapy, particularly with respect to the boxed warning about the potential risk of lymphoma and malignancy associated with TCIs.” Keep reading!
The proposed Medicare fee schedule for 2021, released Aug. 3, 2020, includes important proposals related to telehealth and evaluation and management (E/M) coding.
Telehealth is of particular interest in the proposed rule this year given the many telehealth waivers put in place earlier in the year due to the Public Health Emergency (PHE). The waivers have allowed services to be provided with less restrictions and from areas that were normally not considered appropriate.
Dermatologists have also benefitted as they have been able to deliver timely care with fewer communication restrictions to their most vulnerable and in-need patients. The 2021 proposed rule establishes the intent to continue paying telehealth codes as currently outlined through the end of the calendar year in which the PHE ends or Dec. 31, 2021.
E/M visit codes are by far the most heavily used codes across all specialties. They accounted for about 15% of all dermatology Medicare Part B expenditures in 2018, according to Medicare Part B Utilization Data. As detailed in a previous article series in Derm Coding Consult, many changes to E/M coding are set to take effect on Jan. 1, 2021. Those changes include:
Deletion of CPT code 99201.
Revision of CPT codes 99202 – 99215.
The use of medical decision making (MDM); OR total time (including face-to-face time and non-face-to-face time) spent with the patient on the date of the encounter.
CMS has proposed increased Relative Value Units (RVUs) for these services which will in turn increment payments for these services.
After a couple months of slow or no clinic volume, I’m sure most of us are back to work and busier than ever playing catch up. As I reflect on the early months of the COVID-19 pandemic, I realize I was in somewhat of an existential crisis: My professional life to date has been largely defined by my work as a dermatologist, and not being able to see patients or perform my usual duties was very unsettling. Not knowing how or when the lockdown would end at the time, my mind wandered to what other marketable skills I might possess if not able to practice medicine.
After much introspection, I determined I don’t have any. I tell my patients I am a one-trick pony; I pride myself in being a good clinician and dermatologist, but beyond that I am (at least professionally) useless. Read more from DW Young Physician Advisor Jenna O’Neill.
Participate in MIPS cost measure field testing
CMS and its contractor, Acumen, LLC, will conduct field testing Aug. 17 – Sept. 18 for five episode-based cost measures before consideration of their potential use in the ‘cost’ performance category of the Merit-based Incentive Payment System (MIPS). Cost is one of the four MIPS performance categories. CMS will test episode-based cost measures, which are used to gauge the total cost of care for a condition and related services during the performance year. Among the measures being tested is a melanoma cost measure developed with input from the AADA. These measures were developed with input from various specialty societies and other clinician groups.
Why is it important to participate? Field testing is an opportunity for physicians and other stakeholders to provide feedback on the draft measure specifications of the cost measures. Feedback shared on these draft specifications will be used to consider potential measure refinements following field testing.
Who is qualified to participate? During field testing, physicians and practices who were attributed 10 or more episodes from at least one of the cost measures during the 2019 measurement period will receive a report with information about their cost performance. Qualified providers can also access the report on the QPP website. Dermatologists who meet the 10-episode threshold may volunteer to provide feedback on the resources associated with the measure. Responses will be used to help validate the costs associated with melanoma care.
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