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06.2011 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care www.aad.org A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A00 A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A00 A01 A02 A03 A04 A0 8 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B21 B22 B23 B24 B 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C4 D58 D59 D60 D61 D62 D63 D64 D65 D66 D67 D68 D69 D70 D71 D72 D73 D74 D57 D58 D59 D60 D61 D62 D63 D64 D65 D66 D67 D68 D69 D70 D71 D72 D73 D74 D57 D58 D59 D60 D61 D62 01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E13 E14 E15 E16 E17 E18 E19 E20 E21 E22 E23 E00 E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E13 E14 E15 E16 E17 E18 E19 E20 E21 E22 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K60 K37 K38 K39 K40 K41 K42 K43 K44 K45 K46 K47 K48 K49 K50 K51 K52 K53 K54 K55 K56 K57 K58 K59 K60 K37 K38 K39 K40 K41 K42 K43 K L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80 L81L61 L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80 L81L61 L62 L63 L64 L65 L66 L6 Physicians and practice managers stress early preparation for looming 5010 and ICD-10 deadlines on the horizon + 15 CMS Deadlines 26 Reversing the Ravages of Time 34 Choosing a Meaningful EHR 46 Academy News +DYH<RX 6LJQHG8S)RU <RXU:HE'HPR" in this issue from the editor DEAR READERS, June will always be synonymous with the end of the year in my mind. ll those years of schooling etched in my brain the notion that summer is coming and that all should be winding to a close. Residents at my work are making plans to depart and excitedly looking forward to what their futures will hold. Just this past week we had our department’s annual roast celebrating the residents’ successes and accomplishments…and the faculty, of course, withstood their jibes about our foibles and idiosyncrasies. On the home front it certainly feels that way too. With my younger two children graduating from high school, the talk swirling all around me is about celebrations and making potential summer plans. This summer, however, none of us can afford to “sign out” since many changes are coming. We all will definitely want to read, and then reread, the feature on the upcoming 5010 and ICD-10 changes. It is always unnerving when the government makes changes to the way we do business. Our aim is that after you finish reading this piece we’ll have given you a thorough explanation of these upcoming changes, and possible steps that you’ll need to take. The list of timelines and information websites should be especially useful. Change goes smoother when planned. Remember that the Academy has staff and resources that can help guide you as things move forward. Next on the list of things to read is the article on EHR. If you are currently thinking about purchasing a computer system for your practice Drs. Kaufmann and Siegel clarify this confusing hornet’s nest of a topic. Even if you are sitting on the sidelines for now and not taking the plunge into the electronic record world, you’ll want to read this piece. It’s important to know how long you can wait and still qualify for the Medicare incentives if you change your mind. And if you already have an electronic record system, then you are going to want to confirm that your computer system qualifies for these much-discussed incentives. With deadlines approaching, the market is expanding and these tools are improving. Knowing how to navigate this confusing terrain is going to take some savvy. You’ll find good suggestions and pointers here. I also think that you’ll want to read our pieces on the new developments in melanoma research and on fillers. We normally think of these topics as being on opposite ends of our practices, but these days they seem to have much in common. Both camps are filled with a lot of deserved excitement, and I hope that you take a minute to catch up on the happenings in both areas. From zebrafish melanomas to computers to coding regulations to fillers…so much for the days of just thinking about skin. Learning about all these government regulations is certainly a bit more than any of us wants; there does not ever seem to be a dull moment. Unfortunately for me it’s just as busy on the home front; I’m sure the same can be said for many of you. But come next fall, I’m sure that I’ll miss some of that chaos once it is gone. Doubt I’ll feel the same way once I’m ICD-10 proficient. Hopefully we’ve given you some useful information to help you navigate at least the dermatology stuff. Enjoy your reading, and do feel free to write me with your thoughts and/or questions at [email protected]. A ABBY S. VAN VOORHEES, M.D., PHYSICIAN EDITOR VOL. 21 NO. 6 | JUNE 2011 PRESIDENT CONTRIBUTING WRITERS Ronald L. Moy, M.D. Coura Badiane Jan Bowers Rachna Chaudhari Jeanine Coffman Dirk Elston, M.D. Shannon Gignac Nikki Haton Kara Jilek Blake McDonald Allison Sit Yvonne Urbikas PHYSICIAN REVIEWER Suzanne Olbricht, M.D. PHYSICIAN EDITOR Abby Van Voorhees, M.D. EXECUTIVE DIRECTOR & CEO Ronald A. Henrichs, CAE DEPUTY EXECUTIVE DIRECTORS Karen Collishaw, CAE Eileen Murray, CAE PUBLISHER Lara Lowery EDITOR Katie Domanowski MANAGING EDITOR Richard Nelson STAFF WRITER John Carruthers DESIGN MANAGER Ed Wantuch EDITORIAL DESIGNER Theresa Oloier EDITORIAL ADVISORS Lakshi Aldredge, MSN, ANP-BC Tina Alster, M.D. Rosalie Elenitsas, M.D. John Harris, M.D., Ph.D. Chad Hivnor, M.D. Sylvia Hsu, M.D. Risa Jampel, M.D. Christopher Miller, M.D. Christen Mowad, M.D. Philip Orbuch, M.D. Wendy Roberts, M.D. Robert Sidbury, M.D. Printed in U.S.A. Copyright © 2011 by the American Academy of Dermatology Association 930 E. Woodfield Rd. Schaumburg, IL 60173-4729 Phone: (847) 330-0230 Fax: (847) 330-0050 MISSION STATEMENT: Dermatology World is published monthly by the American Academy of Dermatology Association. Through insightful analysis of the trends that affect them, it provides members with a trusted, inside source for balanced news and information about managing their practice, understanding legislative and regulatory issues, and incorporating clinical and research developments into patient care. Dermatology World® (ISSN 10602445) is published monthly by the American Academy of Dermatology and AAD Association, 930 E. Woodfield Rd., Schaumburg, IL 60173-4729. Subscription price $48.00 per year included in AAD membership dues. Non-member annual subscription price $108.00 US or $120.00 international. Periodicals Postage Paid at Schaumburg, IL and additional mailing offices. POSTMASTER: Send address changes to Dermatology World®, American Academy of Dermatology Association, P.O. Box 4014, Schaumburg, IL 60168-4014. DERMATOLOGY WORLD // June 2011 1 06.2011 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care features www.aad.org depts 01 FROM THE EDITOR 04 CRACKING THE CODE “The upcoming required transition to the 5010 version of the 18 HIPAA transaction code CODING CHANGES ON THE HORIZON sets and the Physicians and practice managers stress early preparation for looming 5010 and ICD-10-CM ICD-10 deadlines diagnosis codes is a matter 26 of vital REVERSING THE RAVAGES OF TIME New injectable agents help dermatologists meet growing demand for anti-aging treatments importance.” COVER STORY BY JOHN CARRUTHERS BY JAN BOWERS 34 MEANINGFUL CERTIFICATION Earning incentives and choosing the right system in a wide-open EHR marketplace BY JOHN CARRUTHERS Correct use of modifier 59. 06 ROUNDS Tanning bill proposed, SGR fix discussed, bill to eliminate IPAB introduced, other news. 11 ACTA ERUDITORUM Can certain genes accelerate melanoma development? 15 IN PRACTICE Navigating CMS incentives, penalties, and deadlines. 45 FROM THE PRESIDENT 46 ACADEMY UPDATE Executive Director’s Report, Advisory Board resolutions, obituaries, more. 52 ACCOLADES Gold Medal winner honored, Member Making a Difference, Media Highlight. 56 Complimentary subscriptions to Dermatology World are provided to residents through support from Graceway Pharmaceuticals, LLC. FACTS AT YOUR FINGERTIPS Melanoma and indoor tanning. 2 DERMATOLOGY WORLD // June 2011 www.aad.org Are your patients confused by the array of Over-the-Counter Acne products? Keep it simple. Recommend PanOxyl®Brand Acne Products Now available in 4%, 8%, and 10% Benzoyl Peroxide (BPO) #1 & #2 Prescribed BPO Creamy Wash Formulations Now Available Without A Prescription OTC Under PanOxyl® Brand Patented delivery system, containing Dimethyl Isosorbide (DMI), solubilizes BPO and helps reduce particulate-based skin irritation and inflammation commonly experienced with conventional BPO formulations Available beginning May 2011 Call your pharmacy today and request they stock the new PanOxyl® Acne Creamy Washes PanOxyl® NDC # PanOxyl® UPC # Product Description NEW 0145-2660-05 0-73462-09870-0 PanOxyl® 4% BPO Acne Creamy Wash with DMI NEW 0145-2661-05 0-73462-09885-4 PanOxyl® 8% BPO Acne Creamy Wash with DMI 0145-0985-05 0-73462-09855-7 PanOxyl® 10% BPO Acne Foaming Wash Data on file, Stief el Laboratories, I nc. cracking the code BY DIRK ELSTON, M.D. Correct use of modifier 59 DIRK M. ELSTON, M.D., addresses important coding and documentation questions each month in Cracking the Code. Dr. Elston, chair of the department of dermatology at Geisinger Medical Center, represents the American Academy of Dermatology on the AMA-CPT® Advisory Committee. I’ve read that modifier 59 is being audited. Is this true? Do I need to worry? The Office of the Inspector General (OIG) reported that 40 percent of code pairs billed with modifier 59 in fiscal year 2003 did not meet Medicare requirements, resulting in $59 million in improper payments. The OIG report recommended that Medicare carriers provide instruction and monitor the use of modifier 59. Dermatologists should be aware of how to use the modifier correctly, as our patients often present with multiple distinct lesions that require treatment on the same day. We need to use modifier 59 to override the Correct Coding Initiative (CCI) edit that might otherwise bundle procedures reported on the same date of service and prevent proper payment. When used properly, modifier 59 ensures appropriate payment for distinct and independent services performed by the same provider on a single date of service. The procedures usually involve distinct anatomic lesions, but could also represent a different patient encounter on the same day. Note that modifier 59 is only used in conjunction with procedures, never with evaluation and management codes. Also note that modifier 59 should only be used for procedures designated as mutually exclusive or where Medicare recognizes one code as a component of the other code (e.g., Column 1 Code/Column 2 Code 17000/11100). It may be helpful to review last month’s article on CCI edits or the Correct Coding Initiative (CCI) Edits Manual, which is available at no cost through the CMS website at www.cms.hhs.gov/NationalCorrectCodInitEd/. Examples of the proper use and misuse of modifier 59: Example 1: Use modifier 59 You excise a presumed melanoma and also biopsy a presumed basal cell on the same day. Append modifier 59 to the biopsy code to indicate that the procedures were performed on two distinct lesions. Example 2: Do not use modifier 59 You sample a portion of a suspected basal cell carcinoma by means of shave technique, curette the base of the lesion, and send the specimen to the lab. This coding tips was a single lesion, so it would be inappropriate to report shave, biopsy, and destruction of the same lesion. In order to receive the full reimbursement for the medically necessary services you provided, wait until the pathology report is received. If the report confirms that the lesion was a basal cell carcinoma, report only destruction of the malignant lesion. The correct diameter to report is the final diameter of the curettage defect. If, on the other hand, the report confirms that this was merely a pearly benign melanocytic nevus, report only the biopsy as this was the medically necessary service. As your intent was to sample a portion of the lesion, you should use the skin biopsy code rather than a shave code. Shave codes are used when your intent is removal of the lesion while remaining in the dermis. Example 3: Use modifier 59 When wart and actinic keratosis (AK) destruction are performed on the same day by the same provider on the same patient, the wart is a benign lesion while the AK is a premalignant lesion. Specific CPT codes are used to report the destruction procedures with modifier 59 appended to the AK destruction code to indicate that the service was performed on a separate distinct lesion during the same encounter, e.g. 17110 and 17000/59. dw Examples of common Modifier 59 dermatologic coding sets — assuming procedures are performed on separate lesions and/or sites — include: 17110/59 and 17311; 17110/59 and 17004; 11301/59 and 11200; 17261/59 and 17110; 11641/59 and 14040. CORRECTION The May Cracking the Code contained an error, which has been corrected in the digital edition of the magazine. In the example, “A patient has a basal cell carcinoma excised. He returns in five days because of an outbreak of poison ivy,” the E/M service should be reported with modifier 24, rather than modifier 79 as indicated. When separately identifiable medically necessary E/M services are provided along with a procedure on the same day of service, modifier 25 should be appended to override the CCI edit that would inappropriately bundle the services. Modifier 24 performs the same function during the global period following a procedure. Modifier 59 is used to prevent inappropriate bundling of a distinct procedural service independent from other procedural services performed on the same day. Modifier 79 performs the same function as modifier 59, but during the global period. 4 DERMATOLOGY WORLD // June 2011 www.aad.org rounds news in brief Medicare payment fix a priority for Congress this summer W hile negotiations on raising the nation’s debt ceiling and discussions of long-term budget proposals by Rep. Paul Ryan (R-Wis.) and President Obama dominated recent news out of Washington, fixing the flawed Medicare physician payment system has been labeled a top priority by a prominent Republican. Rep. Fred Upton (R-Mich.), chair of the House Energy and Commerce Committee, said at a recent hearing that fixing the Sustainable Growth Rate formula is “on the short list of things getting done this summer.” In pursuit of a solution to the problem, Rep. Upton asked more than 50 medical societies, including the American Academy of Dermatology Association, to submit their ideas for payment reform. The AADA’s response acknowledged the complexity of the issue, expressed its concerns, and stated that there is no one-size-fits-all solution, noting that any potential reform proposals would need to be heavily tested and measured as to how they would affect physicians’ ability to treat patients, retain employees, and maintain the viability of their practices. For more information about progress toward a payment fix, including a link to the AADA’s letter to Rep. Upton, visit www. aad.org/member-tools-and-benefits/aada-advocacy/federal-legislative-affairs/medicare-payment-reform. – RICHARD NELSON Academy seeks closure of EHR donation loophole THE ACADEMY WILL SEND A LETTER TO THE OFFICE OF THE INSPECTOR GENERAL and the Centers for Medicare and Medicaid Services asking them to close a loophole that allows pathology labs to donate electronic health records systems to physicians, as it raises concerns about fraud and abuse. It also alerted members to the risks of pursuing such donations. In the message, the Academy noted that dermatologists should “assess all opportunities and risks as they consider acquiring and using EHR systems.” While federal rules allow hospitals and labs to donate up to 85 percent of the cost of EHR software, training, and connectivity (but not hardware or maintenance) through Dec. 31, 2013, he said that “dermatologists interested in pursuing this opportunity should be very careful to follow the [compliance] requirements of the [anti-kickback] safe harbor and [Stark] exception, as well as to comply fully with both federal and state fraud and abuse laws,” noting that some states (including New York) ban such donations. The Academy also reminded members that donations cannot be dependent on referrals, and “dermatologists and labs may not factor in the volume or value of referrals or other business generated between them in connection with the EHR donation.” Indeed, discussion of any quid pro quo arrangement is a violation of the law. – RICHARD NELSON 6 DERMATOLOGY WORLD // June 2011 www.aad.org news in brief rounds continued Academy adopts medical spa position statement and model legislation Attestation system for EHR incentives opens THE ACADEMY’S BOARD OF DIRECTORS approved a new position statement on medical spa standards of practice on May 7, along with a model statute. The position statement, created with the goal of protecting patient safety and quality of care, addresses a rapidly growing segment of the dermatologic treatment market. The statement defines medical spas as “facilities that offer a range of services, including medical and surgical procedures, for the purpose of improving an individual’s well-being and/or appearance. The distinguishing feature of medical spas is that medicine and surgery are practiced in a non-traditional setting.” It recommends that all medical aesthetic services offered in a medical spa facility be performed only by appropriately trained physicians or appropriately trained non-physician personnel only under direct, on-site supervision. Further, the statement calls for identification of medical directors by licensure, specialty, training, and education in all marketing materials and the ultimate acceptance of responsibility for provided services by that director. Lastly, it calls for proper training of medical spa personnel, as well as facility licensing, regular inspection, and enforcement including penalties. The model statute approved by the Board establishes standards of practice for the performance, delegation, assignment, and supervision of medical aesthetic services performed in a medical spa facility. It does not apply to licensed medical facilities that offer aesthetic services as part of a larger medical package, nor does it address the practices of cosmetology or electrology, which are governed by existing state laws. The position statement is available on the Academy’s website at www.aad.org/Forms/Policies/Uploads/PS/PS-Medical-Spa-Standards-ofPractice.pdf. Questions regarding the position statement or model statute can be directed to Kathryn Chandra, assistant director, state policy, at [email protected]. – JOHN CARRUTHERS PHYSICIANS WHO WISH TO PARTICIPATE IN THE MEDICARE ELECTRONIC HEALTH RECORD (EHR) INCENTIVE PROGRAM are now able to attest that they have met the program’s requirements through CMS’s web-based Registration and Attestation System. The system, which launched April 18 at www.cms.gov/EHRIncentive Programs/, qualifies eligible providers for meaningful use incentive payments. The program, started to provide a financial incentive for physicians to implement EHRs in their offices, can qualify physicians for up to $44,000 in incentives over five years ($63,750 over six years if they opt for Medicaid’s version of the program) if they meet government-defined “meaningful use” measures with certified EHR systems. To qualify for the maximum incentive amount, physicians must begin participation by Oct. 1, 2012. The launch of the attestation system allows physicians to begin participating and qualifying for incentive payments. Registered physicians must report numerator, denominator, and applicable exclusion results for meaningful use objectives to attest that they have met the requirements for payment under the program. Once a physician has successfully completed a submission, he or she will be qualified for an incentive payment. Oct. 1, 2011 is the last day for eligible physicians to begin their 90-day reporting period for 2011. Attestation for 2011 must be filed by Feb. 29, 2012 in order to receive payment. Physicians participating in the Medicaid EHR Incentive Program will be able to follow a similar process through their state’s own attestation process; launch dates for Medicaid incentive programs are available at www.cms.gov/apps/files/ medicaid-HIT-sites/. – JOHN CARRUTHERS DERMATOLOGY WORLD // June 2011 7 rounds continued news in brief IRS delays health coverage reporting requirement for small employers Bills in both houses would eliminate IPAB LEGISLATION HAS BEEN INTRODUCED IN BOTH HOUSES OF CONGRESS TO ELIMINATE the Independent Payment SMALL DERMATOLOGY PRACTICES WILL HAVE AN EXTRA YEAR TO COMPLY with a provision of the Patient Protec- tion and Affordable Care Act that requires employers to provide employees with information about the cost of their employer-sponsored group health plan coverage. The law calls for a report regarding this cost to be included on 2012 W-2s (to be issued in January 2013), but the IRS has delayed the requirement until the 2013 rounds of W-2s (to be issued in January 2014) for employers that file fewer than 250 W-2s. Employee health benefits still will not be taxed as income. For more information on the new requirements, including how the cost of coverage should be calculated and how it should be reported, as well as the delay in implementation for small employers, visit the IRS website at www.irs.gov/pub/irs-drop/n-11-28.pdf. – RICHARD NELSON Advisory Board (IPAB), an unelected 15-member board created by last year’s health system reform law. If it is not eliminated, the IPAB will fulfill its charge of slowing growth in national health spending by making binding Medicare policy recommendations that cut the program’s spending by a statutorily mandated percentage starting in 2015. The inclusion of the IPAB in the final reform legislation was a key reason the American Academy of Dermatology Association did not support its passage. The bill to eliminate the IPAB in the House of Representatives has attracted 109 cosponsors, including four Democrats. All 24 cosponsors of the Senate bill are Republicans. For more information about the IPAB, visit www.aad.org/member-tools-and-benefits/practicemanagement-resources/health-system-reform-resourcecenter/ipab. –RICHARD NELSON with an on-site tissue processing lab. Enhance Patient Care Increase Practice Revenue Quick Return on Investment Avantik Biogroup delivers an all-in-one solution for on-site tissue processing lab setup. Our extensive experience, backed by our exceptional service and reliability, enables us to implement your lab setup quickly and efficiently. Through our network of consultants, we also provide access to a range of extended services that include: CLIA and OSHA compliance and Technical training and staffing. To start planning for your new on-site tissue processing lab contact us today at 888.392.8411 or visit www.avantik-us.com to learn more. A Business Unit ofp INSTRUMENT COMPANY, INC. Minimal Space Requirements © 2010 Avantik Biogroup, a business unit of Belair Instrument Co., 32 Commerce Street, P.O. Box 1299, Springfield, NJ 07081-1299 t 888.392.8411 Discover greater profitability Brief Summary of PErescribing InformatEion for STELARA™ (usEtekinumab) STELARA™ Injection, fEor subcutaneous useE See package insertm for Full Prescribimng Information INDICATIONS AND USAGE: STELARA™ is indicated for the treatment of adult patients (18 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. CONTRAINDICATIONS: None. WARNINGS AND PRECAUTIONS: Infections STELARA™ may increase the risk of infections and reactivation of latent infections. Serious bacterial, fungal, and viral infections were observed in subjects receiving STELARA™ (see Adverse Reactions). STELARA™ should not be given to patients with any clinically important active infection. STELARA™ should not be administered until the infection resolves or is adequately treated. Instruct patients to seek medical advice if signs or symptoms suggestive of an infection occur. Exercise caution when considering the use of STELARA™ in patients with a chronic infection or a history of recurrent infection. Serious infections requiring hospitalization occurred in the psoriasis development program. These serious infections included cellulitis, diverticulitis, osteomyelitis, viral infections, gastroenteritis, pneumonia, and urinary tract infections. Theoretical Risk for Vulnerability to Particular Infections Individuals genetically deficient in IL-12/IL-23 are particularly vulnerable to disseminated infections from mycobacteria (including nontuberculous, environmental mycobacteria), salmonella (including nontyphi strains), and Bacillus Calmette-Guerin (BCG) vaccinations. Serious infections and fatal outcomes have been reported in such patients. It is not known whether patients with pharmacologic blockade of IL-12/IL-23 from treatment with STELARA™ will be susceptible to these types of infections. Appropriate diagnostic testing should be considered, e.g., tissue culture, stool culture, as dictated by clinical circumstances. Pre-treatment Evaluation for Tuberculosis Evaluate patients for tuberculosis infection prior to initiating treatment with STELARA™. Do not administer STELARA™ to patients with active tuberculosis. Initiate treatment of latent tuberculosis prior to administering STELARA™. Consider anti-tuberculosis therapy prior to initiation of STELARA™ in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed. Patients receiving STELARA™ should be monitored closely for signs and symptoms of active tuberculosis during and after treatment. Malignancies STELARA™ is an immunosuppressant and may increase the risk of malignancy. Malignancies were reported among subjects who received STELARA™ in clinical studies (see Adverse Reactions). In rodent models, inhibition of IL-12/IL-23p40 increased the risk of malignancy (see Nonclinical Toxicology). The safety of STELARA™ has not been evaluated in patients who have a history of malignancy or who have a known malignancy. Hypersensitivity Reactions Serious allergic reactions, including angioedema and possible anaphylaxis, have been reported post-marketing. If an anaphylactic or other serious allergic reaction occurs, discontinue STELARA™ and institute appropriate therapy [see Adverse Reactions]. Reversible Posterior Leukoencephalopathy Syndrome One case of reversible posterior leukoencephalopathy syndrome (RPLS) was observed during the clinical development program which included 3523 STELARA™-treated subjects. The subject, who had received 12 doses of STELARA™ over approximately two years, presented with headache, seizures and confusion. No additional STELARA™ injections were administered and the subject fully recovered with appropriate treatment. RPLS is a neurological disorder, which is not caused by demyelination or a known infectious agent. RPLS can present with headache, seizures, confusion and visual disturbances. Conditions with which it has been associated include preeclampsia, eclampsia, acute hypertension, cytotoxic agents and immunosuppressive therapy. Fatal outcomes have been reported. If RPLS is suspected, STELARA™ should be discontinued and appropriate treatment administered. Immunizations Prior to initiating therapy with STELARA™, patients should receive all immunizations appropriate for age as recommended by current immunization guidelines. Patients being treated with STELARA™ should not receive live vaccines. BCG vaccines should not be given during treatment with STELARA™ or for one year prior to initiating treatment or one year following discontinuation of treatment. Caution is advised when administering live vaccines to household contacts of patients receiving STELARA™ because of the potential risk for shedding from the household contact and transmission to patient. Non-live vaccinations received during a course of STELARA™ may not elicit an immune response sufficient to prevent disease. Concomitant Therapies The safety of STELARA™ in combination with other immunosuppressive agents or phototherapy has not been evaluated. Ultraviolet-induced skin cancers developed earlier and more frequently in mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone (see Nonclinical Toxicology). Theoretical Risk of Immunotherapy STELARA™ has not been evaluated in patients who have undergone allergy immunotherapy. STELARA™ may decrease the protective effect of allergy immunotherapy and may increase the risk of an allergic reaction to a dose of allergen immunotherapy. Therefore, caution should be exercised in patients receiving or who have received allergy immunotherapy, particularly for anaphylaxis. ADVERSE REACTIONS: The following serious adverse reactions are discussed elsewhere in the label: Infections (see Warnings and Precautions); Malignancies (see Warnings and Precautions); and RPLS (see Warnings and Precautions). Clinical Studies Experience The safety data reflect exposure to STELARA™ in 2266 STELARA™ (ustekinumab) psoriasis subjects, including 1970 exposed for at least 6 months, 1285 exposed for at least one year, and 373 exposed for at least 18 months. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Adverse reactions listed below are those that occurred at a rate of at least 1% and at a higher rate in the STELARA™ groups than the placebo group during the placebocontrolled period of STUDY 1 and STUDY 2. The numbers (percentages) of adverse reactions reported for placebo-treated patients (n=665), patients treated with 45 mg STELARA™ (n=664), and patients treated with 90 mg STELARA™ (n=666), respectively, were: Nasopharyngitis: 51 (8%), 56 (8%), 49 (7%); Upper respiratory tract infection: 30 (5%), 36 (5%), 28 (4%); Headache: 23 (3%), 33 (5%), 32 (5%); Fatigue: 14 (2%), 18 (3%), 17 (3%); Diarrhea: 12 (2%), 13 (2%), 13 (2%); Back pain: 8 (1%), 9 (1%), 14 (2%); Dizziness: 8 (1%), 8 (1%), 14 (2%); Pharyngolaryngeal pain: 7 (1%), 9 (1%), 12 (2%); Pruritus: 9 (1%), 10 (2%), 9 (1%); Injection site erythema: 3 (<1%), 6 (1%), 13 (2%); Myalgia: 4 (1%), 7 (1%), 8 (1%); Depression: 3 (<1%), 8 (1%), 4 (1%). Adverse drug reactions that occurred at rates less than 1% included: cellulitis and certain injection site reactions (pain, swelling, pruritus, induration, hemorrhage, bruising, and irritation). One case of RPLS occurred during clinical trials (see Warnings and Precautions). Infections In the placebo-controlled period of clinical studies of psoriasis subjects (average follow-up of 12.6 weeks for placebo-treated subjects and 13.4 weeks for STELARA™-treated subjects), 27% of STELARA™-treated subjects reported infections (1.39 per subject-year of follow-up) compared with 24% of placebo-treated subjects (1.21 per subject-year of follow-up). Serious infections occurred in 0.3% of STELARA™-treated subjects (0.01 per subject-year of follow-up) and in 0.4% of placebo-treated subjects (0.02 per subject-year of follow-up) (see Warnings and Precautions). In the controlled and non-controlled portions of psoriasis clinical trials, 61% of STELARA™-treated subjects reported infections (1.24 per subject-year of follow-up). Serious infections were reported in 0.9% of subjects (0.01 per subject-year of follow-up). Malignancies In the controlled and non-controlled portions of psoriasis clinical trials, 0.4% of STELARA™-treated subjects reported malignancies excluding non-melanoma skin cancers (0.36 per 100 subject-years of follow-up). Non-melanoma skin cancer was reported in 0.8% of STELARA™-treated subjects (0.80 per 100 subject-years of follow-up) (see Warnings and Precautions). Serious malignancies included breast, colon, head and neck, kidney, prostate, and thyroid cancers. Immunogenicity The presence of ustekinumab in the serum can interfere with the detection of antiustekinumab antibodies resulting in inconclusive results due to assay interference. In STUDIES 1 and 2, antibody testing was done at time points when ustekinumab may have been present in the serum. In STUDY 1 the last ustekinumab injection was between Weeks 28 and 48 and the last test for anti-ustekinumab antibodies was at Week 52. In STUDY 2 the last ustekinumab injection was at Week 16 and the last test for anti-ustekinumab antibodies was at Week 24. In STUDY 1 (N=743), antibody results were found to be positive, negative, and inconclusive in 38 (5%), 351 (47%), and 354 (48%) patients, respectively. In STUDY 2 (N=1198), antibody results were found to be positive, negative, and inconclusive in 33 (3%), 90 (8%), and 1075 (90%) patients, respectively. The data reflect the percentage of subjects whose test results were positive for antibodies to ustekinumab in a bridging immunoassay, and are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications and underlying disease. For these reasons, comparison of the incidence of antibodies to ustekinumab with the incidence of antibodies to other products may be misleading. Post-marketing Experience Adverse reactions have been reported during post-approval use with STELARA™. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to STELARA™ exposure. Immune system disorders: Serious allergic reactions (including angioedema, dyspnea and hypotension), hypersensitivity reactions (including rash and urticaria). DRUG INTERACTIONS: Drug interaction studies have not been conducted with STELARA™. Live Vaccines Live vaccines should not be given concurrently with STELARA™ (see Warnings and Precautions). Concomitant Therapies The safety of STELARA™ in combination with immunosuppressive agents or phototherapy has not been evaluated (see Warnings and Precautions). CYP450 Substrates The formation of CYP450 enzymes can be altered by increased levels of certain cytokines (e.g., IL-1, IL-6, IL-10, TNFα, IFN) during chronic inflammation. Thus, ustekinumab could normalize the formation of CYP450 enzymes. A role for IL-12 or IL-23 in the regulation of CYP450 enzymes has not been reported. However, upon initiation of ustekinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, monitoring for therapeutic effect (e.g., for warfarin) or drug concentration (e.g., for cyclosporine) should be considered and the individual dose of the drug adjusted as needed (see Clinical Pharmacology). USE IN SPECIFIC POPULATIONS: Pregnancy Pregnancy Category B There are no studies of STELARA™ in pregnant women. STELARA™ should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. No teratogenic effects news in brief STELARA™ (ustekinumab) were observed in the developmental and reproductive toxicology studies performed in cynomolgus monkeys at doses up to 45 mg/kg ustekinumab, which is 45 times (based on mg/kg) the highest intended clinical dose in psoriasis patients (approximately 1 mg/kg based on administration of a 90 mg dose to a 90 kg psoriasis patient). Ustekinumab was tested in two embryo-fetal development toxicity studies. Pregnant cynomolgus monkeys were administered ustekinumab at doses up to 45 mg/kg during the period of organogenesis either twice weekly via subcutaneous injections or weekly by intravenous injections. No significant adverse developmental effects were noted in either study. In an embryo-fetal development and pre- and post-natal development toxicity study, three groups of 20 pregnant cynomolgus monkeys were administered subcutaneous doses of 0, 22.5, or 45 mg/kg ustekinumab twice weekly from the beginning of organogenesis in cynomolgus monkeys to Day 33 after delivery. There were no treatmentrelated effects on mortality, clinical signs, body weight, food consumption, hematology, or serum biochemistry in dams. Fetal losses occurred in six control monkeys, six 22.5 mg/kg-treated monkeys, and five 45 mg/kgtreated monkeys. Neonatal deaths occurred in one 22.5 mg/kg-treated monkey and in one 45 mg/kg-treated monkey. No ustekinumab-related abnormalities were observed in the neonates from birth through six months of age in clinical signs, body weight, hematology, or serum biochemistry. There were no treatment-related effects on functional development until weaning, functional development after weaning, morphological development, immunological development, and gross and histopathological examinations of offsprings by the age of 6 months. Nursing Mothers Caution should be exercised when STELARA™ is administered to a nursing woman. The unknown risks to the infant from gastrointestinal or systemic exposure to ustekinumab should be weighed against the known benefits of breastfeeding. Ustekinumab is excreted in the milk of lactating monkeys administered ustekinumab. IgG is excreted in human milk, so it is expected that STELARA™ will be present in human milk. It is not known if ustekinumab is absorbed systemically after ingestion; however, published data suggest that antibodies in breast milk do not enter the neonatal and infant circulation in substantial amounts. Pediatric Use Safety and effectiveness of STELARA™ in pediatric patients have not been evaluated. Geriatric Use Of the 2266 psoriasis subjects exposed to STELARA™, a total of 131 were 65 years or older, and 14 subjects were 75 years or older. Although no differences in safety or efficacy were observed between older and younger subjects, the number of subjects aged 65 and over is not sufficient to determine whether they respond differently from younger subjects. OVERDOSAGE: Single doses up to 4.5 mg/kg intravenously have been administered in clinical studies without dose-limiting toxicity. In case of overdosage, it is recommended that the patient be monitored for any signs or symptoms of adverse reactions or effects and appropriate symptomatic treatment be instituted immediately. PATIENT COUNSELING INFORMATION: Instruct patients to read the Medication Guide before starting STELARA™ therapy and to reread the Medication Guide each time the prescription is renewed. Infections Inform patients that STELARA™ may lower the ability of their immune system to fight infections. Instruct patients of the importance of communicating any history of infections to the doctor, and contacting their doctor if they develop any symptoms of infection. Malignancies Patients should be counseled about the risk of malignancies while receiving STELARA™. Allergic Reactions Advise patients to seek immediate medical attention if they experience any symptoms of seriousy allergic reactionsy. Prefilled Syringe Maynufactured by: Centocor Ortho Biotyech Inc., Horsham, PA 19044, y License No. 1821 aty Baxter Pharmaceuticayl Solutions, Bloomington, IN 47y403 © Centocor Ortho Biyotech Inc. 2010 Vial Manufactured byy: Centocor Ortho Biotyech Inc., Horsham, PA 19044, License No. 1821 aty Cilag AG, Schaffhausen, Switzeyrland 25ST11 Bill calls on FDA to reclassify tanning beds Dermatologists Susan Elliott, M.D., Larry Green, M.D., Ronald Moy, M.D., and Ali Hendi, M.D., screened congressional staffers for skin cancer following a briefing introducing the Tanning Bed Cancer Control Act of 2011 on May 3. A BILL CALLING ON THE FOOD AND DRUG ADMINISTRATION (FDA) to reevaluate the classification of tanning beds was introduced on May 3 at a Capitol Hill briefing about the dangers of indoor tanning hosted by the American Academy of Dermatology Association as part of Melanoma/Skin Cancer Detection and Prevention Month. AADA President Ronald Moy, M.D.; Rep. Charlie Dent (R-Pa.); Centers for Disease Control and Prevention Epidemiology and Applied Research Branch Chief Mary C. White; and Jessica Lilley, M.D., a melanoma survivor and pediatrician, addressed congressional staffers regarding the dangers of indoor tanning. During the briefing, Reps. Dent and Carolyn Maloney (D-N.Y.) introduced H.R. 1676, the Tanning Bed Cancer Control Act of 2011. The act requests that the FDA reevaluate tanning bed restrictions and reclassify them as a class II or III device, which would give the FDA greater regulatory power over tanning beds. Tanning beds are currently classified as a class I device, which includes medical items such as tongue depressors and bandages. A wide contingent of national health care organizations joined the AADA to highlight the dangers of indoor tanning, including: • American Academy of Ophthalmology • American Academy of Pediatrics • American Cancer Society Cancer Action Network • American Congress of Obstetricians and Gynecologists • American College of Physicians • American Medical Association • American Osteopathic Association • Melanoma Research Foundation • National Council on Skin Cancer Prevention • The Skin Cancer Foundation Immediately following the briefing, AADA members Susan Elliott, M.D., Larry Green, M.D., and Ali Hendi, M.D., joined Dr. Moy in performing 50 free skin cancer screenings. – BLAKE MCDONALD dw www.aad.org acta eruditorum research in practice Q&A Finding in fish offers potential explanation for melanoma formation IN THIS MONTH’S ACTA ERUDITORUM COLUMN, Physician Editor Abby S. Van Voorhees, M.D., talks with Craig Ceol, Ph.D., about his recent Nature article, “The histone methyltransferase SETDB1 is recurrently amplified in melanoma and accelerates its onset.” DR. VAN VOORHEES: What is the most common mutation found in melanomas? Is this mutation also found in benign nevi? How is it thought to work? DR. CEOL: The most common mutation in melanomas is a mutation in the BRAF gene, which is a part of the RAS signaling pathway. The RAS pathway is abnormally overactivated in many different types of cancers. BRAF is mutated in about 50-60 percent of all melanomas, and most BRAF mutations are the same — they cause a single amino acid change in the BRAF protein which creates the BRAF(V600E) oncogene. The BRAF(V600E) mutation is found in roughly half of all melanomas and also in benign nevi, so it’s thought that BRAF(V600E) is probably necessary but not sufficient for melanoma formation and that BRAF(V600E) needs to cooperate with other types of genomic changes in order to make a melanoma. These changes can take the form of single DNA nucleotide mutations in the genome or they can be amplifications or deletions of broader regions of the chromosomes. If you look at enough melanomas what you find is the same chromosomal interval can be amplified in many different tumor samples. Some of these regions have known melanoma oncogenes. For example, BRAF itself is in a region that is recurrently amplified. However, there are other recurrently amplified regions where we suspect there are oncogenes but we don’t know which gene is the one that cooperates with BRAF. Finding these new oncogenes is one of the reasons we initiated our study. DR. VAN VOORHEES: Tell us about the model that you used to study these sections of the genome. What made you consider looking further at chromosome 1? DR. CEOL: We have been working with a zebrafish model of melanoma; zebrafish are pretty useful for studies of melanocyte biology. They have melanocytes — that’s where they get their name, their black stripes are made up of melanocytes. We DERMATOLOGY WORLD // June 2011 11 acta eruditorum previously had put the human version of BRAF(V600E) in zebrafish and found that it caused the formation of nevi. Together with another mutation in the p53 gene, BRAF(V600E) gave rise to melanomas in fish. So we wanted to find out, if we throw other things into the mix, can we accelerate or delay tumor onset or change any of the properties of the tumors we see in our model? We considered a number of different regions that are recurrently amplified in the human melanoma genome, in particular ones where we didn’t know the important oncogene in the interval. We focused on an interval of chromosome 1 because it was focally amplified and had no known oncogene. We screened through genes using our zebrafish model to look for an oncogene that substantially accelerated the formation of melanomas. DR. VAN VOORHEES: Was a specific oncogene identified that regulates tumorigenesis in melanomas? How is it thought to function? DR. CEOL: We found a gene, SETDB1, that markedly accelerated melanoma onset. SETDB1 encodes an enzyme that adds methyl groups onto histone proteins and, through this activity, SETDB1 can downregulate the expression levels of hundreds of target genes. In zebrafish melanomas with excess SETDB1 we indeed found that many genes were downregulated. In looking at the most downregulated genes we found that the same set was also downregulated in human melanomas with excess SETDB1. What this says is that we are barking up the right tree, that is, there’s a strong correlation between what we’re seeing in our zebrafish model and what happens in human tumors. DR. VAN VOORHEES: Does SETDB1 work alone or in combination with other mutations? DR. CEOL: SETDB1 by itself does not cause melanoma formation; rather, it 12 DERMATOLOGY WORLD // June 2011 research in practice cooperates with BRAF to accelerate melanomas. You absolutely need BRAF there; what SETDB1 does is speed the process up. What we saw in human tissue samples is consistent with this finding. Levels of SETDB1 were quite high in melanomas but relatively low in nevi and normal melanocytes. We think this means that when a BRAF(V600E) mutation is present along with excess SETDB1, a lesion more easily becomes a tumor. However, with a low level of SETDB1, a lesion is more likely to persist in a benign state. DR. VAN VOORHEES: Is this model thought to be the case in other malignancies? DR. CEOL: At this point we’re not sure. However, we do know that the same region of chromosome 1 is recurrently amplified in many types of cancers, including non small cell lung, hepatocellular, ovarian, and others. So SETDB1 may have a broader role in these other cancers as well, but we have not looked at this directly. DR. VAN VOORHEES: Does there seem to be a dose correlation in those malignancies as well? DR. CEOL: We don’t know that yet. What we’d like to do is the same thing we did with melanomas — get tissue samples and monitor the level of SETDB1 in normal, benign, and malignant stages. But we don’t have hard evidence that SETDB1 is causing the formation of these other tumors; we just know that this small region of the genome is recurrently amplified, which is a nice correlation but doesn’t show causation. DR. VAN VOORHEES: SETDB1 seems to increase the frequency of the tumors; does it also increase their aggressiveness? DR. CEOL: In our fish model, when SETDB1 was present at excess levels the tumors were much more aggressive. We can monitor invasion rather easily. Normally melanomas in zebrafish tend to grow in exophytic fashion— outward off the skin. However, when SETDB1 was there, the melanomas more easily invaded into the underlying musculature and often went into the spinal column of the fish, and they did so in a very short period of time. DR. VAN VOORHEES: Does this study help us better understand what allows for the promotion of cancer? Can it be used to predict the potential aggressiveness of a melanoma? DR. CEOL: SETDB1 appears to have a role in modulating the process of oncogene-induced senescence. In established tumors the BRAF(V600E) oncogene can promote cell division and proliferation. But when it’s initially introduced in a naïve cell, it doesn’t do that; it leads to a senescent arrest. Overcoming that arrest is a key step in tumor formation. When SETDB1 was overexpressed and amplified, we found that BRAF-induced senescence was bypassed. Instead of arresting, cells with a BRAF(V600E) oncogene and excess SETDB1 began proliferating almost immediately. Through our studies we can investigate these early stages of tumor development that are very difficult to capture by looking solely at human tissue biopsies. Whether SETDB1 is a predictor of aggressiveness is an interesting question. Currently we are assembling tissue samples, each of which is tied to a thorough clinical history, so this question can be addressed. In addition to being a prognostic marker, it is also possible that SETDB1 could be a useful therapeutic target. In well-publicized recent trials, BRAF inhibitors have shown remarkable efficacy in patients with BRAF-mutant melanomas. However, relapses are frequent and typically occur within months of initial treatment. It will be interesting to see if SETDB1 inhibitors, in combination with BRAF inhibitors, can prevent or delay relapses. dw DR. CEOL is assistant professor in the programs in molecular medicine and cell dynamics at the University of Massachusetts School of Medicine. His article was published in Nature, 471, 513–517 (24 March 2011). doi:10.1038/nature09806. www.aad.org cy… Delivers on effica Handles Patients With Care the topical l is indicated for DUAC Topic al Ge ammator y acne vulgaris. ve any infl of t en treatm mons trated to ha l has not been de same Ge the al in pic ne To alo AC ide DU with benzoyl perox acne. d y are tor mp ma co am fl en nonin fit wh additional bene the treatment of for d use en wh vehicle DUAC Topical Gel is the once-daily clindamycin/benzoyl peroxide combination with a patented formula containing both glycerin and dimethicone The contribution to efficacy by individual components of the veGhicle has not been eGstablished. 1 • No therapeutically Gequivalent generic Gsubstitute • More than 6 million prescriptions of DUAC Topical Gel 2 dispensed since lauGnch PLEASE NOTE: The soap-free cleanser is no longer included. in the package. Please prescribe DUAC Topical Gel 45 g. DUAC 45 g Apply once daily Dispense as written Important Safety Information for DUAC Topical Gel • DUAC Topical Gel is contraindicated in patients who have shown hypersensitivity to any of its components or lincomycin • DUAC Topical Gel is contraindicated in patients with a history of regional enteritis, ulcerative colitis, pseudomembranous colitis, or antibiotic-associated colitis • Orally and parenterally administered clindamycin has been associated with severe colitis which may result in patient death. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with the use of topical and systemic clindamycin. The colitis is usually characterized by severe persistent diarrhea and severe abdominal cramps and may be associated with the passage of blood and mucus • For dermatologic use only; not for ophthalmic use • Concomitant topical acne therapy should be used with caution because a possible cumulative irritancy effect may occur, especially with the use of peeling, desquamating, or abrasive agents • The use of antibiotic agents may be associated with the overgrowth of nonsusceptible organisms, including fungi. If this occurs, discontinue use of this medication and take appropriate measures • Clindamycin- and erythromycin-containing products should not be used in combination. In vitro studies have shown antagonism between these two antimicrobials. The clinical significance of this in vitro antagonism is not known • DUAC Topical Gel may bleach hair and colored fabrics • Excessive or prolonged exposure to sunlight should be limited. To minimize exposure to sunlight, a hat or other clothing should be worn • DUAC Topical Gel should be given to a pregnant woman only if clearly needed • It is not known whether DUAC Topical Gel is secreted into human milk after topical application. However, orally and parenterally administered clindamycin has been reported to appear in breast milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother • Safety and effectiveness of this product in pediatric patients below the age of 12 have not been established • Adverse reactions may include erythema, peeling, burning, and dryness • Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported in postmarketing use with DUAC Topical Gel. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure Please see brief summary of Prescribing Information on following page. References: 1. Electronic Orange Book. US Food and Drug Administration Web site. http://www.accessdata.fda.gov/scripts/cder/ob/docs/tempai.cfm. Accessed February 25, 2011. 2. SDI. VectorOne: National (VONA). October 2009. BRIEF SUMMARY DUAC ® Topical Gel (clindamycin, 1% - benzoyl peroxide, 5%) The following is a brief summary only; see full prescribing information for complete product information. For Dermatological Use Only. Not for Ophthalmic Ucse. Rx Only INDICATIONS AND USAGE DUAC Topical Gel is indicated for the topical treatment of inflammatory acne vulgaris. DUAC Topical Gel has not been demonstrated to have any additional benefit when compared to benzoyl peroxide alone in the same vehicle when used for the treatment of non-inflammatory acne. CONTRAINDICATIONS DUAC Topical Gel is contraindicated in those individuals who have shown hypersensitivity to any of its components or to lincomycin. It is also contraindicated in those having a history of regional enteritis, ulcerative colitis, pseudomembranous colitis, or antibiotic-associated colitis. WARNINGS ORALLY AND PARENTERALLY ADMINISTERED CLINDAMYCIN HAS BEEN ASSOCIATED WITH SEVERE COLITIS WHICH MAY RESULT IN PATIENT DEATH. USE OF THE TOPICAL FORMULATION OF CLINDAMYCIN RESULTS IN ABSORPTION OF THE ANTIBIOTIC FROM THE SKIN SURFACE. DIARRHEA, BLOODY DIARRHEA, AND COLITIS (INCLUDING PSEUDOMEMBRANOUS COLITIS) HAVE BEEN REPORTED WITH THE USE OF TOPICAL AND SYSTEMIC CLINDAMYCIN. STUDIES INDICATE A TOXIN(S) PRODUCED BY CLOSTRIDIA IS ONE PRIMARY CAUSE OF ANTIBIOTIC-ASSOCIATED COLITIS. THE COLITIS IS USUALLY CHARACTERIZED BY SEVERE PERSISTENT DIARRHEA AND SEVERE ABDOMINAL CRAMPS AND MAY BE ASSOCIATED WITH THE PASSAGE OF BLOOD AND MUCUS. ENDOSCOPIC EXAMINATION MAY REVEAL PSEUDOMEMBRANOUS COLITIS. STOOL CULTURE FOR Clostridium difficile AND STOOL ASSAY FOR Clostridium difficilefi TOXIN MAY BE HELPFUL DIAGNOSTICALLY. WHEN SIGNIFICANT DIARRHEA OCCURS, THE DRUG SHOULD BE DISCONTINUED. LARGE BOWEL ENDOSCOPY SHOULD BE CONSIDERED TO ESTABLISH A DEFINITIVE DIAGNOSIS IN CASES OF SEVERE DIARRHEA. ANTIPERISTALTIC AGENTS SUCH AS OPIATES AND DIPHENOXYLATE WITH ATROPINE MAY PROLONG AND/OR WORSEN THE CONDITION. DIARRHEA, COLITIS AND PSEUDOMEMBRANOUS COLITIS HAVE BEEN OBSERVED TO BEGIN UP TO SEVERAL WEEKS FOLLOWING CESSATION OF ORAL AND PARENTERAL THERAPY WITH CLINDAMYCIN. Mild cases of pseudomembranous colitis usually respond to drug discontinuation alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation and treatment with an antibacterial drug clinically effective against Clostridium difficil5e colitis. PRECAUTIONS General: For dermatological use only; not for ophthalmic use. Concomitant topical acne therapy should be used with caution because a possible cumulative irritancy effect may occur, especially with the use of peeling, desquamating, or abrasive agents. The use of antibiotic agents may be associated with the overgrowth of nonsusceptible organisms, including fungi. If this occurs, discontinue use of this medication and take appropriate measures. Avoid contact with eyes and mucous membranes. Clindamycin and erythromycin containing products should not be used in combination. In vitro studies have shown antagonism between these two antimicrobials. The clinical significance of this in vitro antagonism is not known. Information for Patients: Patients using DUAC Topical Gel should receive the following information and instructions: 1. DUAC Topical Gel is to be used as directed by the physician. It is for external use only. Avoid contact with eyes, and inside the nose, mouth, and all mucous membranes, as this product may be irritating. 2. This medication should not be used for any disorder other than that for which it was prescricbed. 3. Patients should not use any other topical acne preparation unless otherwise directed byc their physician. 4. Patients should report any signs of local adverse reactions to their physician. Patients who develop allergic symptoms such as severe swelling or shortness of breath should discontinue use and contact their physician immediately. 5. DUAC Topical Gel may bleach hair or colored fabric. 6. DUAC Topical Gel can be stored at room temperature up to 25°C (77°F) for up to 2 months. Do not freeze. Keep tube tightly closed. Keep out of the reach of small children. Discard any unused product after 2 months. 7. Before applying DUAC Topical Gel to affected areas, wash the skin gently, rinse with warm water, and pat dry. 8. Excessive or prolonged exposure to sunlight should be limited. To minimize exposure to sunlight, a hat or other clothing should be worn. Carcinogenesis, Mutagenesis, Impairment of Fertility: Benzoyl peroxide has been shown to be a tumor promoter and progression agent in a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg administered twice per week induced squamous cell skin tumors in transgenic TgAC mice in a study using 20 weeks of topical treatment. The clinical significance of this is unknown. In a 2-year dermal carcinogenicity study in mice, treatment with DUAC Topical Gel at doses up to 8000 mg/kg/day (16 times the highest recommended adult human dose of 2.5 g DUAC Topical Gel, based on mg/m2) did not cause an increase in skin tumors. However, topical treatment with another formulation containing 1% clindamycin and 5% benzoyl peroxide at doses of 100, 500, or 2000 mg/kg/day caused a dose-dependent increase in the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal carcinogenicity study in rats. In a 52-week photocarcinogenicity study in hairless mice (40 weeks of treatment followed by 12 weeks of observation), the median time to onset of skin tumor formation decreased and the number of tumors per mouse increased relative to controls following chronic concurrent topical treatment with DUAC Topical Gel and exposure to ultraviolet radiation. Genotoxicity studies were not conducted with DUAC Topical Gel. Clindamycin phosphate was not genotoxic in Salmonella typhimuri5um or in a rat micronucleus test. Benzoyl peroxide has been found to cause DNA strand breaks in a variety of mammalian cell types, to be mutagenic in Salmonella typhimuri5um tests by some but not all investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells. Studies have not been performed with DUAC Topical Gel or benzoyl peroxide to evaluate the effect on fertility. Fertility studies in rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times the amount of clindamycin in the highest recommended adult human dose of 2.5 g DUAC Topical Gel, based on mg/m2) revealed no effects on fertility or mating ability. Pregnancy: Teratogenic Effects: Pregnancy Category C: Animal reproduction studies have not been conducted with DUAC Topical Gel or benzoyl peroxide. It is also not known whether DUAC Topical Gel can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. DUAC Topical Gel should be given to a pregnant woman only if clearly needed. Developmental toxicity studies performed in rats and mice using oral doses of clindamycin up to 600 mg/kg/day (240 and 120 times the amount of clindamycin 2 in the highest recomcmended adult human docse based on mg/m , respectively) or subcutaneous doses of clindamycin up to 250 mg/kg/day (100 and 50 times the amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) revealed no evidence of teratogenicity. Nursing Women: It is not known whether DUAC Topical Gel is secreted into human milk after topical application. However, orally and parenterally administered clindamycin has been reported to appear in breast milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of this product in pediatric patients below the age of 12 have not been established. ADVERSE REACTIONS During clinical trials, all patients were graded for facial erythema, peeling, burning, and dryness on the following scale: 0 = absent, 1 = mild, 2 = moderate, and 3 = severe. The percentage of patients that had symptoms present before treatment (at baseline) and during treatment were as follows: Local reactions witMh use of DUAC TopiMcal Gel % of patients usinMg DUAC Topical GelM with symptom presMent Combined results fMrom 5 studies (n =M 397) Before Treatment (Baseline) During Treatment Mild Moderate Severe Mild Moderate Severe Erythema 28% 3% 0 26% 5% 0 Peeling 6% <1% 0 17% 2% 0 Burning 3% <1% 0 5% <1% 0 Dryness 6% <1% 0 15% 1% 0 (Percentages derived by # subjects with symptom score/# enrolled DUAC Topical Gel subjects, n = 397). Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported in post-marketing use with DUAC Topical Gel. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. ©2010 Stiefel Laboratories, Inc. DUA:2BRS January 2011 ©2011 Stiefel Laboratories, Inc. All rights reserved. Printed in USA. DUA063R0 March 2011 management insights BY RACHNA CHAUDHARI Navigating CMS incentives, penalties, and deadlines EACH MONTH DERMATOLOGY WORLD tackles issues “in Practice” for dermatologists. This month Rachna Chaudhari, the Academy’s practice management manager, offers tips on an area she commonly receives questions about from members. answers in practice Once providers begin e-prescribing, they will have to notify CMS by reporting G8553 on their Medicare claim form in box 24D at least 10 times for each provider before June 30, 2011 and 15 additional times before Dec. 31, 2011. An E/M code must be also listed on the claim form for the same date of service as the e-prescribing code. If reporting is successful, the providers in the practice are eligible to earn a 1 percent incentive on their total Medicare Part B allowed charges for this year and will avoid a 1 percent penalty in 2012 and a 1.5 percent penalty in 2013. (A penalty of 2 percent is scheduled for subsequent years for non-e-prescribers.) There are some exemptions available to dermatologists; more information is available at www.aad.org/hitkit. EHR INCENTIVE PROGRAM ermatology practices today face constant pressure to keep up to date with regulatory changes in an environment of increased administrative burdens and decreased revenue. This article will outline the most important changes in the next several years. Most of the regulatory changes are due to laws passed by Congress, which are later overseen by the Centers for Medicare and Medicaid Services (CMS). There are four distinct CMS incentive programs that all dermatology practices need to understand: • the Electronic Prescribing (eRx) Incentive Program, • the Electronic Health Record (EHR) Incentive Program, • the Maintenance of Certification (MOC) Incentive Program, and • the Physician Quality Reporting System (PQRS), formerly known as PQRI. CMS has structured these programs so they operate independently of each other. Thus, as a practice, you must participate in each program if you wish to receive the incentive and avoid a penalty in the future. D E-PRESCRIBING INCENTIVE PROGRAM The eRx Incentive Program is the first to be implemented, with the penalty for not participating starting Jan. 1, 2012. All dermatology practices should be aware of this and begin e-prescribing immediately if they do not meet any of the exclusion criteria for the program. Providers, including physician assistants and nurse practitioners, who do not have at least 100 eligible cases, mostly encounters coded as office visits, will automatically be excluded from the program’s penalties. Providers who practice in a rural area without sufficient high-speed Internet access can report the code G8642 to be excluded; providers who practice in an area without sufficient access to pharmacies that accept electronic prescriptions can report the code G8643. To begin e-prescribing, providers can either purchase a stand-alone e-prescribing software system or use an EHR with an e-prescribing component integrated within it. If you do not currently have an EHR in your practice, you can visit www.getrxconnected.org/aad to search for standalone e-prescribing products or use a free e-prescribing system at www. nationalerx.com. (The free system does not provide technical support.) The EHR Incentive Program is significantly more complex than the e-prescribing incentive program. Only physicians are eligible, and they must meet several requirements to obtain the $44,000 in incentive funds, including: • using a certified system (a list of certified systems is available at http://onc-chpl.force. com/ehrcert), • using their system in a meaningful way (which will be determined through the reporting of various measures), and • reporting clinical quality measures. Dermatologists can register for the EHR Incentive Program on the CMS website at www.cms.gov/EHRIncentivePrograms/20_ RegistrationandAttestation.asp, and will only need to perform the required measures for 90 days in the first year of reporting. Thus, a provider would need to begin using certified EHR technology in a meaningful way by Oct. 1, 2011 to receive the incentive funds this year. For a full list of the measures you will be required to report and more information, visit www.aad. org/hitkit. MOC INCENTIVE PROGRAM The MOC Incentive Program requires dermatologists to meet certain guidelines through the American Board of Dermatology to obtain the 0.5 percent incentive available from now until 2014. These guidelines include participating in an MOC program, completing additional CME, participating in an approved registry, attesting that they will complete the MOC DERMATOLOGY WORLD // June 2011 15 answers in practice management insights PQRS MELANOMA MEASURES Measure #137 – Melanoma: Continuity of Care – Recall System Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12-month period, into a recall system that includes: • A target date for the next complete physical skin exam • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment Measure #138 – Melanoma: Coordination of Care Percentage of patient visits, regardless of patient age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis. Measure #224 – Melanoma: Overutilization of Imaging Studies in Stage 0-IA Melanoma Percentage of patients, regardless of age, with Stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies have been ordered related to the melanoma diagnosis. exam, and completing a qualified MOC practice assessment. In addition to these objectives, providers would also have to participate in the PQRS program in the same year. Visit the ABD website at www.abderm.org for more information. For more on the Academy’s MOC-D resources, visit www.aad.org/educationand-quality-care/moc-d. PQRS PROGRAM PQRS allows physicians to be eligible for a bonus payment of 1 percent of their total Medicare Part B allowed charges if they report on at least three quality measures in 2011. Dermatologists can report on melanoma measures 137, 138, and 224, which measure whether providers have a recall system for melanoma patients, how care is coordinated with the physician providing continuing care, and how often imaging studies are ordered for asymptom- June 30, 2011: Deadline to submit e-prescribing information to CMS to avoid penalty in 2012 Dec. 16, 2011: Deadline to register for the AAD PQRS registry to obtain bonus for 2011 Oct. 1, 2011: Deadline to register for the EHR Incentive Program to obtain incentive dollars in 2011 16 DERMATOLOGY WORLD // June 2011 atic stage 0 or 1A melanoma patients. Descriptions of each measure appear in the sidebar above; they reflect recommendations that are also included in the Academy’s guidelines of care for melanoma. The PQRS measures can be reported only through a qualified electronic registry. If dermatologists choose to report on the three melanoma measures, they must report on at least 80 percent of their eligible patients for measures 137 and 224, and on at least 80 percent of their eligible visits for measure 138. Each of the quality measures must have at least one eligible instance for a dermatologist to qualify for the incentive. Since the only applicable diagnosis for measure 138 is a new diagnosis of melanoma, dermatologists must see at least one patient with a new diagnosis of melanoma (who is also a Medicare patient) in order to report measure 138 Dec. 31, 2011: Deadline to participate in the MOC incentive program to obtain bonus for 2011 Dec. 31, 2011: Deadline to attest for the EHR Incentive Program for participation in 2011 Jan. 1, 2012: E-prescribing penalty of 1% goes into effect Jan. 1, 2012: Deadline to adopt HIPAA 5010 standards successfully. Additionally, you must successfully meet the measure for at least one patient per measure. The Academy continues to provide practice support by offering an online reporting registry — the Quality Reporting System (QRS) — for members to report their PQRS data to CMS. Participants will be able to choose either a one-year reporting period, Jan. 1 – Dec. 31, 2011, or a six-month reporting period, July 1 – Dec. 31, 2011. The incentive will be based only on claims filed during the chosen reporting period. The final day to purchase the Academy’s registry ($249) will be Dec. 16, 2011 and the final day to enter and submit all data into the registry is Jan. 31, 2012. All associated claims must be processed by the end of February 2012. Visit www.aad.org/QRS to read more about the quality measures or purchase the 2011 Physician Quality Reporting System Melanoma Reporting module. HIPAA 5010 In addition to the programs instituting incentives and penalties through Medicare, CMS has also made significant regulatory changes to HIPAA. Beginning Jan. 1, 2012, all entities in the health care industry that submit electronic claims will have to operate under a new technical version labeled 5010 to process all claims, remittance advice, referrals, eligibility standards, and authorizations. This change will require installing an update to your practice management software system to allow the practice to operate under the new technical standards. Practices need to be aware of this update since claims will not be processed after Jan. Oct. 1, 2012: Deadline to register for the EHR Incentive Program to obtain the maximum incentive dollars Jan. 31, 2012: Deadline to submit PQRS measures to AAD registry Jan. 1, 2013: E-prescribing penalty of 1.5% goes into effect Dec. 31, 2012: Deadline to attest for the EHR Incentive Program for the maximum incentive dollars www.aad.org answers in practice management insights OVERALL CMS INCENTIVES AVAILABLE TO PROVIDERS 1, 2012 if the update is not installed. Additionally, minor data changes may be required on all claims since the 5010 standards require providers to list a physical address for their billing address instead of a post office box, submit nine-digit ZIP codes, and list an NPI number for all providers. Your practice management system may also require additional data entries. Practices should contact their vendors immediately to formulate a plan of action in advance of the implementation date of Jan. 1, 2012. (For more information on the 5010 transition, see p. 18.) PQRS Incentive* MOC Incentive* Total Incentives Available 2011 $44,000 (dispersed over a 5 year period) 1% 1% 0.5% 2.5% OR $44,000 + 1.5% 2012 $44,000 (dispersed over a 5 year period) 1% 0.5% 0.5% 2% OR $44,000 + 1% 2013 $39,000 (dispersed over a 4 year period) 0.5% 0.5% 0.5% 1.5% OR $39,000 + 1% 2014 $24,000 (dispersed over a 3 year period) 0% 0.5% 0.5% 1% + $24,000 OVERALL CMS PENALTIES APPLICABLE TO PROVIDERS Year EHR Penalty E-Prescribing Penalty PQRS Penalty Total Penalties 2012 0% 1% 0% 1% 2013 0% 1.5% 0% 1.5% 2014 0% 2% 0% 2% 2015 1% 2% 1.5% 4.5% 2016 2% 2% 2% 6% 2017 and beyond 3% 2% 2% 7% Percentages based on Medicare Part B allowed charges. Despite the differences between the two classification systems, however, the coding process is the same. Starting Oct. 1, 2013, health care claims will be submitted to payers using ICD-10-CM diagnosis codes. ICD-10-CM will have a significant impact on dermatologists. There will be changes involving claims software programs, fee schedules and contracts, coding documentation, claim forms, and superbills. Physicians and staff will need to be trained on all of the new coding guidelines as well as Jan. 1, 2014: E-prescribing penalty of 2% goes into effect permanently Dec. 31, 2013: Deadline to attest for the EHR Incentive Program for 2013 incentive dollars eRx Incentive* Percentages based on Medicare Part B allowed charges. *EHR and e-prescribing incentive cannot be combined. Providers must select one program to participate in. ICD-10 Oct. 1, 2013: Deadline to adopt ICD-10-CM standards EHR Incentive* The most significant regulatory change to affect medical practices in the next several years will be the implementation of ICD-10-CM. ICD-10-CM will replace the current ICD-9-CM code system for all diagnosis codes. ICD-10-CM consists of more than 68,000 codes, compared to the approximately 13,000 ICD-9-CM codes. This will allow for greater granularity, more specificity, and enough clinical detail to provide information for clinical decision making and outcomes research. ICD-10 codes are three to seven characters in length, with the first character being alpha, the second numeric, and the third through seventh either alpha or numeric. The first three characters have common traits, and each additional character adds specificity. ICD-10’s alphanumeric system allows for the creation of a post-procedural category, description of which side of the body is affected, and other factors that can affect health (e.g., lifestyle, socioeconomic, family relationships). Oct. 1, 2013: Deadline to register for the EHR Incentive Program for 2013 incentive dollars Year Dec. 31, 2014: Deadline to attest for the EHR Incentive Program to obtain minimum incentive dollars Oct. 1, 2014: Deadline to register for the EHR Incentive Program to obtain minimum incentive dollars documentation standards. Productivity will be affected when the ICD-10-CM code set goes into effect, so it is to the practice’s benefit to be as prepared as possible. The Academy plans to release additional educational materials, training webinars, and other resources to aid practices in their preparation. (For more information on the ICD-10 transition, see p. 18.) For further assistance with any of these topics, email [email protected]. Cindy Bracy, Alison Shippy, and Scott Weinberg contributed to this column. dw Jan. 1, 2015: EHR penalty of 1% goes into effect Jan. 1, 2015: PQRS penalty of 1.5% goes into effect Jan. 1, 2016: EHR penalty of 2% goes into effect Jan. 1, 2016: PQRS penalty of 2% goes into effect permanently Jan. 1, 2017: EHR penalty of 3% goes into effect permanently DERMATOLOGY WORLD // June 2011 17 BY JOHN CARRUTHERS, STAFF WRITER A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A00 A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A00 A01 A02 A03 A04 A0 8 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B21 B22 B23 B24 B 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C4 D58 D59 D60 D61 D62 D63 D64 D65 D66 D67 D68 D69 D70 D71 D72 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N19 N20 N21 N22 N23 N24 N 3 O44 O45 O46 O47 O48 O49 O50 O51 O52 O53 O54 O55 O56O43 O44 O45 O46 O47 O48 O49 O50 O51 O52 O53 O54 O55 O56O43 O44 O45 O46 O4 P58 P59 P60 P61 P62 P63 P64 P65 P66 P67 P68 P69 P70 P71 P72 P73 P74 P75P57 P58 P59 P60 P61 P62 P63 P64 P65 P66 P67 P68 P69 P70 P71 P72 P73 P74 P75P57 P58 P59 P60 P61 P62 01 Q02 Q03 Q04 Q05 Q06 Q07 Q08 Q09 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18 Q19 Q20 Q21 Q22 Q23 Q00 Q01 Q02 Q03 Q04 Q05 Q06 Q07 Q08 Q09 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18 Q19 Q20 Q21 Q22 Q23 Q00 Q01 Q02 Q03 Q04 Q05 Q06 Q0 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 R39 R40 R41 R42 R43R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 R39 R40 R41 R42 R43R24 R25 R26 R27 R28 R29 R S45 S46 S47 S48 S49 S50 S51 S52 S53 S54 S55 S56 S57 S58 S59 S60 S61 S44 S45 S46 S47 S48 S49 S50 S51 S52 S53 S54 S55 S56 S57 S58 S59 S60 S61 S44 S45 S46 S47 S48 S49 1 T02 T03 T04 T05 T06 T07 T08 T09 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 T21 T22 T23 T24 T25 T26 T27 T00 T01 T02 T03 T04 T05 T06 T07 T08 T09 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 T21 T22 T23 T24 T25 T26 T27 T00 T01 T02 T03 T04 T05 T06 T07 T08 8 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U3 8 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U V43 V44 V45 V46 V47 V48 V49 V50 V51 V52 V53 V54 V55 V56 V57 V58 V59 V60 V61 V42 V43 V44 V45 V46 V47 V48 V49 V50 V51 V52 V53 V54 V55 V56 V57 V58 V59 V60 V61 V42 V43 V44 V45 V46 V47 V W01 W02 W03 W04 W05 W06 W07 W08 W09 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21W00 W01 W02 W03 W04 W05 W06 W07 W08 W09 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21W00 W01 W02 W03 W04 W05 W0 X23 X24 X25 X26 X27 X28 X29 X30 X31 X32 X33 X34 X35 X36 X37 X38 X39 X40 X41 X42 X22 X23 X24 X25 X26 X27 X28 X29 X30 X31 X32 X33 X34 X35 X36 X37 X38 X39 X40 X41 X42 X22 X23 X24 X25 X26 X27 X Y44 Y45 Y46 Y47 Y48 Y49 Y50 Y51 Y52 Y53 Y54 Y55 Y56 Y57 Y58 Y59 Y60 Y61Y43 Y44 Y45 Y46 Y47 Y48 Y49 Y50 Y51 Y52 Y53 Y54 Y55 Y56 Y57 Y58 Y59 Y60 Y61Y43 Y44 Y45 Y46 Y47 Y48 01 Z02 Z03 Z04 Z05 Z06 Z07 Z08 Z09 Z10 Z11 Z12 Z13 Z14 Z15 Z16 Z17 Z18 Z19 Z20 Z21 Z22 Z23 Z24 Z25 Z26 Z27Z00 Z01 Z02 Z03 Z04 Z05 Z06 Z07 Z08 Z09 Z10 Z11 Z12 Z13 Z14 Z15 Z16 Z17 Z18 Z19 Z20 Z21 Z22 Z23 Z24 Z25 Z26 Z27Z00 Z01 Z02 Z03 Z04 Z05 Z06 Z07 Z0 A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A00 A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14 A15 A16 A00 A01 A02 A03 A04 A 18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B21 B22 B23 B24 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C D58 D59 D60 D61 D62 D63 D64 D65 D66 D67 D68 D69 D70 D71 D72 D73 D74 D57 D58 D59 D60 D61 D62 D63 D64 D65 D66 D67 D68 D69 D70 D71 D72 D73 D74 D57 D58 D59 D60 D61 D6 E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E13 E14 E15 E16 E17 E18 E19 E20 E21 E22 E23 E00 E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E13 E14 E15 E16 E17 E18 E19 E20 E21 E22 E23 E00 E01 E02 E03 E04 E05 E06 E F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43 F44 F24 F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43 F44 F24 F25 F26 F27 F28 F29 F3 G46 G47 G48 G49 G50 G51 G52 G53 G54 G55 G56 G57 G58 G59 G60 G61 G45 G46 G47 G48 G49 G50 G51 G52 G53 G54 G55 G56 G57 G58 G59 G60 G61 G45 G46 G47 G48 G49 G 63 H64 H65 H66 H67 H68 H69 H70 H71 H72 H73 H74 H75 H76 H77 H78 H79 H80 H81 H82 H83 H84 H85 H86 H87 H62 H63 H64 H65 H66 H67 H68 H69 H70 H71 H72 H73 H74 H75 H76 H77 H78 H79 H80 H81 H82 H83 H84 H85 H86 H87 H62 H63 H64 H65 H66 H67 H68 H69 I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15 I16 I00 I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15 I16 I00 I01 I02 I03 I04 I J18 J19 J20 J21 J22 J23 J24 J25 J26 J27 J28 J29 J30 J31 J32 J33 J34 J35 J36J17 J18 J19 J20 J21 J22 J23 J24 J25 J26 J27 J28 J29 J30 J31 J32 J33 J34 J35 J36J17 J18 J19 J20 J21 J22 J K38 K39 K40 K41 K42 K43 K44 K45 K46 K47 K48 K49 K50 K51 K52 K53 K54 K55 K56 K57 K58 K59 K60 K37 K38 K39 K40 K41 K42 K43 K44 K45 K46 K47 K48 K49 K50 K51 K52 K53 K54 K55 K56 K57 K58 K59 K60 K37 K38 K39 K40 K41 K42 K43 K L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80 L81L61 L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80 L81L61 L62 L63 L64 L65 L66 L6 Physicians and practice managers stress early preparation for looming 5010 and ICD-10 deadlines M11 18 DERMATOLOGY WORLD // June 2011 G40 on the horizon E64 U85 www.aad.org M06 D53 F F88 J73 or physicians and practice managers, the upcoming required transition to the 5010 version of the HIPAA transaction code sets and the ICD-10-CM diagnosis codes is a matter of vital importance. The interlinked transition will require a great deal of work on the part of physicians — especially those in smaller practices that may not have an abundance of resources to devote to educating their office managers and coders. The 5010 standards must be met by Jan. 1, 2012, and lead directly to the mandatory adoption of the new ICD-10 code set by Oct. 1, 2013. Working with vendors, pursuing early education, and creating a transition plan foru staff will prove cruitical for an uninterruputed transition. >> DERMATOLOGY WORLD // June 2011 19 X You Spoke. We Listened. Your feedback is critical to the success of the programs and services the AAD offers to members. Because of your comments, the AAD’s flagship publication, Dermatology World, has been enhanced to provide even more trustworthy information to help you navigate practice, policy, and patient care. As a member you can move mountains. Your feedback today can help us generate ideas for future issues of Dermatology World as we continue to strive to serve you better. We are still listening. Tell us what you think about the new Dermatology World and be entered for a chance to win a $500 Visa Gift Card. Click on the DW logo at the right to tell us what you think! You Spoke. We Listened. Your feedback is critical to the success of the programs and services the AAD offers to members. Because of your comments, the AAD’s flagship publication, Dermatology World, has been enhanced to provide even more trustworthy information to help you navigate practice, policy, and patient care. As a member you can move mountains. Your feedback today can help us generate ideas for future issues of Dermatology World as we continue to strive to serve you better. We are still listening. Tell us what you think about the new Dermatology World and be entered for a chance to win a $500 Visa Gift Card. Click on the DW logo at the right to tell us what you think! D02 N14 A00 A01 A02 A03 A0 4 A A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 A00 A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 B42B18 B19 B20 B2 1 B22 B23 B24 8 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B2 1 B22 B23 B24 B25 B26 B27 B28 B29 B3 0 B31 B32 B33 B34 B35 B36 B37 B38 B3 9 B40 B41B17 O26 E13 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C4 D58 D59 D60 D6 1 D62 D63 D64 D65 D66 D67 D68 D69 D7 0 D71 D72 D73 D74 D57 D58 D59 D60 D6 1 D62 D63 D64 D65 D66 D67 D68 D69 D7 0 D71 D72 D73 D74 D57 D58 D59 D60 D6 1 D 01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E 13 E14 E15 E16 E17 E18 E19 E20 E21 E 22 E23 E00 E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E 13 E14 E15 E16 E17 E18 E19 E20 E21 E 22 E23 E00 E01 E02 E03 E04 E05 E06 E0 F25 F26 F27 F28 F29F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43 F24 F44 F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43F24 F44F25 F26 F27 F28 F29 F G46 G47 G48 G4 9 G50 G51 G52 G53 G54 G55 G56 G57 G5 8 G59 G60 G61 G45 G46 G47 G48 G4 9 G50 G51 G52 G53 G54 G55 G56 G57 G5 8 G59 G60 G61 G45 G46 G47 G48 G4 9 G 63 H64 H65 H6 6 H67 H68 H69 H70 H71 H72 H73 H74 H7 5 H76 H77 H78 H79 H80 H81 H82 H83 H8 4 H85 H86H62H87H63 H64 H65 H6 6 H67 H68 H69 H70 H71 H72 H73 H74 H7 5 H76 H77 H78 H79 H80 H81 H82 H83 H8 4 H85 H86H62H87H63 H64 H65 H6 6 H67 H68 H69 I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15I00 I16I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15I00 I16I01 I02 I03 I04 J18 J19 J20 J2 1 J22 J23 J24 J25 J26 J27 J28 J29 J3 0 J31 J32 J33 J34 J35J17 J36J18 J19 J20 J2 1 J22 J23 J24 J25 J26 J27 J28 J29 J3 0 J31 J32 J33 J34 J35J17 J36J18 J19 J20 J2 1 J22 38 K39 K40 K4 1 K42 K43 K44 K45 K46 K47 K48 K49 K5 0 K51 K52 K53 K54 K55 K56 K57 K58 K5 K37 9 K60 K38 K39 K40 K4 1 K42 K43 K44 K45 K46 K47 K48 K49 K5 0 K51 K52 K53 K54 K55 K56 K57 K58 K5 K37 9 K60 K38 K39 K40 K4 1 K42 K43 K L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80L61 L81L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80L61 L81L62 L63 L64 L65 L66 L M02 M03 M04 M0 5 M06 M07 M08 M09 M10 M11 M12 M13 M1 4 M15 M16 M01 M02 M03 M04 M0 5 M06 M07 M08 M09 M10 M11 M12 M13 M1 4 M15 M16 M01 M02 M03 M04 M0 5 18 N19 N20 N2 1 N22 N23 N24 N25 N26 N27 N28 N29 N3 0 N31 N32 N33 N34 N35 N36 N37 N38 N3 9 N40 N41N17 N42N18 N19 N20 N2 1 N22 N23 N24 N25 N26 N27 N28 N29 N3 0 N31 N32 N33 N34 N35 N36 N37 N38 N3 9 N40 N41N17 N42N18 N19 N20 N2 1 N22 N23 N24 3 O44 O45 O46 O47 O48 O49 O50 O51 O52 O53 O54 O55 O56 O43 O44 O45 O46 O47 O48 O49 O50 O51 O52 O53 O54 O55 O56 O43 O44 O45 O46 O4 P58 P59 P60 P6 1 P62 P63 P64 P65 P66 P67 P68 P69 P7 0 P71 P72 P73 P74 P57 P75P58 P59 P60 P6 1 P62 P63 P64 P65 P66 P67 P68 P69 P7 0 P71 P72 P73 P74 P57 P75P58 P59 P60 P6 1 P62 01 Q02 Q03 Q0 4 Q05 Q06 Q07 Q08 Q09 Q10 Q11 Q12 Q1 3 Q14 Q15 Q16 Q17 Q18 Q19 Q20 Q21 Q2 Q00 2 Q23 Q01 Q02 Q03 Q0 4 Q05 Q06 Q07 Q08 Q09 Q10 Q11 Q12 Q1 3 Q14 Q15 Q16 Q17 Q18 Q19 Q20 Q21 Q2 Q00 2 Q23 Q01 Q02 Q03 Q0 4 Q05 Q06 Q Y39 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 R39 R40 R41 R42R24 R43R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 R39 R40 R41 R42R24 R43R25 R26 R27 R28 R29 S45 S46 S47 S4 8 S49 S50 S51 S52 S53 S54 S55 S56 S5 7 S58 S59 S60 S44 S61 S45 S46 S47 S4 8 S49 S50 S51 S52 S53 S54 S55 S56 S5 7 S58 S59 S60 S44 S61 S45 S46 S47 S4 8 S4 1 T02 T03 T0 4 T05 T06 T07 T08 T09 T10 T11 T12 T1 3 T14 T15 T16 T17 T18 T19 T20 T21 T2 2 T23 T24 T25 T26 T00 T27 T01 T02 T03 T0 4 T05 T06 T07 T08 T09 T10 T11 T12 T1 3 T14 T15 T16 T17 T18 T19 T20 T21 T2 2 T23 T24 T25 T26 T00 T27 T01 T02 T03 T0 4 T05 T06 T07 T0 8 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U3 8 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U V43 V44 V45 V4 6 V47 V48 V49 V50 V51 V52 V53 V54 V5 5 V56 V57 V58 V59 V60V42 V61V43 V44 V45 V4 6 V47 V48 V49 V50 V51 V52 V53 V54 V5 5 V56 V57 V58 V59 V60V42 V61V43 V44 V45 V4 6 V47 W01 W02 W03 W0 4 W05 W06 W07 W08 W09 W10 W11 W12 W1 3 W14 W15 W16 W17 W18 W19 W20W00 W21W01 W02 W03 W0 4 W05 W06 W07 W08 W09 W10 W11 W12 W1 3 W14 W15 W16 W17 W18 W19 W20W00 W21W01 W02 W03 W0 4 W05 W X23 X24 X25 X26 X27 X28 X29 X30 X31 X32 X33 X34 X35 X36 X37 X38 X39 X40 X41X22 X42X23 X24 X25 X26 X27 X28 X29 X30 X31 X32 X33 X34 X35 X36 X37 X38 X39 X40 X41X22 X42X23 X24 X25 X26 X27 X E36 B99 L20 A62 Y44 Y45 Y46 Y4 7 Y48 Y49 Y50 Y51 Y52 Y53 Y54 Y55 Y5 6 Y57 Y58 Y59 Y60 Y43 Y61Y44 Y45 Y46 Y4 7 Y48 Y49 Y50 Y51 Y52 Y53 Y54 Y55 Y5 6 Y57 Y58 Y59 Y60 Y43 Y61Y44 Y45 Y46 Y4 7 Y4 01 Z02 Z03 Z0 4 Z05 Z06 Z07 Z08 Z09 Z10 Z11 Z12 Z1 3 Z14 Z15 Z16 Z17 Z18 Z19 Z20 Z21 Z2 2 Z23 Z24 Z25 Z26 Z00 Z27 Z01 Z02 Z03 Z0 4 Z05 Z06 Z07 Z08 Z09 Z10 Z11 Z12 Z1 3 Z14 Z15 Z16 Z17 Z18 Z19 Z20 Z21 Z2 2 Z23 Z24 Z25 Z26 Z00 Z27 Z01 Z02 Z03 Z0 4 Z05 Z06 Z07 Z A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 A00 A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 A00 A01 A02 A03 A0 4 18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B2 1 B22 B23 B24 B25 B26 B27 B28 B29 B3 0 B31 B32 B33 B34 B35 B36 B37 B38 B3 9 B40 B41B17 B42B18 B19 B20 B2 1 B22 B23 B2 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C D58 D59 D60 D6 1 D62 D63 D64 D65 D66 D67 D68 D69 D7 0 D71 D72 D73 D74 D57 D58 D59 D60 D6 1 D62 D63 D64 D65 D66 D67 D68 D69 D7 0 D71 D72 D73 D74 D57 D58 D59 D60 D6 1 D E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E 13 E14 E15 E16 E17 E18 E19 E20 E21 E 22 E23 E00 E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E 13 E14 E15 E16 E17 E18 E19 E20 E21 E 22 E23 E00 E01 E02 E03 E04 E05 E06 E F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43F24 F44F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43F24 F44F25 F26 F27 F28 F29 G46 G47 G48 G4 9 G50 G51 G52 G53 G54 G55 G56 G57 G5 8 G59 G60 G61 G45 G46 G47 G48 G4 9 G50 G51 G52 G53 G54 G55 G56 G57 G5 8 G59 G60 G61 G45 G46 G47 G48 G4 9 63 H64 H65 H6 6 H67 H68 H69 H70 H71 H72 H73 H74 H7 5 H76 H77 H78 H79 H80 H81 H82 H83 H8 4 H85 H86H62H87H63 H64 H65 H6 6 H67 H68 H69 H70 H71 H72 H73 H74 H7 5 H76 H77 H78 H79 H80 H81 H82 H83 H8 4 H85 H86H62H87H63 H64 H65 H6 6 H67 H68 H6 I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15I00 I16I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15I00 I16I01 I02 I03 I04 J18 J19 J20 J2 1 J22 J23 J24 J25 J26 J27 J28 J29 J3 0 J31 J32 J33 J34 J35J17 J36J18 J19 J20 J2 1 J22 J23 J24 J25 J26 J27 J28 J29 J3 0 J31 J32 J33 J34 J35J17 J36J18 J19 J20 J2 1 J22 K38 K39 K40 K4 1 K42 K43 K44 K45 K46 K47 K48 K49 K5 0 K51 K52 K53 K54 K55 K56 K57 K58 K5 K37 9 K60 K38 K39 K40 K4 1 K42 K43 K44 K45 K46 K47 K48 K49 K5 0 K51 K52 K53 K54 K55 K56 K57 K58 K5 K37 9 K60 K38 K39 K40 K4 1 K42 K43 L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80L61 L81L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80L61 L81L62 L63 L64 L65 L66 G62 P87 Q57 W29 vendors — including practice management software providers, clearinghouses, and health insurance payers — in advance of the The upcoming transition to 5010 entails a change to the electronic 5010 switchover. They are ultimately the ones responsible for data transaction standards under HIPAA, replacing the current implementing the necessary updates. Vendors, she said, should 4010 standards. It affects every practice that electronically submits have already started testing by the beginning of 2010. HIPAA transactions including patient eligibility checks, claims filing, or receiving Hremittance advice H— whether directly Hto an insur- “For practice owners, their vendor is going to be their primary focus in terms of making sure that their practice management ance provider or through a clearinghouse. The 5010 transition is system is updated with whatever changes are needed,” Amatayakul aimed at fixing a number of technical issues identified under 4010 said. “If they have not heard from their vendor, then they should and making more billing and insurance information available to health care provideHrs. Additionally, tHhe adoption of theH new ICD-contact them as soHon as possible.” “If they are using a clearinghouse or billing service, they 10 code set — mandatory October 2013 — cannot happen until should be in touch with them to make sure they know what they’re the 5010 standards have been adopted. The relatively short period doing. I think that for the average physician, that’s probably not of time between the two deadlines highlights the need to prepare going to be an enormous deal, but they do need to make sure that oneself and one’s pHractice as early asH possible. something is happening. They don’t want to have their claims With a great deal of billing work done electronically, delayed because they’re not in compliance [with 5010] by Jan. 1 of practice management consultant Margret Amatayakul stresses next year. I think that’s probably sufficient for most practices.” the importance of clear and frequent communication with Melinda Lomax, executive committee member for the Association of Dermatology Administrators and Managers (ADAM), agreed, saying that the importance of confirming that the vendor and practice are both 100 percent prepared on Jan. 1 cannot be overstated. “The first thing I think we need to do now is communicate with our software vendors and practice management people and make sure they’re testing for 5010 now,” she said. “Will they be Jan. 1, 2012: Use of 5010 version of the HIPAA Transactions ready to transmit/Hsubmit by Jan. 1 of Hnext year?” Reston, Va., dermatologist Maithily Nandedkar, M.D., said that and Code Sets required. she relies extensively on the vendor to see her practice through the vital 5010 transition, as the demands of her small practice leave Oct. 1, 2012: A National Health Plan Identifier Number must her and her employees little time to grapple with the minutiae of be adopted. This will give practices better information about the transition. who to contact for claims processing information. “It’s just making the time to deal with the change,” Dr. Nandedkar said. “We are relying heavily on our vendor. Luckily, Jan. 1, 2013: New operating rules for eligibility and claims they’re very much on top of the situation. What I’ve learned is that status transactions go into effect. These rules address the you’ve got to ask,H not assume. That’Hs a lesson learned Hfor me.” electronic exchange of information, and will be standardized EDUCATING YOUR PRACTICDE ON ICD-10 across health plans. Coupled with 5010, this set of regulaFollowing the transition to the 5010 transaction standards, tions will enable easier real-time transactions. The following practices will be able to pursue adoption of the ICD-10 code set, transaction sets will be affected: which replaces ICD-9, volumes I and II. As the first complete revision of the ICD-9 code set in 30 years, the transition may seem • 837 — Claims/Encounter intimidating to physicians who are used to previous revisions. But • 835 — Claim Payment/Remittance Advice according to Lomax, the changes for dermatology are minor — • 270/271 — Eligibility Inquiry/Response especially in compaHrison to other speHcialties. • 276/277 — Claim Status Request/Response “I’ve seen a lot of the proposed changes, and our specialty • 278 — Health Care Services Review Request doesn’t seem to be as involved as others,” Lomax said. “Dermatology diagnoses are going to be very specific to the • 820 — Premium Payments CONTINUED on p. 23 • 834 — Health Plan Enrollment THE 5010 TRANSITION 5010 AND ICD-10 DEADLINES Oct. 1, 2013: ICD-10-CM use becomes mandatory 20 DERMATOLOGY WORLD // June 2011 www.aad.org Hats Off To taking control of scalp plaque psoriasis with once-daily Taclonex Scalp® 1 Individual results may vary. Taclonex Scalp® (calcipotriene 0.005% and betamethasone dipropionate 0.064%) Topical Suspension is indicated for the topical treatment of moderate to severe psoriasis vulgaris of the scalp in adults 18 years of age and older. Taclonex Scalp® should be applied to affected areas on the scalp once daily for 2 weeks or until cleared and may be continued for up to 8 weeks. The maximum weekly dose should not exceed 100 g. IMPORTANT SAFETY INFORMATION ABOUT TACLONEX SCALP® TOPICAL SUSPENSION FOR TOPICAL USE ONLY. Taclonex Scalp® should not be applied to the face, axillae, or groin. Taclonex Scalp® is not for oral, ophthalmic, or intravaginal use. Taclonex Scalp® should not be used in patients with hypersensitivity to any of its components or atrophy at the treatment site. The safety and efficacy of Taclonex Scalp® have not been evaluated in patients with known or suspected disorders of calcium metabolism. Taclonex Scalp® has not been evaluated in patients with erythrodermic, exfoliative, or pustular psoriasis or in patients with severe renal insufficiency or severe hepatic disorders. Hypercalcemia and hypercalciuria have been observed with Taclonex Scalp®. Reversible hypothalamic-pituitary-adrenal (HPA)–axis suppression has also been observed with Taclonex Scalp® in combination with Taclonex® Ointment. The rate of adrenal suppression due to the combination of Taclonex® Ointment and Taclonex Scalp® increased with treatment duration. Systemic absorption may require evaluation for HPA-axis suppression. Potent corticosteroids, use on large areas, prolonged use, or occlusive use may increase systemic absorption. Cushing’s syndrome, hyperglycemia, and unmasking of latent diabetes mellitus can also result from systemic absorption of topical corticosteroids. In clinical trials with Taclonex Scalp®, the most frequent adverse reactions were folliculitis and burning sensation of skin. Local adverse reactions may include atrophy, striae, irritation, acneiform eruptions, hypopigmentation, and allergic contact dermatitis and may be more likely with occlusive use or more potent corticosteroids. Reference: 1. Taclonex Scalp® [package insert]. Parsippany, NJ: LEO Pharma Inc. November 2010. PLEASE SEE BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION ON THE FOLLOWING PAGE. The LEO and Lion Design trademarks and all other marks included herein are owned by LEO Pharma A/S. ©2010 LEO Pharma Inc. 3428-TAC-1210-043 December 2010 Printed in USA Rx Only BRIEF SUMMARY: These highlights do not include all the information needed to use Taclonex Scalp® (calcipotriene 0.005% and betamethasone dipropionate 0.064%) Topical Suspension safely and effectively. See Full Prescribing Information for Taclonex Scalp® Topical Suspension available at www.taclonex.com. INDICATIONS AND USAGE: Taclonex Scalp® (calcipotriene and betamethasone dipropionate) Topical Suspension is indicated for the topical treatment of moderate to severe psoriasis vulgaris of the scalp in adults 18 years of age and older. Taclonex Scalp® should not be applied to the face, axillae, or groin. Taclonex Scalp® should not be used if there is skin atrophy at the treatment site. DOSAGE AND ADMINISTRATION: Apply Taclonex Scalp® to affected area(s) on the scalp once daily for 2 weeks or until cleared. Treatment may be continued for up to 8 weeks. The maximum weekly dose should not exceed 100 g. Shake before use. Patients should wash their hands after applying Taclonex Scalp®. Taclonex Scalp® is not for oral, ophthalmic, or intravaginal use. CONTRAINDICATIONS: None. WARNINGS AND PRECAUTIONS: Effects on Calcium Metabolism: Hypercalcemia and hypercalciuria have been observed with use of Taclonex Scalp®. If hypercalcemia or hypercalciuria develop, treatment should be discontinued until parameters of calcium metabolism have normalized. The effects of Taclonex Scalp® on calcium metabolism following treatment durations of more than 8 weeks have not been evaluated. Effects on Endocrine System: Systemic absorption of topical corticosteroids can produce reversible hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for clinical glucocorticosteroid insufficiency. This may occur during treatment or upon withdrawal of the topical corticosteroid. HPA axis suppression has been observed with Taclonex Scalp® when used in combination with Taclonex® Ointment. In a study of 32 subjects treated with Taclonex Scalp® on the scalp and Taclonex® Ointment on the body, adrenal suppression was identified in 5 of 32 subjects (15.6%) after 4 weeks of treatment and in 2 of 11 subjects (18.2%) who continued treatment for 8 weeks. Because of the potential for systemic absorption, use of topical corticosteroids may require that patients be periodically evaluated for HPA axis suppression. Factors that predispose a patient using a topical corticosteroid to HPA axis suppression include the use of more potent steroids, use over large surface areas, use over prolonged periods, use under occlusion, use on an altered skin barrier, and use in patients with liver failure. An ACTH stimulation test may be helpful in evaluating patients for HPA axis suppression. If HPA axis suppression is documented, an attempt should be made to gradually withdraw the drug, to reduce the frequency of application, or to substitute a less potent steroid. Manifestations of adrenal insufficiency may require supplemental systemic corticosteroids. Recovery of HPA axis function is generally prompt and complete upon discontinuation of topical corticosteroids. Cushing’s syndrome, hyperglycemia, and unmasking of latent diabetes mellitus can also result from systemic absorption of topical corticosteroids. Use of more than one corticosteroid-containing product at the same time may increase the total systemic corticosteroid exposure. Pediatric patients may be more susceptible to systemic toxicity from use of topical corticosteroids [see Use in Specific Populations]. Local Adverse Reactions with Topical Corticosteroids: Local adverse reactions may be more likely to occur with occlusive use, prolonged use or use of higher potency corticosteroids. Reactions may include atrophy, striae, telangiectasias, burning, itching, irritation, dryness, folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary infection, and miliaria. Some local adverse reactions may be irreversible. Allergic Contact Dermatitis with Topical Corticosteroids: Allergic contact dermatitis to any component of topical corticosteroids is usually diagnosed by a failure to heal rather than a clinical exacerbation. Clinical diagnosis of allergic contact dermatitis can be confirmed by patch testing. Allergic Contact Dermatitis with Topical Calcipotriene: Allergic contact dermatitis has been observed with use of topical calcipotriene. Clinical diagnosis of allergic contact dermatitis can be confirmed by patch testing. Concomitant Skin Infections: Concomitant skin infections should be treated with an appropriate antimicrobial agent. If the infection persists, Taclonex Scalp® should be discontinued until the infection has been adequately treated. Unevaluated Uses: The safety and efficacy of Taclonex Scalp® in patients with known or suspected disorders of calcium metabolism have not been evaluated. The safety and efficacy of Taclonex Scalp® in patients with erythrodermic, exfoliative, or pustular psoriasis have not been evaluated. The safety and efficacy of Taclonex Scalp® in patients with severe renal insufficiency or severe hepatic disorders have not been evaluated. Eye Exposures: Avoid eye exposures. Taclonex Scalp® may cause eye irritation. Ultraviolet Light Exposures: Patients who apply Taclonex Scalp® to exposed skin (e.g., a bald scalp) should avoid excessive exposure to either natural or artificial sunlight, including tanning booths, sun lamps, etc. Physicians may wish to limit or avoid use of phototherapy to the scalp in patients who use Taclonex Scalp®. ADVERSE REACTIONS: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Clinical Study Experience: The rates of adverse reactions given below were derived from randomized, multicenter, prospective vehicle- and/or active-controlled clinical studies in subjects with scalp psoriasis. Subjects applied study product once daily for 8 weeks, and the median weekly dose was 12.6 g. Adverse reactions that occurred in *1% of subjects treated with Taclonex Scalp® and at a rate higher than in subjects treated with vehicle are presented in Table 1: Table 1 Number and Percentage of Patients with Adverse Reactions in Scalp Psoriasis Studies Other less common reactions (less than 1% but more than 0.1%) were, in decreasing order of incidence: acne, exacerbation of psoriasis, eye irritation, and pustular rash. In a 52-week study, adverse reactions that were reported by greater than 1% of subjects treated with Taclonex Scalp® were pruritus (3.6%), psoriasis (2.4%), erythema (2.1%), skin irritation (1.4%), and folliculitis (1.2%). The effects of Taclonex Scalp® on calcium metabolism and the HPA axis were not investigated in the 52-week study. To report SUSPECTED ADVERSE REACTIONS, contact LEO Pharma Inc. at 1-877-494-4536 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. USE IN SPECIFIC POPULATIONS: Pregnancy: Teratogenic Effects: Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women. Pregnant women were excluded from the clinical studies conducted with Taclonex Scalp®. Taclonex Scalp® should be used during pregnancy only if the potential benefit to the patient justifies the potential risk to the fetus. Animal reproduction studies have not been conducted with Taclonex Scalp®. Taclonex Scalp® contains calcipotriene that has been shown to be fetotoxic and betamethasone dipropionate that has been shown to be teratogenic in animals when given systemically. Nursing Mothers: Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. It is not known whether topically administered calcipotriene or corticosteroids could result in sufficient systemic absorption to produce detectable quantities in human milk. Because many drugs are excreted in human milk, caution should be exercised when Taclonex Scalp® is administered to a nursing woman. Pediatric Use: Safety and effectiveness of the use of Taclonex Scalp® in pediatric patients have not been studied. Because of a higher ratio of skin surface area to body mass, children under the age of 12 years may be at particular risk of systemic adverse effects when they are treated with topical corticosteroids [see Warnings and Precautions]. HPA axis suppression, Cushing’s syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have been reported in children receiving topical corticosteroids. Manifestations of adrenal suppression in children include low plasma cortisol levels and absence of response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema. Geriatric Use: Of the total number of subjects in the clinical studies of Taclonex Scalp®, 334 were 65 years or older, while 84 were 75 years or older. No overall differences in safety or effectiveness of Taclonex Scalp® were observed between these patients and younger patients. All other reported clinical experience has not identified any differences in response between elderly and younger patients. OVERDOSAGE: Taclonex Scalp® can be absorbed in sufficient amounts to produce systemic effects [see Warnings and Precautions]. CLINICAL PHARMACOLOGY: Mechanism of Action: Taclonex Scalp® combines the pharmacological effects of calcipotriene hydrate as a synthetic vitamin D3 analogue and betamethasone dipropionate as a synthetic corticosteroid. However, while their pharmacologic and clinical effects are known, the exact mechanisms of their actions in psoriasis vulgaris are unknown. NONCLINICAL TOXICOLOGY: Carcinogenesis, Mutagenesis, Impairment of Fertility: Calcipotriene may enhance the effect of UVR to induce skin tumors. Long-term animal studies have not been performed to evaluate the carcinogenic potential of betamethasone dipropionate. CONCOMITANT USE OF OTHER CORTICOSTEROIDS: Other products containing calcipotriene or a corticosteroid should not be used with Taclonex Scalp® without first talking to a physician. HOW SUPPLIED: Taclonex Scalp® is available in bottles of: 60 gram (NDC 50222-501-06) 100 gram (NDC 50222)-227-81) 2 x 60 gram (NDC 50)222-501-66) Store Taclonex Scalp® between 68 - 77˚ F (20 - 25˚ C); excursions permitted between 59 - 86˚ F (15 - 30˚ C). Keep out of reach of) children. Manufactured by: LEO Laboratories Ltd. (LEO Pharma) Dublin, Ireland Distributed by: LEO Pharma Inc. 1 Sylvan Way, Parsippany, NJ 07054 USA U.S. Patent Nos.: RE39,706 E and 6,753,013. 024598-01 024599-01 Revised: November 2010 www.taclonex.com ©2010 LEO Pharma Inc. Taclonex Scalp® is a registered trademark. LEO Pharma Inc. 1 Sylvan Way, Parsippany, NJ 07054 3428-TAC-0710-008 July 2010 Printed in USA Reference: 1. Taclonex Scalp® [package insert]. Parsippany, NJ: LEO Pharma Inc; November 2010. Events Reported by *1% of Subjects and for Which a Relationship is Possible Taclonex Scalp® Topical Suspension N=1,953 Event Folliculitis Burning sensation o)f skin 16 (1%) 13 (1%) Betamethasone dipropionate in vehicle N=1,214 Calcipotriene in vehicle N=979 # of subjects (%) 12 (1%) 5 (1%) 10 (1%) 29 (3%) Vehicle N=173 0 (0%) 0 (0.0%) 5IF-&0BOE-JPO%FTJHOUSBEFNBSLTBOEBMMPUIFSNBSLTJODMVEFEIFSFJOBSFPXOFECZ-&01IBSNB"4 -&01IBSNB*OD 5"$C %FDFNCFS 1SJOUFEJO64" J92 D02 S18 V52 N14 R46 W65 O16 V52 location and the symptoms. There are specific diagnoses used in each office that need to be evaluated — what is documented in each patient’s record, which codes are used more often, and how will that cross over into the new coding?” Dr. Nandedkar noted that much of the most important information for practitioners and managers can be found through the Centers for Medicare and Medicaid Services (CMS) website and the American Academy of Dermatology’s resources on the transition. “The CMS website is amazing. On 5010 and ICD-10, it’s excellent. It gives the timeline of what’s required of us and I know that like most physicians, I’m really busy and grateful to be able to find that information at a glance,” Dr. Nandedkar said. “My staff and I will be taking a course and talking to Medicare about how best to do the upgrade for ICD-10. We need to use our Academy to our advantage.” (See sidebar below for information on resources available from the AHcademy, CMS, and oHthers.) In addition to the government resources available and internal resources, ADAM board member and University of Missouri School of Medicine practice manager Pamela Matheny, M.B.A., said that many of the professional management and coding organizations are stepping up their educational offerings with deadlines looming. “ADAM is taking a proactive approach. At our annual meetings this year, in 2012,H and in 2013, we’reH going to have a loHt of ICD10 sessions for those that don’t have the resources of a large institution to begin preparing themselves for ICD-10,” Matheny said. “I think it’s just a matter of being very prepared. We’re going to help a lot of people get prepared so that they can hit the ground running. I think we’ll be able to have enough planning in advance that it’s going toH be a pretty smoothH process.” PLANNING FOR CHANGED According to Matheny, physicians and managers have plenty of time to adapt to the upcoming changes so long as they’re willing to implement an education plan where necessary for support staff. While it’s unclear this early on exactly how choosing a code during a typical day will change, she said, her organization is willing to put the resources behind early education in hope of a quick start when the changeover occurs. (For more specifics on how codes will change, see AnHswers in Practice, Hp. 15.) “It’s very hard to make people aware of the fact that what’s happening in the ICD-10 has to do with anatomy, and you really need a clear understanding of anatomy — whether there’s two of something, whether there’s a left and right, that kind of thing,” Matheny said. She said that non-clinical staff may need a new kind of training. “Dermatologists should send them for training, not O26 W65 X51 W65 N00 necessarily for ICD-10 right away, but it wouldn’t be a bad idea for staff members to start brushing up on anatomy if they don’t know it really well. Physicians know anatomy, but their administrators and managers may not have a whole lot of that.” In order to recognize and address the specific needs of your staff and practice during the change, Lomax advises a measured plan for absorbing tHhe new material. “One thing I think [practices] need to be doing now is to develop a task force to assess our needs and the changes that are going to happen in our office and keep everyone updated in the process,” Lomax said. “This is definitely not going to be a oneperson job. Everyone’s going to have something to do with ICD-10 whether they realize it or not. Your task force is really going to be identifying all theHse processes and cHhanges,” she said.H “By the fourth quarter of 2012, I plan on working with all my physicians and providers and my clinical staff on documentation,” Lomax added. “I think that’s going to be the key to choosing what codes you need. Their documentation is going to have to change. And at that point, we won’t know for sure what we need to do, but I do think we need to start working on more thorough documentation in order to choose the right diagnosis code set,” she said. IMPLEMENTATION RESOURCES A wide variety of resources are available for physicians, other clinical staff, managers, and coders to familiarize themselves with the 5010 standards and ICD-10. American Academy of Dermatology ICD-10 resources: www.aad.org/member-tools-andbenefits/practice-management-resources/codingand-reimbursement/icd-10 Getting Ready for ICD-10 Webinar: www.aad.org/webcasts Center for Medicare and Medicaid Services ICD-10: www.cms.gov/ICD10 Version 5010: www.cms.gov/Versions5010andD0 American Academy of Professional Coders ICD-10 Hub (includes 5010 information): www.icd10hub.com American Health Information Management Association ICD-10: http://ahima.org/icd10 DERMATOLOGY WORLD // June 2011 23 D02 N14 A00 A01 A02 A03 A0 4 A A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 A00 A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 8 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B2 1 B22 B23 B24 B25 B26 B27 B28 B29 B3 0 B31 B32 B33 B34 B35 B36 B37 B38 B3 9 B40 B41B17 B42B18 B19 B20 B2 1 B22 B23 B24 O26 E13 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 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S58 S59 S60 S44 S61 S45 S46 S47 S4 8 S4 1 T02 T03 T0 4 T05 T06 T07 T08 T09 T10 T11 T12 T1 3 T14 T15 T16 T17 T18 T19 T20 T21 T2 2 T23 T24 T25 T26 T00 T27 T01 T02 T03 T0 4 T05 T06 T07 T08 T09 T10 T11 T12 T1 3 T14 T15 T16 T17 T18 T19 T20 T21 T2 2 T23 T24 T25 T26 T00 T27 T01 T02 T03 T0 4 T05 T06 T07 T0 8 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U3 8 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U32 U33 U34 U35 U36 U37 U38 U39 U40 U41 U28 U29 U30 U31 U V43 V44 V45 V4 6 V47 V48 V49 V50 V51 V52 V53 V54 V5 5 V56 V57 V58 V59 V60V42 V61V43 V44 V45 V4 6 V47 V48 V49 V50 V51 V52 V53 V54 V5 5 V56 V57 V58 V59 V60V42 V61V43 V44 V45 V4 6 V47 W01 W02 W03 W0 4 W05 W06 W07 W08 W09 W10 W11 W12 W1 3 W14 W15 W16 W17 W18 W19 W20W00 W21W01 W02 W03 W0 4 W05 W06 W07 W08 W09 W10 W11 W12 W1 3 W14 W15 W16 W17 W18 W19 W20W00 W21W01 W02 W03 W0 4 W05 W X23 X24 X25 X26 X27 X28 X29 X30 X31 X32 X33 X34 X35 X36 X37 X38 X39 X40 X41X22 X42X23 X24 X25 X26 X27 X28 X29 X30 X31 X32 X33 X34 X35 X36 X37 X38 X39 X40 X41X22 X42X23 X24 X25 X26 X27 X E36 B99 L20 A62 Y44 Y45 Y46 Y4 7 Y48 Y49 Y50 Y51 Y52 Y53 Y54 Y55 Y5 6 Y57 Y58 Y59 Y60 Y43 Y61Y44 Y45 Y46 Y4 7 Y48 Y49 Y50 Y51 Y52 Y53 Y54 Y55 Y5 6 Y57 Y58 Y59 Y60 Y43 Y61Y44 Y45 Y46 Y4 7 Y4 01 Z02 Z03 Z0 4 Z05 Z06 Z07 Z08 Z09 Z10 Z11 Z12 Z1 3 Z14 Z15 Z16 Z17 Z18 Z19 Z20 Z21 Z2 2 Z23 Z24 Z25 Z26 Z00 Z27 Z01 Z02 Z03 Z0 4 Z05 Z06 Z07 Z08 Z09 Z10 Z11 Z12 Z1 3 Z14 Z15 Z16 Z17 Z18 Z19 Z20 Z21 Z2 2 Z23 Z24 Z25 Z26 Z00 Z27 Z01 Z02 Z03 Z0 4 Z05 Z06 Z07 Z A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 A00 A01 A02 A03 A0 4 A05 A06 A07 A08 A09 A10 A11 A12 A1 3 A14 A15 A16 A00 A01 A02 A03 A0 4 18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B17 B18 B19 B20 B2 1 B22 B23 B24 B25 B26 B27 B28 B29 B3 0 B31 B32 B33 B34 B35 B36 B37 B38 B3 9 B40 B41B17 B42B18 B19 B20 B2 1 B22 B23 B2 3 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C47 C48 C49 C50 C51 C52 C53 C54 C55 C56 C43 C44 C45 C46 C D58 D59 D60 D6 1 D62 D63 D64 D65 D66 D67 D68 D69 D7 0 D71 D72 D73 D74 D57 D58 D59 D60 D6 1 D62 D63 D64 D65 D66 D67 D68 D69 D7 0 D71 D72 D73 D74 D57 D58 D59 D60 D6 1 D E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E 13 E14 E15 E16 E17 E18 E19 E20 E21 E 22 E23 E00 E01 E02 E03 E04 E05 E06 E07 E08 E09 E10 E11 E12 E 13 E14 E15 E16 E17 E18 E19 E20 E21 E 22 E23 E00 E01 E02 E03 E04 E05 E06 E F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43F24 F44F25 F26 F27 F28 F29 F30 F31 F32 F33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43F24 F44F25 F26 F27 F28 F29 G46 G47 G48 G4 9 G50 G51 G52 G53 G54 G55 G56 G57 G5 8 G59 G60 G61 G45 G46 G47 G48 G4 9 G50 G51 G52 G53 G54 G55 G56 G57 G5 8 G59 G60 G61 G45 G46 G47 G48 G4 9 63 H64 H65 H6 6 H67 H68 H69 H70 H71 H72 H73 H74 H7 5 H76 H77 H78 H79 H80 H81 H82 H83 H8 4 H85 H86H62H87H63 H64 H65 H6 6 H67 H68 H69 H70 H71 H72 H73 H74 H7 5 H76 H77 H78 H79 H80 H81 H82 H83 H8 4 H85 H86H62H87H63 H64 H65 H6 6 H67 H68 H6 I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15I00 I16I01 I02 I03 I04 I05 I06 I07 I08 I09 I10 I11 I12 I13 I14 I15I00 I16I01 I02 I03 I04 J18 J19 J20 J2 1 J22 J23 J24 J25 J26 J27 J28 J29 J3 0 J31 J32 J33 J34 J35J17 J36J18 J19 J20 J2 1 J22 J23 J24 J25 J26 J27 J28 J29 J3 0 J31 J32 J33 J34 J35J17 J36J18 J19 J20 J2 1 J22 K38 K39 K40 K4 1 K42 K43 K44 K45 K46 K47 K48 K49 K5 0 K51 K52 K53 K54 K55 K56 K57 K58 K5 K37 9 K60 K38 K39 K40 K4 1 K42 K43 K44 K45 K46 K47 K48 K49 K5 0 K51 K52 K53 K54 K55 K56 K57 K58 K5 K37 9 K60 K38 K39 K40 K4 1 K42 K43 L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80L61 L81L62 L63 L64 L65 L66 L67 L68 L69 L70 L71 L72 L73 L74 L75 L76 L77 L78 L79 L80L61 L81L62 L63 L64 L65 L66 G62 P87 Q57 W29 In identifying the Hcodes, Lomax said,H practices will be aHble toeducational processH early is a wise deHcision. speed their converHsion with the use Hof the General EquiHvalence “Dermatologists shouldn’t wait until the last minute. They Mapping (GEM) tool.H The utility, develHoped by CMS, acts aHs a need to send their practice managers and coders to some of two-way translationH resource between ICHD-9 and ICD-10 codeHs.the professional events and take advantage of the resources of She said, however,H that GEM has been Hdesigned and releasHed aslarger organizations. It will help them come up to speed on a guide for practiHces, rather than aH full conversion plaHn. It cannot the coding,” Matheny said. “Their local American Academy of fully address the iHncreased complexityH of the ICD-10 convHersion.Professional Coders (AAPC) chapters will help as well. They’re going to have to rely on the AAD and ADAM in order to get “By the first quarter of 2013 we should be able to identify the codes that are specific to dermatology, and every practice is that derm-specific coding information that they’re going to need,” she said. probably going to have to go through and identify those that they use the most. The GEM tool will help them know which codes Physicians hoping tHo get an early starHt on the 5010 and IHCDare going to replace those that they’ve been using. By the same 10 conversion process should acquaint themselves with the time, we’re going to need to start implementing those changes in information available on the CMS website (see sidebar, p. 23), as well as the educational resources provided by the Academy, process that we’ve talked about in 2012. Hopefully, then, by Oct. 1, ADAM, and the AAPC. Each of these organizations is committed 2013, we’d be ready Hto use them.” to ensuring a smooth transition for the 5010 and ICD-10 Matheny said that in light of the myriad educational sessions being offered well in advance of the deadline, beginning the deadlines. dw 5010 TRANSITION CHECKLIST To smooth the 5010 transition process, experts recommend the following steps for physicians. • Create an implementation team and transition plan — Identify those most likely to be impacted by the transition, gather them to form a transition plan, and hold regular meetings to discuss and document the ongoing progress of the transition. • Contact your vendors — Ask your vendors to provide you with information about when specific steps toward the transition will be taken and what you need to do to ensure your practice’s transition plans coordinate with the vendor’s. • Utilize testing schedules — Compile a list of your vendors and their test schedules. Keep track of the vendor’s progress, along with your practice’s. • Update your EHR software — Communicate with your software vendor to update to the latest version and harness the benefits of 5010. Budget for the time and expense of any upgrade costs and downtime. • Train your staff — Keep yourself and your staff knowledgeable throughout the process by taking advantage of classes, webinars, and online information. Budget for additional staff training, if necessary. • Test your system — Utilize extensive internal testing on practice processes at the minimum. It may also help to undergo external testing, should time and budget allow. • Monitor your operations — Log any and all issues, and periodically review data to check whether certain problems tend to repeat. Pay special attention to your payer rejection/denial percentages and your reimbursement. Contact vendors if problems persist. (Source: American Academy of Professional Coders, ICD10hub.com) 24 DERMATOLOGY WORLD // June 2011 www.aad.org =<7$=(LVDPHGLFDOIRRGWKDWSURYLGHVQXWULWLRQDOVXSSRUWWR HQKDQFHDQGSURORQJWKHHIIHFWVRIERWXOLQXPWR[LQLQMHFWLRQVVXFK DV%RWR['\VSRUWDQG0\REORF :K\=<7$=("7REHHIIHFWLYHERWXOLQXPWR[LQVUHTXLUHWKHSUHVHQFH RI]LQFDQGXQIRUWXQDWHO\QRWDOO]LQFLVHTXDOO\DEVRUEHG=<7$=( FRQWDLQVDXQLTXHEOHQGRIRUJDQLF]LQFDQGSK\WDVHDQHQ]\PH WKDWDLGV]LQFDEVRUSWLRQWRLPSURYHERWXOLQXPWR[LQHIÀFDF\DQG H[WHQGWKHGXUDWLRQRIUHVXOWVE\DOPRVW 6DWLVÀHGSDWLHQWVOHDGWRPRUHSDWLHQWUHIHUUDOV:K\QRWWDNH DGYDQWDJHRIWKLVSUDFWLFHEXLOGLQJRSSRUWXQLW\"$OOLWWDNHVLV FDSVXOHVHDFKGD\GD\VSULRUWRDQGRQWKHGD\RILQMHFWLRQV $YDLODEOHIRU2IÀFH'LVSHQVLQJ &DOO .RVK\-&6KDUDEL6()HOGPDQ(0+ROOLHU/0+ROOLHU/+3DWULQHO\-56RSDUNDU &16(IIHFWRI'LHWDU\=LQF6XSSOHPHQWDWLRQRQ%RWXOLQXP7R[LQ7UHDWPHQWV PDQXVFULSWLQUHYLHZ %RWR[LVDUHJLVWHUHGWUDGHPDUNRI$OOHUJDQ,QF '\VSRUWLVDUHJLVWHUHGWUDGHPDUNRI,SVHQ%LRSKDUP/LPLWHG 0\REORFLVDUHJLVWHUHGWUDGHPDUNRI6ROVWLFH1HXURVFLHQFHV,QF =<7$=(LVDUHJLVWHUHGWUDGHPDUNRI2&X62)7,QF /HDUQPRUHDWZZZ]\WD]HFRP 2&X62)7,QF5LFKPRQG7; Reversing the RAVAGES of time New injectable agents help dermatologists meet growing demand for anti-aging treatments 26 DERMATOLOGY WORLD // June 2011 www.aad.org BY JAN BOWERS, CONTRIBUTING WRITER L ess than 10 years ago, the launch of two injectable products ushered in a new era for aesthetic dermatology. OnabotulinumtoxinA (Botox), approved by the U.S. Food and Drug Administration (FDA) for cosmetic use in 2002, and the first hyaluronic acid-based dermal filler (Restylane), approved by the FDA in 2003, provided nonsurgical alternatives to rhytidectomy, forehead lifts, cheek implants, and other surgical procedures that target the effects of aging. According to a 2010 report from the American Society of Plastic Surgeons (ASPS), the number of rhytidectomy procedures declined 16 percent in the past decade (to 112,955), while the number of botulinum toxin type A procedures increased 584 percent in the same period, reaching a total of 5,379,360 sites injected in 2010. Minimally invasive procedures using soft tissue fillers increased 172 percent to 1,773,328, with hyaluronic acid procedures accounting for nearly 68 percent of the 2010 total. (These statistics represent procedures performed by board-certified physician specialistsN.) >> DERMATOLOGY WORLD // June 2011 27 Reversing the RAVAGES of time A confluence of factors is driving the trend toward less invasive procedures, according to leading aesthetic dermatologists. Changing patient demographics and the desire to appear younger in a competitive workplace environment are growing the overall market for antiaging procedures, and minimally invasive options are more subtle, less expensive, and less disruptive to daily routine. “Patients want procedures with less downtime with the fillers prior to injection. Last year, new forms of Restylane, Perlane, and Juvederm became available premixed with lidocaine. “I actually think that the Juvederm product with powdered lidocaine from the company is less painful than when we mixed the lidocaine ourselves,” said Susan Weinkle, M.D., affiliate clinical professor of dermatology at the University of South Florida College of Medicine. “I also like Restylane with lidocaine, because the A key advantage of hyaluronic acid fillers is that their manufacturer puts in liquid lidocaine, effects are reversible with the injection of hyaluronidase. which alters the viscosity and improves the flow characteristics.” — office-based procedures that let them resume normal When choosing among hyaluronic acid fillers, daily activities,” said Seth L. Matarasso, M.D., clinical dermatologists take into account patient preference professor of dermatology at the University of California, and their own perceptions of the subtle differences San Francisco School of Medicine. “They don’t want to among the products. “I do a lot of volume replacement look like they’ve had work done — they’re looking at and frequently use Perlane for that because it’s a staying refreshed and staying ahead of the curve. It’s a deeper hyaluronic acid filler,” said Mark Nestor, pretty exciting time because science has really kept up M.D., Ph.D., associate professor of dermatology at with patient demand.” Within the category of injectable the University of Miami’s Miller School of Medicine. products, an influx of new agents and enhancements “I use Restylane for places such as the tear trough to older products provide dermatologists with a broad and nasolabial fold, where I want extra lift. I use a lot array of options to offer their patients. of Juvederm in the lips, and in the nasolabial fold of patients who want a softer look and don’t necessarily HYALURONIC ACID DOMINATES FILLERS need as much lift.” Bovine and human collagen products, once the A key advantage of hyaluronic acid fillers is mainstay of the dermal filler category, have virtually that their effects are reversible with the injection disappeared from the U.S market, Dr. Matarasso said. of hyaluronidase. “If there’s an unwanted lump or “I think it’s a shame, because they were fine products even an impending necrosis, you can dissolve the that had a niche; the problem was they didn’t really material and relieve some of the pressure on the last that long,” he said. “Now the hyaluronic acid blood vessel,” said Mary Lupo, M.D., clinical professor fillers, Restylane and Juvederm, are the gold standard.” of dermatology at Tulane School of Medicine. The The effects of hyaluronic acid fillers can last from six “forgiving” nature of these products encourages to 12 months, compared to a duration of three to six dermatologists to branch out to new indications, months for collagen products. Dr. Matarasso said. “These fillers are FDA-approved Restylane, Perlane, and Juvederm (FDA-approved for nasolabial folds, but we’re also now using them in 2006) are all composed of cross-linked, nonanimal around the eye, the neck, the earlobe area, the back source hyaluronic acid. Perlane is similar to Restylane of the hand, and in the depressions of scars. There’s but has larger gel particles; both have a hyaluronic more flexibility in these products than in some of acid concentration of 20 mg/mL. Both Juvederm the other ones.” Dr. Lupo cited the temples, cheeks, Ultra and Juvederm Ultra Plus have a hyaluronic and lips as “the three big off-label areas where we’re acid concentration of 24 mg/mL, but Juvederm injecting hyaluronic acid fillers.” Ultra Plus has a higher proportion of cross-linking New hyaluronic acid products in the pipeline than Juvederm Ultra, giving it a somewhat firmer (not yet FDA-approved) include Bolotero Balance, a consistency. hyaluronic acid-based monophasic gel; Voluma, a Because the hyaluronic acid fillers cause pain upon volumnizing filler from the manufacturer of injection, dermatologists frequently mixed lidocaine CONTINUED ON P. 31 28 DERMATOLOGY WORLD // June 2011 www.aad.org Proven effective in moderate to severe acne1,2 Power To treat To please In studies with more than 2800 patients with moderate to severe acne, Acanya®Gel demonstrated: ● ● ● 64% median reduction in inflammatory lesion counts at 12 weeks (34% for vehicle)1,2 49% median reduction in noninflammatory lesion counts at 12 weeks (26% for vehicle)1,2 ● No patient treated with Acanya Gel discontinued treatment due to erythema, scaling, burning, stinging, or itching in pivotal trials1 ● Neat and simple: No jar, no mess ● No pharmacy admixing: Pump now replaces the Acanya Gel jar ● Measured dose: Consistent delivery Low potential for cutaneous irritation may lead to increased adherence to treatment Indication and Important Safety Information Acanya Gel is indicated for the topical treatment of acne vulgaris in patients 12 years of age or older. Acanya Gel is contraindicated in patients with a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis. Discontinuation is recommended if significant diarrhea develops. In controlled clinical trials, the following application-site adverse reactions occurred in less than 0.2% of patients treated with Acanya Gel: applicationsite pain (0.1%), application-site exfoliation (0.1%), and application-site irritation (0.1%). Of the patients who experienced cutaneous symptoms of erythema, scaling, itching, burning, and/or stinging, regardless of the relationship to therapy, the majority of cases were mild to moderate in severity, occurred early in treatment, and decreased thereafter. To learn more, please visit www.AcanyaGel.com Please see the following page for references and brief summary of full prescribing information. © 2010 CORIA Laboratories ACAN-0510-6004 With ease! Now in a ready-to-use 50g pump for your patients’ convenience Acanya Gel Disp: 50g Sig: Apply to affected area once daily ® 4 refills ACAN-1010-0002 USE IN SPECIFIC POPULATIONS Pregnancy Category C There are no well-controlled trials in pregnant women treated with ACANYA Gel. It also is not known whether ACANYA Gel can cause fetal harm when administered to a pregnant woman. ACANYA Gel should be used during pregnancy only if the potential benefi t justifies the potential risk to the fetus. ACANYA® (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/2.5% Brief summary. Please see full prescribing information for complete product information. INDICATIONS AND USAGE ACANYA Gel is indicated for the topical treatment of acne vulgaris in patients 12 years or older. The safety and efficacy of this product in the treatment of any other disorders have not been evaluated. DOSAGE AND ADMINISTRATION Apply a pea-sized amount of ACANYA Gel to the face once daily. Use of ACANYA Gel beyond 12 weeks has not been evaluated. ACANYA Gel is not for oral, ophthalmic, or intravaginal use. CONTRAINDICATIONS ACANYA Gel is contraindicated in patients with a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis. WARNINGS AND PRECAUTIONS Colitis Systemic absorption of clindamycin has been demonstrated following topical use of clindamycin. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with the use of topical and systemic clindamycin. When significant diarrhea occurs, ACANYA Gel should be discontinued. Animal reproductive/developmental toxicity studies have not been conducted with ACANYA Gel or benzoyl peroxide. Developmental toxicity studies of clindamycin performed in rats and mice using oral doses of up to 600 mg/kg/day (240 and 120 times amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) or subcutaneous doses of up to 200 mg/kg/day (80 and 40 times the amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) revealed no evidence of teratogenicity. Nursing Mothers: It is not known whether clindamycin is excreted in human milk after topical application of ACANYA Gel. However, orally and parenterally administered clindamycin has been reported to appear in breast milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to use ACANYA Gel while nursing, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of ACANYA Gel in pediatric patients under the age of 12 have not been evaluated. Clinical trials of ACANYA Gel included patients 12-17 years of age. Geriatric Use Clinical studies of ACANYA Gel did not include sufficient numbers of patients aged 65 and older to determine whether they respond differently from younger patients. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity, mutagenicity and impairment of fertility testing of ACANYA Gel have not been performed. Severe colitis has occurred following oral and parenteral administration of clindamycin with an onset of up to several weeks following cessation of therapy. Antiperistaltic agents such as opiates and diphenoxylate with atropine may prolong and/or worsen severe colitis. Severe colitis may result in death. Benzoyl peroxide has been shown to be a tumor promoter and progression agent in a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg administered topically twice per week for 20 weeks induced skin tumors in transgenic Tg.AC mice. The clinical significance of this is unknown. Studies indicate toxin(s) produced by Clostridia is one primary cause of antibiotic-associated colitis. The colitis is usually characterized by severe persistent diarrhea and severe abdominal cramps and may be associated with the passage of blood and mucus. Stool cultures for Clostridium difficile and stool assay for C. difficile toxin may be helpful diagnostically. Carcinogenicity studies have been conducted with a gel formulation containing 1% clindamycin and 5% benzoyl peroxide. In a 2-year dermal carcinogenicity study in mice, treatment with the gel formulation at doses of 900, 2700, and 15000 mg/kg/day (1.8, 5.4, and 30 times amount of clindamycin and 3.6, 10.8, and 60 times amount of benzoyl peroxide in the highest recommended adult human dose of 2.5 g ACANYA Gel based on mg/m2, respectively) did not cause any increase in tumors. However, topical treatment with a different gel formulation containing 1% clindamycin and 5% benzoyl peroxide at doses of 100, 500, and 2000 mg/kg/ day caused a dose-dependent increase in the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal carcinogenicity study in rats. In an oral (gavage) carcinogenicity study in rats, treatment with the gel formulation at doses of 300, 900 and 3000 mg/kg/day (1.2, 3.6, and 12 times amount of clindamycin and 2.4, 7.2, and 24 times amount of benzoyl peroxide in the highest recommended adult human dose of 2.5 g ACANYA Gel based on mg/m2, respectively) for up to 97 weeks did not cause any increase in tumors. In a 52-week dermal photocarcinogenicity study in hairless mice, (40 weeks of treatment followed by 12 weeks of observation), the median time to onset of skin tumor formation decreased and the number of tumors per mouse increased relative to controls following chronic concurrent topical administration of the higher concentration benzoyl peroxide formulation (5000 and 10000 mg/kg/day, 5 days/week) and exposure to ultraviolet radiation. Mild cases of pseudomembranous colitis usually respond to drug discontinuation alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation and treatment with an antibacterial drug clinically effective against C. difficile colitis. Ultraviolet Light and Environmental Exposure Minimize sun exposure following drug application. (See NONCLINICAL TOXICOLOGY.) ADVERSE REACTIONS Clinical Studies Experience Because clinical trials are conducted under prescribed conditions, adverse reaction rates observed in the clinical trial may not reflect the rates observed in practice. Because clinical trials are also conducted under widely varying conditions, adverse reactions observed in the clinical trials of a drug cannot always be directly compared to rates in the clinical trials of another drug. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse reactions that appear to be related to drug use and for approximating rates. The following selected adverse reactions occurred in less than 0.2% of patients treated with ACANYA Gel: application site pain (0.1%); application site exfoliation (0.1%); and application site irritation (0.1%). During clinical trials, patients were assessed for local cutaneous signs and symptoms of erythema, scaling, itching, burning and stinging. Most local skin reactions increased and peaked around week 4 and continually decreased over time reaching near baseline levels by week 12. The percentage of patients that had symptoms present before treatment, the maximum value recorded during treatment, and the percent with symptoms present at week 12 are shown below. Local Skin Reactions—Percent Patients with Symptoms Present. Combined Results from the Two Phase 3 Trials (N = 773) Before Treatment (Baseline) Maximum During Treatment Clindamycin phosphate was not genotoxic in the human lymphocyte chromosome aberration assay. Benzoyl peroxide has been found to cause DNA strand breaks in a variety of mammalian cell types, to be mutagenic in S. typhimurium tests by some but not all investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells. Fertility studies have not been performed with ACANYA Gel or benzoyl peroxide, but fertility and mating ability have been studied with clindamycin. Fertility studies in rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times the amount of clindamycin in the highest recommended adult human dose of 2.5 g ACANYA Gel, based on mg/m2) revealed no effects on fertility or mating. HOW SUPPLIED ACANYA Gel is supplied as a 50 g pump (NDC 13548-132-50). Dispensing instructions for the pharmacist Dispense ACANYA Gel with a 10 week expiration date. Specify “Store at room temperature up to 25°C (77°F). Do not freeze.” End of Treatment (Week 12) Storage and Handling PHARMACIST: Prior to dispensing, store in a refrigerator, 2°C to 8°C (36°F to 46°F). Mild Mod* Severe Mild Mod* Severe Mild Mod* Severe Erythema 22 4 0 25 5 <1 15 2 0 Scaling 8 <1 0 18 3 0 8 1 0 Keep out of the reach of children. Itching 10 2 0 15 2 0 6 <1 0 Keep container tightly closed. Burning 3 <1 0 8 2 0 2 <1 0 RX Only Stinging 2 <1 0 6 1 0 1 <1 0 Distributed by CORIA Laboratories, a division of Valeant Pharmaceuticals North America, Fort Worth, TX 76107 *Mod=Moderate DRUG INTERACTIONS Erythromycin ACANYA Gel should not be used in combination with topical or oral erythromycin-containing products due to its clindamycin component. In vitro studies have shown antagonism between erythromycin and clindamycin. The clinical significance of this in vitro antagonism is not known. PATIENT: Store at room temperature at or below 25°C (77°F). Protect from freezing. Manufactured by Contract Pharmaceuticals Limited Niagara, Buffalo, NY 14213 © 2010 CORIA Laboratories Concomitant Topical Medications Concomitant topical acne therapy should be used with caution because a possible cumulative irritancy effect may occur, especially with the use of peeling, desquamating, or abrasive agents. Neuromuscular Blocking Agents Clindamycin has been shown to have neuromuscular blocking properties that may enhance the action of other neuromuscular blocking agents. Therefore, ACANYA Gel should be used with caution in patients receiving such agents. References: 1. Pivotal studies, data on file, CORIA Laboratories. 2. Gold M. A new, once daily, optimized, fi xed combination of clindamycin phosphate 1.2% and low-concentration benzoyl peroxide 2.5% gel for the treatment of moderate-to-severe acne. J Clin Aesthet Derm. 2009;5:44-48. Juvederm; Teosyal, a group of eight fillers; and EMERVEL, a group of nine fillers available with or without lidocaine. “Bolotero has a higher extrusion force because it has longer chains of hyaluronic acid,” said Dr. Weinkle. “It has less of a Tyndall effect, so it doesn’t cause the blue discoloration that some other hyaluronic acid products can [when injected too superficially]. Thus, we think it’s going to be very good for treating fine lines.” pointed out that great care must be taken when injecting Sculptra because “it’s a little more unforgiving than other fillers. If you get a nodule you didn’t want, it’s difficult or impossible to remove except by the passage of time.” He added that Radiesse and Sculptra are not appropriate for thinner skin of the periocular area, or in the lips, “which are more prone to lumps and bumps.” Permanent fillers include polymethylmethacrylate with bovine collagen (Artefill), FDA-approved in 2007, NON-HYALURONIC ACID FILLERS ADD VOLUME, LONGEVITY and hydrogel (Aquamid, 97.5 percent sterile water and Two fillers approved in 2009 are gaining popularity 2.5 percent polyacrylamide), which is not yet approved. for a variety of indications, including facial While a permanent filler might be cost effective over revolumnization and nasolabial folds. Poly-L-lactic the long run, it has distinct drawbacks. “Number acid (Sculptra) and calcium hydroxylapatite (Radiesse) one, if the substance starts causing problems, you are thought to increase facial volume by stimulating can’t get rid of it,” Dr. Nestor said. “Also, as we age, fibroblasts to produce more collagen. More skill the shape and the relationships between different aspects of the face change, so putting something in place Botulinum type A injections accounted for nearly 47 percent permanently isn’t ideal. of all cosmetic minimally invasive procedures in 2010. necessarily For something like acne scarring, or a depression is required to inject these products, and they’re here and there, there may be tremendous benefits, but frequently used in combination with procedures using those are very limited circumstances.” hyaluronic acid-based fillers to achieve optimal results, the experts said. Results can last a year or longer. TOXINS LEAD THE PACK “I think the patient gets the most bang for the Approved by the FDA in 2002 for the treatment of buck with Radiesse and Sculptra when you need moderate to severe glabellar lines, botulinum type global revolumnization: the cheeks and temples, the A injections accounted for nearly 47 percent of all marionette lines, the nasolabial folds, the prejowl cosmetic minimally invasive procedures in 2010, sulcus,” Dr. Lupo said. “I will use Sculptra in a panaccording to the ASPS survey. A new type A agent, facial revolumnization, then layer on top of that a abobotulinumtoxinA (Dysport), was approved by hyaluronic acid filler or maybe Radiesse in a deep the FDA in 2009 and now coexists with Botox as dermal position for a localized correction. Radiesse key component of the dermatologist’s anti-aging is my favorite product for men because it’s stiffer. armamentarium. Men’s skin is thicker and heavier, so I need “I believe they’re both remarkable products, with something a little more robust to give the lift a very high patient satisfaction rate,” Dr. Matarasso I’m looking for.” Dr. Weinkle said. “And I think what we’re finding with time is said she also combines that they’re more similar than dissimilar in terms the non-hyaluronic of indications, onset of action, duration, and risk of fillers, occasionally adverse events. However, there’s been a fair amount injecting a patient of confusion with Dysport regarding how much saline with Radiesse in to reconstitute with, and what the potential conversion the marionette ratio is from Botox to Dysport.” Recounting her lines and struggle with that issue, Dr. Lupo said that at first, Sculptra in the some of her patients “were not happy with their cheeks. Dysport. They didn’t get enough improvement or Dr. it didn’t last long enough. Then I had an epiphany Matarasso last spring, and decided to increase the ratio to three DERMATOLOGY WORLD // June 2011 31 Reversing the RAVAGES of time units of Dysport to one unit of Botox. I dilute with two cc’s of saline for both, and that gives me a biological response equivalency. So if there’s ever a mixup in the office and I’m handed Dysport instead of Botox, there’s no risk of over- or under-injecting the patient.” With two equally good alternatives, patient preference often determines which toxin is used, Dr. Matarasso said. “If a patient’s happy with one product, I wouldn’t change. But if a patient has heard of the newer product and wants to try it, or says ‘Gee, I’m not getting the duration I used to get,’ I might switch.” Dr. Lupo expressed a strong preference for Dysport the mathematical gyrations. I don’t think many people are using it off label yet because they’re so comfortable with the toxins they have, and there haven’t been that many publications to offer physicians guidance.” In addition, a topical botulinum toxin type A, RT001 (Revance), is under investigation for the treatment of crow’s feet wrinkles. PATIENT DEMOGRAPHICS DRIVE MARKET GROWTH While the aging of the U.S. population expands the traditional market for anti-aging treatments, dermatologists said patient demographics are changing in fundamental ways that predict even further growth. “I’ve seen a tremendous increase in minority patients The optimal use of fillers and toxins is as ethnic coming in for cosmetic a preventative of aging. procedures,” Dr. Lupo said. “I call it the ‘Obama effect’ — more minorities are feeling like they’re part of America, they see the Obamas as glamorous, in a particular area. “It’s ideal for patients with very and they feel it’s okay to have toxins and fillers. high and wide foreheads because you see a little more Patients are also coming in at an earlier age, which is diffusion with Dysport than with Botox, and thus a great because the optimal use of fillers and toxins is as wider area of effect,” she said. “In fact, I’ve combined a preventative of aging. The younger you are when you Dysport and Botox in the same patient, same visit, and start, the more dramatic the improvement.” had very nice results. I’ll use the Dysport in the crow’s Dr. Matarasso maintained that having a broader feet and the frontalis, and Botox in the glabellar and in palette of minimally invasive procedures is also the lower face.” drawing more patients. “The bottom line is that it’s A third type A agent, incobotulinumtoxin A a new era,” he said. “No longer do we wait too long (Xeomin), was FDA-approved in 2010 for the and just do surgery. We have a more proactive society, treatment of cervical dystonia or blepharospasm. and younger people as well as older, men as well as Unlike Botox and Dysport, Xeomin is a “naked” toxin women, are looking to prevent senescence. You’re with no accessory proteins. “I think there’s a great deal looking at multi-therapy procedures: optimizing their of potential there,” Dr. Matarasso said. “They’re saying topical regimen, neuromodulator, and filler. We have it doesn’t require refrigeration, and it has a one-to-one so much more to offer patients.” dw conversion ratio with Botox, so you don’t have to do DISCLOSURES Dr. Lupo is a trainer and speaker for Sanofi-aventis, an advisory board member for Merz Pharmaceuticals, an advisory board member and speaker for Medicis Pharmaceutical Corp., and an advisory board member, trainer, and investigator for Allergan, Inc. Dr. Matarasso is a consultant to Medicis Pharmaceutical Corp. and Allergan, Inc. Dr. Nestor has received research grants from and is a speaker and consultant for Medicis Pharmaceutical Corp. He is a speaker and consultant for Allergan, Inc. and Merz Pharmaceuticals, and has received research grants from Human Med. Dr. Weinkle is an advisory board member and speaker for Allergan, Inc., BioForm Medical, Inc., Sanofi-aventis, Galderma, Ortho Dermatologics, and Procter & Gamble; an advisory board member for Kythera Biopharmceuticals and Stiefel; a stockholder in Derm Advance; and a consultant for Medicis Pharmaceutical Corp. 32 DERMATOLOGY WORLD // June 2011 www.aad.org ADVERTISEMENT Upcoming CME Activities Fundamentals of Mohs Surgery Please note new location, Rancho Bernardo Inn, San Diego and Mohs Closures session. (Physicians may register separately for the Closures and Fundamentals of Mohs Surgery sessions.) November 1 & 2, 2011 – Closures Session taught by Kenneth G. Gross, M.D. Due to popular demand, we are pleased to add this 2-day Closures session to the course. Prerequisite is basic skill in surgical repairs. This session will emphasize diverse closure techniques of surgical defects following skin cancer removal by Mohs micrographic surgery. November 3-6, 2011 – Regular Fundamentals of Mohs Surgery Session Developed as a comprehensive introduction to Mohs surgery, the course provides an overview of Mohs indications, mapping techniques, office set-up and instrumentation, and interpretation of Mohs histopathology. Instruction in key concepts is facilitated through lectures, “pearls” discussions, interactive Q & A sessions, video microscope demonstrations, and challenging microscope electives. The Mohs technician program will feature hands-on training in Mohs lab techniques and incorporate important safety and regulatory guidelines and updates. A high faculty-to-student ratio helps to ensure rapid skill development and advancement, and allows for discussion of critical troubleshooting techniques relative to tissue processing and slide preparation. AMA PRA Category 1 Credit Available Save the Date! Annual Clinical Symposium – Dermatologic Surgery: Focus on Skin Cancer Memorial Day Weekend, May 24-27, 2012 Location to be Announced Top experts in the field will provide updates on a wide range of dermatologic surgery and Mohs surgery topics. Separate interactive panels will discuss appropriate repair strategies for a variety of surgical wounds and innovative approaches to melanoma treatment. Both Mohs and non-Mohs cases will be featured in the microscope laboratory. Mohs nursing staff, technicians and other Mohs support personnel will increase their knowledge of skin cancer treatment and develop a greater appreciation for their unique roles in supporting high quality patient care. AMA PRA Category 1 Credit Available For additional information regarding ASMS educational activities, membership opportunities, and patient resources, please contact: Novella Rodgers, Executive Director American Society for Mohs Surgery 5901 Warner Avenue, Box 391 Huntington Beach, CA 92649-4659 Tel: 800-616-2767 or 714-379-6262 Fax: 714-379-6272 www.mohssurgery.org [email protected] BY JOHN CARRUTHERS, STAFF WRITER MEANINGFUL Certification Earning incentives and choosing the right system in a wide-open EHR marketplace 34 DERMATOLOGY WORLD // June 2011 www.aad.org W ith penalties looming in 2015 and “meaningful use” incentive payments for adoption available from Medicare and Medicaid (see article, p. 15), many dermatologists are taking a new look at the market for electronic health records (EHRs). They face a marketplace in which many systems are certified to meet the government’s meaningful use requirements and allow them to earn bonus payments — but only three have undergone the process of being certified to meet the needs of dermatologists. What should dermatologists look for? According to dermatologists who have been involved in the development of certification requirements for the specialty and a practice management consultant who works with dermatologists, choosing a system that can meet a dermatologist’s specific needs requires careful, hands-on research, particularly in light of changes to the certification process in the last year. But with a handy checklist of features to look for and a willingness to shop around, dermatologists can make an educated choice that will serve their needs and allow thAem to earn incentivAe payments and avoiAd future penaltiesA. >> DERMATOLOGY WORLD // June 2011 35 MEANINGFUL Certification CERTIFICATION AND MEANINGFUL USE DEFINED The financial incentives offered by the Centers for Medicare and Medicaid Services (CMS) for practices that meet requirements for the “meaningful use” of EHR systems require physicians to adopt an EHR system certified for meaningful use and utilize it to meet a set of CMS-defined objectives for an extended period. These meaningful use objectives are the baseline requirements that practices must meet to qualify for incentive payments. (A list of the 15 required objectives and a menu from which meaningful users must select five more objectives to complete is available at www. aad.org/hitkit.) For physicians who decide to commit to EHR in 2011 or 2012, these payments can total $44,000 over five years if you participate with Medicare, or up to $63,750 over six years if you participate with Medicaid. This potential financial incentive, according to practice management consultant Margret Amatayakul, underscores the importance of meaningful use certification. EHR systems that can be used to earn meaningful use incentives receive certification from an Authorized Testing and Certification Body approved by the Office of the National Coordinator and are designated by an ONC-ATCB seal (see sidebar, p. 38). However, not all products certified for meaningful use are necessarily the optimal choice for dermatology practices. “I think the most important thing for dermatologists is to be sure the products they are looking at are both certified for meaningful use and meet the criteria [that ensure they will be useful for dermatologists],” Amatayakul said. (See sidebar below for a list of criteria to consider.) “Just because a product is certified for meaningful use doesn’t mean it incorporates every function that may be desired,” she said “In fact, the government acknowledges this in the preamble to the regulations.” One way to assess whether a product is useful for dermatologists is to look for dermatology-specific certification from the Certification Committee for Healthcare Information Technology (CCHIT). As recently as 2010 CCHIT was the only body certifying EHR systems and well-known in the industry for CONTINUED on p. 38 CHECKLIST OF FEATURES Before approaching a vendor, it’s important to consider the features that best serve one’s practice. Many Academy members participated in the development of the CCHIT criteria for dermatology-specific certification, the only dermatologyspecific certification on the market. These features include: The ability to capture the characteristics of a lesion as discrete data fields, including color, size, shape, arrangement, distribution, type, scale, and signs. The ability to annotate body diagrams and photos with text, as well as the ability to draw on them. The ability to create a log with statuses of dermatologic specimens removed — from the time of the removal through final action by the dermatologist — without duplicate entry. Free-hand diagrams for each patient encounter. The ability to compare two photos on one screen. A library of cutaneous anatomic diagrams to select from. Exportation of Maintenance of Certification data. 36 DERMATOLOGY WORLD // June 2011 Amatayakul and Drs. Siegel and Kaufmann also recommended that dermatologists evaluate systems based on the following criteria: Inventory management E&M coding assistance Billing and scheduling interface Tablet-enabled Integrated e-prescribing Automatic refill requests Medication history Clinical charting Drug and allergy alerts Electronic billing Lab orders, results, history, and management Surgical templates www.aad.org MEANINGFUL Certification its rigor. The independent nonprofit organization, created in 2004, began certifying EHR technology two years later, and began offering a dermatology-specific certification, based on criteria developed by a work group of dermatologists, for 2011. But while CCHIT is the only body offering dermatology-specific certification, it isn’t the only one approved by the Office of the National Coordinator to certify products for meaningful use and award the ONC-ATCB seal. In 2010 the ONC re-launched the EHR certification program in conjunction with the development of meaningful use incentives and opened up the process to new organizations, creating the Authorized Testing and Certification Bodies (ONCATCBs) certification category. Today CCHIT is one of six ONC-ATCBs that have certified more than 400 EHR systems as qualifying for meaningful use incentives. (An up-to-date list of systems that can be used to earn meaningful use incMentives is availabMle at http://oncchpl.force.com/ehrcert. See sidebar, p. 42, for a list of certifying bodies.) As a result of the changes, and the emphasis on meaningful-use certification over certifying products for specialties, only three EHR systems have qualified for CCHIT’s dermatology-specific certification (see sidebar for more information), according to dermatologist Mark Kaufmann, M.D., who chairs the EHR demonstration sessions at the Academy’s Annual and summer meetings and serves on the advisory board of Modernizing Medicine. “As you might imagine, there are fewer people going for the rigorous CCHIT certification because they don’t have to,” Dr. Kaufmann said. “There are three derm-certified systems — NextGen, NexTech, and VersaSuite — out of more than 400 systems that are certified for meaningful use.” But, as AAD Presidentelect Daniel M. Siegel, M.D., who consults for software makers Ensight and DermFirst, points out, some of the remaining 400 systems may well meet a dermatology practice’s needs. M“There are programMs that are derm- functional, but don’t get the derm certification because they would have to spend more money on that.” (To read more about how CCHIT certification for dermatology was developed, turMn to the sidebar oMn p. 40.) CHOOSING A SYSTEM With many vendors forgoing dermatology certification, dermatologists need to do some digging if they want to look beyond the three CCHIT-Dermatology certified vendors. In choosing a system, it’s important to plan for as much hands-on experience as possible, according to Dr. Kaufmann. The EHR demonstration session at the Annual Meeting, which usually attracts capacity crowds, allows physicians a hands-on demonstration of current EHR software by their colleagues, rather than vendors. Afterwards, he said, many physicians feel far more comfortable explorMing the marketplacMe. “During the demonstrations, we get anywhere from four to six physicians to demonstrate their use of their EHR. They give the good, bad, and ugly of each of their systems. I think that would be a really great way to get your feet wet [for physicians] without EHR experience,” Dr. Kaufmann said. “For those people who are a little savvier, I’d encourage them to see a demo from a vendor, but not rely on a vendor for the decision. They do this all day, so it’s important to take it with a grain of salt. The most important advice that I can give anyone is to go visit a physician who is using a product live and ask if you can just follow them around for an hour or two. Just to see what it’s like to use the system in a live environment. It’s always going to be a little different to see someone using the system in a completely unpredicMtable way.” Dr. Siegel agreed that seeing a colleague demonstrate EHR use would offer those considering a purchase the best sense of what might work for them. For physicians who Mmay be unable to utMilize that option,M he said, there are a number of options to gauge a system’s CONTINUED on p. 40 CERTIFICATION SEALS When browsing a vendor’s website or marketing materials, it’s important to look for certification seals to ensure the product qualifies for government incentives. The CCHIT + Dermatology seal signifies an ambulatory product with dermatology features that satisfies CCHIT’s rigorous standards. (All three currently certified systems are also ONC-ATCB certified.) The ONC-ATCB seal denotes products that have been certified by one of the six ONC-ATCB organizations (see sidebar, p. 42) as qualifying for meaningful use. 38 DERMATOLOGY WORLD // June 2011 www.aad.org She’s paid 45% of her bill after 90 days. † Your hard-earned reputation means patients will wait months for your dermatology services. You shouldn’t have to wait months for payment. With CareCredit Patient Payment Plans, a GE Money company, you receive your money in just 2 business days, even if the patient delays payment or never pays. You reduce your A/R, improve your cash flow, and eliminate the time and money spent on collections. Your patients will also like the convenience CareCredit provides. They can pay over time in easy monthly payments that fit their budget. Plus, they can keep using it for additional or follow-up treatment you’ve recommended. It’s an ideal way to pay for cosmetic procedures or procedures not covered by their insurance. It’s a win-win for your practice and your patients. ® ❯ Helps attract new patients with over 7 million cardholders already approved. ❯ More than 120,000 practices nationwide now offer the convenience of CareCredit. ❯ Enrollment is free. Costs are comparable to credit cards. To enroll at no cost, call 866-247-3049 ext. 2 today. † Does not include processing fees. CareCredit.com 866-247-3049 ext. 2 ©2010 CareCredit MEANINGFUL Certification suitability for their practice. Many vendors offer inpractice demonstrations that give the physician an idea of how the system and its features would integrate into their practice. Further, larger vendors will be able to point one to successful adopters nearby who will be able to discuss the features and functionality of a system with them on the level of a colleague without the necessity of an all-day visit. Speaking with a physician, he said, can often give one an idea of how intuitive the EHR interface is — often a sticking point with new adopters. “The problem is that with many of the text-based systems, there seems to be a lot of fumbling. Things don’t always seem intuitive,” Dr. Siegel said. “What is intuitive to some people may not be for others. There’s great variation on this. The problem is how you tell them what [choices are] out there. Hopefully, with the demo, a physician can look up and say ‘the logic of this is something that works for me,’” Dr. Siegel said. When choosing a system, Amatayakul, who has herself participated in past EHR demonstrations at Academy meetings, said that it’s vital for the physician to negotiate not just for a better financial deal, but for help in training and implementation. In addition to training staff on capturing meaningful use data, additional training can create a much better EHR transition, which will ultimately prove healthier for the practice. “Physicians need to negotiate, negotiate, negotiate the contract. Every contract is negotiable, but price is not the only thing to negotiate,” Amatayakul said. The schedule of payments for the system is potentially more important for dermatologists to negotiate, she said, and noted that with so many physicians trying to become meaningful users in order to earn incentive payments, “vendors will be strapped to do good implementations,” and dermatologists should be sure they carefully scrutinize the level of implementation support, training, and go-live assistance included in their contracts. AWAITING THE FUTURE Dr. Siegel said that physicians experiencing anxiety over the inability to choose a program should remember that waiting, while a progressively less-discussed option, also remains on the table, and he continues to see enhancements from a variety of vendors. CONTINUED on p. 42 DERMATOLOGY, MEANINGFUL USE, AND CCHIT CERTIFICATION Prior to the creation of additional certifying bodies, Mark Kaufmann, M.D., chaired CCHIT’s workgroup on dermatology certification. His experiences help illuminate why dermatology-specific EHRs remain an extremely small sector of the marketplace. “It goes back to CCHIT’s original marching orders. During the previous administration, they were the only game in town — the only body that was certified by the Department of Health and Human Services to certify EHRs. This was before meaningful use. When the AAD got involved trying to get them to hear our complaints, they heard them and said ‘You have a point. Why don’t we put together a work group and create a derm certification?’ “Dr. Kaufmann said. “I co-chaired that work group, and we worked for six months on developing criteria that addressed our concerns about the way they tested the vendors. We came up with a lot of criteria related to photography, graphics, and being able to put photos side by side. [See sidebar, p. 36, for a list of criteria.] They were all things that we wanted in our systems that weren’t being addressed at the time by CCHIT. In the end, it was great, they accepted all of our criteria, and it was all looking really good. Then, all of the sudden, meaningful use came out. So what happened?” Increased government focus on these mandated quality mea- 40 DERMATOLOGY WORLD // June 2011 sures, according to Dr. Kaufmann, took the focus away from EHR vendors addressing specialties and placed it mostly on satisfying meaningful use. The result is a marginalization of CCHIT certification, he said, due to the existence of six certifying bodies instead of one and the way certification in dermatology is structured. “CCHIT decided not to make [certification for dermatology] just a straight derm certification, but rather an add-on certification for ambulatory,” Dr. Kaufmann said. “So what that means is that you had to pass all the other ambulatory requirements before you could pass certification for dermatology as an add-on. It would always be ambulatory plus derm,” he said. Academy President-elect Daniel M. Siegel, M.D., agreed. “The important point to make is that CCHIT or other [ONC-ATCB] certifications are important to get [meaningful use] money back for the user, but all CCHIT certification for derm does is operate like a subspecialty add-on. It doesn’t mean that you’re getting rid of the extraneous stuff that we don’t use, it just means that there are image capture and other features that we use. It’s an important distinction,” Dr. Siegel said. “There are programs that are derm-functional, but don’t get the derm certification because they would have to spend more money on that. And having it doesn’t necessarily mean that it’s user-friendly.” www.aad.org Bio-Oil® is a skincare oil that helps improve the appearance of scars, stretch marks and uneven skin tone. It contains natural oils, vitamins and the breakthrough ingredient PurCellin Oil™. For comprehensive product information and results of clinical trials, please visit bio-oil.com. Bio-Oil is the No.1 selling scar and stretch mark product in 11 countries. $11.99 (2fl.oz.). MEANINGFUL Certification “I’m gung-ho aboutM seeing EHRs truly Mwork. The bar Dr. Siegel’s beliefM in the ability of Mthe EHR is being raised quite a bit in terms of image-based marketplace to groMw and advance is sMupported by the remarkably rapid adMvances in both theM hardware and functionality and intuitive navigation. I can’t imagine the larger players not continuing to evolve,” Dr. Siegel software. “We’ve watched a lot of things change. When we first said. “They’re going to have to try to be better. Everyone wants to have the best features. And by definition, if started down this road, all the software was server-based. you’ve got something new that works, you’re in the lead. You had to buy a server and have it in your office. Now, even the server-based vendors have options where you It will be interesting to see what happens. If I hadn’t yet converted, I mightM be tempted to waiMt for about a year.M” can use software as a service and work in the cloud,” Dr. Siegel said. “Now, all you need is a good connection The window to wait a year and still earn meaningful use incentives remains open for the moment. to the Internet, rather than a large investment in Physicians only have to attest to meaningful use for the infrastructure. Someone coming out of residency who last three months of their first year on the program. wants to go digital can make use of an option where they can get software as a service and a wireless router Physicians who are able to get their practices up and with security features — and be up and running within running on a certified EHR system before October of 2012 can still recMeive the maximum iMncentive amount. hours. It’s very imMpressive.” dw CERTIFYING BODIES Products accredited by the ONC-ATCB are evaluated by one of the following six organizations. • Surescripts LLC (Arlington, Va.) o Date of Authorization: Dec. 23, 2010 o Scope: EHR modules — e-prescribing, privacy, and security • ICSA Labs (Mechanicsburg, Pa.) o Dec. 10, 2010 o Complete EHR and EHR modules • SLI Global Solutions (Denver) o Dec. 10, 2010 o Complete EHR and EHR modules 42 DERMATOLOGY WORLD // June 2011 • InfoGard Laboratories, Inc. (San Luis Obispo, Calif.) o Sept. 24, 2010 o Complete EHR and EHR modules • Drummond Group, Inc. (Austin, Texas) o Sept. 3, 2010 o Complete EHR and EHR modules • CCHIT (Chicago) o Sept. 3, 2010 o Complete EHR and EHR modules www.aad.org &ORTHETREATMENTOFACTINICKERATOSIS :YCLARA Significant lesion reduction WITHLONGTERMBENElTS Once-daily dosing tin a simple courset sWEEKSONWEEKSOFFWEEKSON -ANYPATIENTSWHOCLEAREDWITH:YCLARAREMAINEDCLEAR sOFPATIENTSHADCOMPLETECLEARANCE1 sHADPARTIALCLEARANCE1 – Partial clearance defined as *REDUCTIONINTHENUMBER OFLESIONSATBASELINE sREDUCTIONINOVERALLLESIONCOUNT1 s!TMONTHSPOSTTREATMENTOFPATIENTSWITHCOMPLETECLEARANCE REMAINEDLESIONFREE s!TMONTHSPOSTTREATMENTOFPATIENTSWITHCOMPLETECLEARANCE REMAINEDLESIONFREE 7EEKS/N 7EEKS/FF 7EEKS/N Zyclara Cream is indicated for the topical treatment of clinically typical visible or palpable actinic keratoses (AK) of the full face or balding scalp in immunocompetent adults. In clinical studies, the most common side effects involved skin reactions in the application area. These reactions included erythema, scabbing or crusting, flaking, scaling or dryness, edema, erosion or ulceration, and weeping or exudate. Most skin reactions were rated as mild to moderate. Intense local inflammatory reactions and/or flu-like systemic signs and symptoms can occur. Dosing interruptions may be required. Exposure to natural or artificial sunlight (tanning beds or UVA/B treatment) should be avoided or minimized during use of Zyclara Cream. Please see Brief Summary of Full Prescribing Information on adjacent page. Visit us at www.ZyclaraCream.com References: 1. Swanson N, Abramovits W, Berman B, et al. Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: results of 2 placebo-controlled studies of daily application to the face and balding scalp for two 2-week cycles. J Am Acad Dermatol. 2010;62(4):582-590. 2. Hanke CW, Swanson N, Bruce S, et al. Complete clearance is sustained for at least 12 months after treatment of actinic keratoses of the face or balding scalp via daily dosing with imiquimod 3.75% or 2.5% cream. J Drugs Dermatol. 2011;10(2):165-170. ©2011 Graceway Pharmaceuticals, LLC, Bristol, TN www.gracewaypharma.com www.ZyclaraCream.com ZYC021122 academy perspective from the president BY RONALD L. MOY, M.D., AADA PRESIDENT SkinPAC donations key to specialty’s success ur specialty’s successful pursuit of our advocacy agenda in the present legislative environment requires a strong presence in Washington and good relationships with members of Congress and key policymakers. If you want to help dermatology build relationships with members of Congress and key policymakers, there are few things you can do as an individual dermatologist that will be more helpful than contributing to SkinPAC, the American Academy of Dermatology Association’s political action committee. The relationships that SkinPAC helps to build on Capitol Hill make the AADA the trusted voice of dermatology in Washington, D.C., ensuring that we have the influence we need. Without those relationships we’d have no seat at the table as important decisions are made, and no ability to influence legislation. SkinPAC provides our members and representatives access to legislators and affords us the opportunity to start a dialogue about dermatology and the practice of medicine. Our primary goal is to become a valuable and trusted resource on the major issues facing our specialty. Think about the way we are often viewed in the media. Our Academy’s focus on skin cancer prevention makes headlines, of course — but many of the stories lawmakers see about us relate to aesthetic, elective procedures and attempt to trivialize what we do. They can perceive our specialty to be over-compensated and presume that dermatologists mainly perform cosmetic procedures. Which specialty do you think Congress might pursue for reimbursement cuts or tax increases to balance the budget based on such perceptions? SkinPAC lets us teach lawmakers about the full scope of what dermatologists actually do. We treat more than 3,000 skin diseases, many of which are debilitating or life-threatening; the access SkinPAC provides reminds lawmakers of this fact. We are, largely, a specialty made up of small business owners, meaning we have particular concerns among physicians regarding many payment reform proposals; SkinPAC lets lawmakers know how their proposals will impact our small businesses and the many people we employ. We seek regulation of the use of indoor tanning beds; SkinPAC reminds lawmakers why that regulation is vital to public safety, encourages lawmakers to support it, and thanks those who have stood with us in the past. We want to ensure that patients have access to a dermatologist for their skin, hair, and nail health concerns, not a non-physician clinician in their general practitioner’s office; SkinPAC reminds lawmakers that this is what most Americans want, too. Although success in advocacy may be hard to quantify, we have seen how SkinPAC is an effective tool on a number of our legislative priorities. Winning often means that a bad bill O never gets introduced in Congress or that a particularly bad provision is stripped out of a bill and replaced with a better one. The new health care law, for instance, included a provision that required business owners to report to the Internal Revenue Service transactions of $600 or more. This would have been tremendously burdensome for our practices. Though there were many other stakeholders outside of health care providers, SkinPAC’s resources allowed the AADA to play a leading role in the physician community on this issue. Our combined efforts helped ensure passage of the repeal of this provision, which President Obama recently signed into law. Also, before the new health care law was released to the public, it included a tax on cosmetic procedures. SkinPAC’s relationships allowed us to replace the cosmetic tax with a 10 percent tax on indoor tanning. We have also helped to delay implementation of penalties for not using electronic health records. Finally, another provision in the new health care law required drug and device manufacturers to report all payments to physicians. Through SkinPACsupported relationships, the AADA worked to get significant protections for physicians included. We were able to meet these challenges, but there are more to come. We must support SkinPAC as we continue to advocate for positive change in the health care delivery system. Convinced? Wondering how you can give to SkinPAC? Contributions can be made on a one-time basis or via scheduled automatic deductions, either monthly or quarterly. For more information, visit www.skinpac.org or contact Sam Hewitt, the AADA’s manager of political affairs, at [email protected] or (202) 712-2609. dw DERMATOLOGY WORLD // June 2011 45 academy update BY RONALD A. HENRICHS, CAE Academy ready to be your partner in coping with change EXECUTIVE DIRECTOR’S REPORT WHAT WILL THE DERMATOLOGY PRACTICE OF THE FUTURE LOOK LIKE? What role will dermatologists play in the health care delivery system as it evolves? And the question senior Academy staff have been pondering most often and recently — how can the Academy best anticipate any resultant challenges and help members thrive in the face of these likely changes? Given the potential scope of the evolution, Dr. Moy has asked senior staff and a newly appointed Ad Hoc Task Force (AHTF) on Positioning Dermatology for Success, chaired by AAD Vice President Suzanne Connolly, M.D., to focus on how to engage members in shaping their own futures in these uncertain times. These questions have become especially vital for us to consider in the wake of the passage of health system reform last year. As the Patient Protection and Affordable Care Act is implemented, even with some key modifications along the way, it is clear that it could significantly alter the environment in which dermatologists provide their patients with the best possible care. Answering the questions above will take time, however — there are rules to be analyzed and commented on, pilots to be monitored and evaluated, and lobbying efforts to lead or join before the outcome is unambiguous. What we know in the meantime is that, regardless of how reform’s implementation progresses, Academy members will continue to need to conduct research, deliver dermatologic care based on the best available evidence, and achieve — to the extent possible — measurable, demonstrable outcomes. Now more than ever, we hope you’ll look to your Academy as a trusted partner, working with you to ensure that you have the information, guidance on clinical best practices, and advice on navigating changing practice and socioeconomic environments necessary to remain successful. The coming change may be unsettling at times, but your Academy is committed to listening to and reflecting your concerns in its advocacy efforts, while at the same time helping you prepare for any contingency. Being the best advocate and partner for you required the Academy to evaluate the way it communicates with and receives feedback from members. We recently undertook a systematic look at the way we deliver content to you, from our print and online publications to the educational and practice support products we offer. This audit resulted in 46 DERMATOLOGY WORLD //June 2011 an effort to develop a comprehensive plan to achieve our goal of delivering the right information to you at the right time in the right way. The task force noted above, together with several Academy Councils, will be actively helping to shape that plan. You can already see a preview of how we’re changing to better meet your needs in the magazine you’re holding (or, perhaps, browsing online). Dermatology World has been updated based on your feedback, both in surveys and in person, to reflect your information needs, from brief news updates to clinical and coding pearls to in-depth coverage of important topics. Our website, AAD.org, has undergone a similar process. Behind the scenes, the Academy has invested in a new information technology management system that will ultimately allow us to better customize our flow of information based on your specific preferences. I’m proud of these enhancements and invite you to provide your ideas to help continually refine them. In the final analysis, the Academy’s ultimate goal is to ensure a constructive dialogue with you while better meeting your needs in these changing times. www.aad.org news + events Board of Directors votes on Advisory Board resolutions THE ACADEMY’S BOARD OF DIRECTORS CONSIDERED 11 RESOLUTIONS passed by the AAD and AADA Advisory Boards in February during its May 7 meeting, referring most of them to the appropriate councils and committees for further consideration or action. The Board of Directors did not support a resolution calling on the Academy to add the words “dermatologic surgery” to its name, instead charging the Council on Communications with evaluating ways the Academy’s vision statement could reflect the breadth of the specialty while taking into account the inherent value of the organization’s present branding. It also did not support a resolution calling on the Academy to support the teaching of Mohs surgery in all dermatology residency programs and the inclusion of the topic on the American Board of Dermatology’s certifying exam; the Board of Directors felt this was a matter that would be more appropriately handled by the dermatology residency review committee. The Board referred to the Council on Communications a resolution calling on the Academy to embrace a media strategy that reflects the importance of isotretinoin in dermatology, while sending a resolution calling for the Academy to coordinate with state medical societies to urge schools to provide education on the dangers of tanning to the Melanoma Skin Cancer Committee. The Council on Science and Research was called on to consider a resolution to investigate whether airport x-ray scanners are harmful to skin cancer patients as it develops a prioritized research agenda. A resolution calling on the AADA to urge the Federal Drug Administration to approve cantharadin as a treatment for pediatric molluscum was referred to the Regulatory Policy Committee, which has already been actively engaged in working with the FDA to identify the source of and solutions to the cantharadin shortage. The committee was also charged with developing a position statement on cantharidin. A resolution to help unite efforts to pass state legislation prohibiting indoor tanning by minors was referred to the State Policy Committee, which has been working on this issue as a top priority for years. Another resolution to develop model state legislation based on the recent Pennsylvania law regarding ID badges was also referred to the State Policy Committee for further consideration. A resolution about educating members regarding accountable care organizations (ACOs) was referred to the ACO Workgroup, which has been actively leading the AADA’s efforts to develop policy on ACOs. A resolution calling on the Academy to work with the American Medical Association to obtain an exemption from electronic medical records adoption for small-practice physicians nearing retirement was referred to the Council on Government Affairs, Health Policy and Practice and the Dermatology Section Council. A resolution urging the AADA to use a variety of more effective ways to report to members on federal developments such as MedPac meetings was also referred to the Council on Government Affairs, Health Policy and Practice. – RICHARD NELSON DATEBOOK WHAT’S COMING UP Members Making a Difference nominees sought GIVE ACADEMY MEMBERS THE OPPORTUNITY TO BE INSPIRED by compassionate volunteer work being done by dermatologists by nominating yourself or a colleague for the Members Making a Difference Award. This special award honors members of the Academy for their volunteer work. Volunteer activities can take place in a variety of dermatologic settings, or be a unique volunteer experience. Award winners have their volunteer work profiled in Dermatology World. Visit www.aad.org/forms/MakingADifferenceAward/Default.aspx to complete the online nomination form. Looking for volunteer opportunities? The Academy offers many ways for members to get involved. For more information, visit www.aad.org/member-tools-and-benefits/ volunteer-opportunities. - NIKKI HATON DERMATOLOGY WORLD // June 2011 47 academy update Grants available to attend international meetings THROUGH ARRANGEMENTS BETWEEN THE ACADEMY AND SEVERAL INTERNATIONAL DERMATOLOGICAL SOCIETIES, a number of travel grants are available for U.S. and Canadian residents, fellows, or young dermatologists (within five years of completing residency) to attend the 2012 annual meetings of the societies. The grants offer successful applicants the opportunity to meet foreign colleagues and establish longlasting professional relationships. Applicants should clear scheduling conflicts before applying. Criteria for the scholarships include: • Applicants may apply for only one scholarship. • Each residency program may only submit two applicants for the scholarships and only one applicant per international meeting. • Applicants must have completed at least one year of training by the time of the meeting. • Previous recipients of any of these scholarships are not eligible for another scholarship. • Applicants must attach a letter of nomination from their dermatology residency training director to their application. Applications and nominations are due Sept. 30, 2011 at www.aad. org/scholarshipopportunities/#ismtg. Nominations will be reviewed and decisions made by the International Affairs Committee; individuals will be notified in November 2011 about the status of their applications. Each scholarship program has different requirements and provisions; visit the AAD website for specifics. Participating international dermatology societies include: • Brazilian Society of Dermatology • British Association of Dermatologists • Chilean Society of Dermatology • European Academy of Dermatology and Venereology • French Society of Dermatology • Indian Association of Dermatologists, Venereologists and Leprologists • Irish Association of Dermatologists • Israel Society of Dermatology & Venereology • Italian Society of Dermatology • Scottish Dermatological Society • Dermatological Society of Singapore - COURA BADIANE news + events Academy Board adopts updates to “Fellow” logo usage policy, ethics code THE ACADEMY’S BOARD OF DIRECTORS APPROVED A PAIR OF UPDATES at its May 7 meeting regarding use of the American Academy of Dermatology “Fellow” logo and the applicability of its code of ethics to non-dermatologist, physician members. The first change, recommended by the Council on Communications, refines the acceptable usage policy of the AAD “Fellow” logo on member websites. Under the revision, U.S. and Canadian Fellows are permitted to use a specially designed “Fellow” logo on their websites, but only on pages of the site where the Fellow member is featured. This is to prevent the use of the logo “in any way that could reasonably be considered to cause confusion regarding the status of non-dermatologist employees of the practice.” The second regulation adopted by the board, recommended by the Ethics Committee, sets out a more specific definition of “dermatologists” as it relates to the administrative regulations of the Code of Medical Ethics for Dermatologists. The code’s provisions related to “dermatologists” apply to all members “except Adjunct Members and Honorary or Life Members who were Adjunct Members and are not eligible under any other membership categories.” This new language means that the code not only applies to dermatologist members, but that any provision not uniquely applicable to the practice of dermatology will also apply to non-physician and non-dermatologist physician members. Members with questions about either of the revised policies can contact the Member Resource Center at (866) 503-7546 or [email protected]. Members can download the logo at www.aad.org/forms/FellowLogos/ Default.aspx. - JOHN CARRUTHERS Academy seeks volunteers for committees and task forces EACH YEAR, HUNDREDS OF DERMATOLOGISTS SERVE THE ACADEMY through its organizational governance structure and other volunteer opportunities. President-elect Daniel M. Siegel, M.D., M.S., is now accepting applications to fill 2012 open appointments. The online appointment application is now available at www.aad.org. Applications must be submitted by June 30; members who are selected to serve will be contacted in early winter. Letters of recommendation are suggested but not required. Information about specific committees and task forces, committee member responsibilities, and other volunteer opportunities is available at www.aad.org/about-aad. - JEANINE COFFMAN 48 DERMATOLOGY WORLD //June 2011 www.aad.org Teach the fundamentals of skin cancer and sun safety Perfect for school presentations and screening events, the See SPOT CD contains four dynamic PowerPoint™ slide presentations, each specially targeted to a different age group. In addition to the presentations, the See SPOT CD also includes: • Scripts that follow along with each presentation, slide by slide • Pre- and post-presentation evaluations to test your audience’s sun-safety knowledge • Printable coloring pages and word finds – great as a giveaway or for your waiting room Adults Pre-teens and Teens Children Grades K-2 Children Grades 3-5 Order at www.aad.org today. Copyright © 2011 American Academy of Dermatology. All rights reserved. academy update news + events Academy offers grants for development of innovative CME THE ACADEMY SUPPORTS THE DEVELOPMENT OF INNOVATIVE CONTINUING MEDICAL EDUCATION through its Program for Innovative Continuing Medical Education in Dermatology (PICMED). Supported by a contribution from the Elsevier Foundation and the Skin Disease Education Foundation, PICMED’s endowment fund is used to support excellence in dermatology through the development of CME that includes: • Creative needs assessment mechanisms, • Innovative uses of technology, • Unique approaches to specific subject matter, • Novel presentation techniques, and/or • Utilization of existing educational paradigms in new environments. Requests for grants for 2011 are due Aug. 31. Successful applicants will be notified by Dec. 15. To learn more and apply for a grant, visit www.aad.org/forms/picmed/default.aspx. -RICHARD NELSON Nominate 2012 Honorary Members Due Sept. 1 Academy to pursue social media strategy THE ACADEMY SEEKS NOMINATIONS FOR INDIVIDUALS to be considered for 2012 Honorary Membership. Nominees for Honorary Membership must meet certain criteria; primarily they must have demonstrated leadership and service that affirms an uncommon and sustained dedication to dermatology and the goals of the Academy. In most cases, this honor is bestowed for a “lifetime” of dedication and distinguished service. Although not a determining factor, nominees should have held a prominent office in the Academy. Please submit Honorary Member nomination(s) online at www.aad. org/forms/honorarymembership/ by Sept.1, 2011. When submitting a nomination you are also required to submit a brief biography of the nominee, including his or her accomplishments and reasons for granting honorary membership. The Board of Directors will select the 2012 Honorary Membership recipients and they will be announced during the 70th Annual Meeting, March 16–20, 2012 in San Diego. – SHANNON GIGNAC IN RECOGNITION OF THE NEED FOR EFFECTIVE AND EFFICIENT COMMUNICATIONS TACTICS in the immediate future, the Academy’s Board of Directors adopted a recommendation from the Council on Communications that the organization pursue a social media communications strategy aligned with the AAD Strategic Framework. The Council’s recommendation followed a long period of study and research. The Council recommended the establishment of initial participation in social media through the two most popular category leaders in social media — Facebook and Twitter. In doing so, the Academy will be able to serve its key constituent goals — addressing the public, encouraging advocacy, and direct communication with members. More information will appear in Dermatology World as the Academy launches its Facebook and Twitter presences. – JOHN CARRUTHERS Obituaries The Academy recently learned with sorrow of the passing of the following members of the dermatologic community. A. Russell Brenneman, M.D., 77, Muskogee, Okla. Completed dermatology residency training at Yale University School of Medicine. Died Dec. 23, 2009q. Joseph G. Daddabbo, M.D., 61, Liberty Township, Ohio. Completed dermatology residency training at University of Cincinnati. Died Jan. 3, 2010. Jose Fernandez-Vozmediano, M.D., 60, Puerto Real, Spain. Completed dermatology residency training at University of Cadiz. Died March 22. Donald H. Huldin, M.D., 77, East Lansing, Mich. Completed dermatology residency training at University of Michigan. Died July 17, 2010. Dallas A. Johnson, M.D., 75, Stilwell, Kan. Completed dermatology 50 DERMATOLOGY WORLD //June 2011 residency training at University of Texas. Died Jan. 19. Roger Laubenheimer, M.D., 85, Brookfield, Wis. Completed dermatology residency training at University of Michigan. Died March 24. Allan L. Lorincz, M.D., 86, Oak Lawn, Ill. Completed dermatology residency training at University of Chicago. Died Sept. 1, 2010. Fenwick Leigh Watts, M.D., 86, College Station, Texas. Completed dermatology residency training at University of Texas. Died March 23. David John Yanase, M.D., 55, San Antonio. Completed dermatology residency training at San Antonio Uniformed Services Health Education Consortium. Died May 5, 2010. Obituaries are published in Dermatology World after information is submitted to the AAD. Information on member obituaries should be submitted in writing to Sandra Christmas, AAD Member Services Dept., P.O. Box 4014, Schaumburg, IL, 60168-4014, via fax at (847) 330-1090, or via e-mail at [email protected]. dw www.aad.org Recommend a stretch marks therapy that lives up to its promises. Wear your skin proudly.™ Mederma® Stretch Marks Therapy is dermatologist tested and clinically proven to reduce discoloration, improve texture and enhance softness .* 80% ACTUAL RESULTS of women in a clinical study showed visible improvement in 12 weeks. Mederma® Stretch Marks Therapy delivers results. Results your patients will see. Available for in-office dispensing. More information at Mederma.com. *SKINmed: Dermatology for the Clinician, April 2010. Before After 12 weeks accolades Dermatologist Richard B. Odom honored with AAD Gold Medal he Academy presented Sonoma, Calif., dermatologist Richard B. Odom, M.D., with the organization’s highest honor earlier this year during the Academy’s 69th Annual Meeting in New Orleans. Dr. Odom was nominated by William D. James, M.D., immediate past president, in recognition of his exceptional and uncommon contributions to the specialty of dermatology and commitment to the Academy’s mission. Dr. Odom is a past president of the Academy, as well as a past member of the AAD board of directors. He has served as chief of dermatology at the former Letterman Army Medical Center in San Francisco, as well as a professor of dermatology and dean of continuing medical education at the University of California, San Francisco. As a writer and editor, he has served on the editorial board for the Journal of the American Academy of Dermatology and co-edited multiple editions of Andrews’ Diseases of the Skin. He has also authored more than 125 abstracts, book chapters, and journal articles. “It’s the highlight of my professional life,” Dr. Odom said. “It was thrilling, humbling, and quite an honor to receive it — particularly in view of all of the previous winners. It’s a very distinguished group of people, and it’s an honor to be recognized this way by the AAD.” –JOHN CARRUTHERS T Media Highlight The Academy’s Key Messages booklet provides tips for media interviews and talking points on the dermatology topics about which media most frequently inquire. The online booklet can be found in the Academy’s Media Relations Toolkit at www.aad.org/member-tools-and-benefits/ media-relations-toolkit. In the May issue of Allure (circulation: 1,082,873), Lisa Rhodes, M.D., Melissa Lazarus, M.D., Fredric Brandt, M.D., Elisabeth Shim, M.D., Francesca Fusco, M.D., Neal Schultz, M.D., Steven Wang, M.D., Leslie Baumann, M.D., and Zoe Draelos, M.D., were all featured in a “Sun & Skin Special” that provided readers with tips for sunscreen selection and application. The article also promoted the Academy’s free skin cancer screening program and directed readers to the Academy’s website, MelanomaMonday.org. To read other dermatology stories in the news, visit the Academy’s Media Relations Toolkit. –KARA JILEK 52 DERMATOLOGY WORLD //June 2011 celebrating members Members Making A Difference: Tina Chen, M.D. RESIDENT TAKES DERMATOLOGIC TEACHING ABROAD DESPITE A FAIRLY SHORT CAREER COMPARED TO MANY OF HER COLLEAGUES, Tina Chen, M.D., has undertaken a great deal of volunteer work both in the U.S. and abroad as part of her mission to share her dermatology skills with those in most need of them. The third-year resident at the University of CaliforniaIrvine has traveled to Mexico and China to deliver dermatologic care, as well as volunteering with a severely underserved community of sex workers and transgendered people during her time in medical school in San Francisco. “I think my favorite part is being able to love those who are underserved. There’s a real need, not just internationally, but domestically, to serve them.” • Dr. Chen has undertaken a number of trips through the Global Health Outreach, traveling to Wafangdian, China and Valladolid, Mexico. • During her volunteer trips, Dr. Chen has seen a number of uncommon conditions, including x-linked ichthyosis and chromoblastomycosis. • Prior to her trip to China, Dr. Chen worked with her mother — who is fluent in Mandarin — to translate the Academy’s teaching cards. They’re now available through the Academy for dermatologists traveling to China who wish to leave behind teaching material for local primary care physicians. • “I would encourage everyone to participate in an international volunteer trip. It’s a lot of fun; you get to work with other amazing doctors who share a passion for caring for the needy. You learn about a new culture and form relationships with people you may otherwise never have met.” –JOHN CARRUTHERS www.aad.org classifieds PRACTICES FOR SALE PROFESSIONAL OPPORTUNITIES BOULDER, COLORADO ARIZONA Established Cosmetic/General We are proud to offer the opportunity Derm Practice For Sale. Contact to join our team as our practice Cathy Higgins at (303) 530-3405. rapidly grows progressively, and professionally, expanding locations in North- ST. LOUIS, MISSOURI ern, Southwestern and Central Arizona. A well-established solo general We are in search of Dermatologists derm practice for sale in a very desir- and/or Mohs surgeons for our well- able lcation in South County suburb. established dermatology practices. Turn key operation with experienced Ideal candidates would be comfortable staff. Available at (314) 822-4433 or [email protected]. performing medical, surgical and cosmetic dermatology. We offer BREMERTON, WASHINGTON competitive salary and benefit package Turn key solo medical derm practice to the right candidate, excellent office with huge potential for development team, state-of-the-art facilities and of aesthetic services and/or multiple equipment, and the stability of a practitioners. Current owner is retir- dominate practice in our communities. ing. Fax: (360) 479-0225 or email: Salary, benefits, and contract specifics ecarmick@qwestoffice.net based on experience and training. For further inquiries contact: Christina Petersen, Practice Administrator Email: [email protected]. We Buy Practices • Retiring • Monetization of your practice • Locking in your value now • Succession planning • Sell all or part of your practice Please call Jeff Queen at (866) 488-4100 or e-mail ger ope pa ethosc st A PD screen n su Discover Beebe Medical Center, a progressive hospital located jusht six blocks from hthe Atlantic coast in Lewes, Delhaware. Close proximihty to Baltimore, DC, Philahdelphia and NYC. DERMATOLOGY OPPORTUNITY: Q General dermatologist with opportunity for full surgical and cosmetic surgical dermatologic services Q Full-time board elivgible/board certifived dermatologist Q Unlimited opportunity to expand existing practice Q No start up costs vplus full hospital vsupport Q Competitive salary & compensation package Q Acute care 210-bed hcommunity hospital Q 200 physicians on shtaff in 36 specialthies Q Facilities include hcancer center with hradiation ® Q 2010 & 2011 Distinhguished Hospital frohm HealthGrades E-mail cover lette,r and CV to: Marily,n Hill, Director of ,Physician Services, [email protected]. Phone: 302-645-3100h ext 3669 l Fax:h 302-644-9032 SOUTHERN ARIZONA Beebe Medical Cente,r www.beebemed.org 424 Savannah Road hl Lewes, DE 19958 h Immediate opening. Established No recruiting firms, please. No visa opportunities. practice. Partnership is offered – no cash required. Experienced staff. Contact Jeff Queen, (866) 4884100 or [email protected]. www.mydermgroup.com. [email protected] Visit www.MyDermGroup.com OFFICE SPACE AVAILABLE NORTHERN CALIFORNIA Located midway b/w San Francisco, BEVERLY HILLS Luxury Sublease Space Available in the premier Beverly Hills building. Adjoining 2 operating room surgery center with full accreditiaion makes this the perfect opportunity for dermatologic and Mohs surgery. (310) 385-0000. Napa, & Tahoe, we are seeking a BC/ BE Dermatologist 4-5 days per week to join well established General & Cosmetic Derm practice. Outstanding staff, warm office environment, suburban setting, state-of-the-art surgery, laser & computer equipment. Partnership opportunity. Mentorship in ad- 2 O.R. Surgery Center available for use / investment user in Beverly Hills. (310) 860-0000. vanced cosmetic & reconstructive procedures if desired. Productivity, hours, vacations all flexible based on your goals. Excellent opportunity for income FOR MORE INFORMATION: Contact: Carrie Parratt Phone: (847) 240-1770 Fax: (847) 240-8618 E-mail: [email protected] www.aad.org and Family/Life Balance. To apply, please send CV, and short Bio with your goals to: [email protected]. DERMATOLOGY WORLD // June 2011 53 classifieds PROFESSIONAL OPPORTUNITIES BOULDER, COLORADO SUBURBAN CHICAGO NEW JERSEY Established Mohs/Cosmetic dermatol- Full time medical dermatologist A thriving multi-facility Dermatology ogy practice seeks exceptional BC/BE wanted to join busy practice. Great practice with locations near the beau- dermatologist to take over all general opportunity to develop Derm Pathol- tiful New Jersey coast and Philadel- dermatology. State-of-the-art office, ogy or Cosmetic Derm program in phia, Pa. is seeking a career oriented excellent staff, established EHR, out- dynamic clinical setting with two physician with a strong general, door activities abound. Guaranteed sal- Mohs Surgeons. Short commute from cosmetic and surgical/Mohs Derm ary and incentives. Please submit a CV downtown Chicago. Two new office background to join a fast-paced team 4100 or [email protected]. and letter of interest to cdevore.dsb@ locations with new equipment. In oriented work environment. This pri- www.mydermgroup.com. gmail.com or fax to (303) 442-2696. house Permanent Section Pathology vate practice also offers Laser treat- and Mohs Micrographic Surgery Labs. ments and Aesthetic services. Com- CENTRAL FLORIDA Compensation proportionate to petitive salary, health insurance and Physician opportunity available in a clinical activities with generous employee discounts are only some of busy Central Florida dermatology prac- incentives. First year income guaran- the generous benefits. The ideal can- HUNTINGTON, WEST VIRGINIA tice. Family oriented community close tee and malpractice insurance cover- didate should be detail oriented, BC/BE Derm/Derm Path needs to theme parks, cruises, and beautiful age. CME stipend. Coverage shared energetic, progressive individual who BC/BE Derm in the charming river city beaches. Full time position with ben- among group. Contact: Clarence likes a challenge. Email resume to of Huntington, WV. Very competitive efits. Pay range negotiable. Please see Brown at (773) 294-0107 or at [email protected] or salary plus bonus. Minimum call. our website at www.fladermdoc.com [email protected]. fax (609) 653-8713. Excellent benefits include sign bonus, SOUTH CENTRAL, MICHIGAN PORTLAND, OREGON Dermatologist needed in South Central The Portland Clinic, a large partner- FLORIDA Michigan for an amazing opportunity owned multi-specialty clinic, is seeking Southeast Treasure Coast Florida. to develop a fully supported practice. a BC/BE general dermatologist to join huntingtonmedicalaFssociates@gmail. 2-1/2 Days/week, BC/BE Dermatolo- Currently only two other dermatologists one other in a very busy practice. Please com, www.huntingtondermcare.com. gist. Salary plus bonus & Benefits. serving a patient population up to contact Jan Reid at (503) 221-0161 Send CV to [email protected]. 300,000. Opportunity offers a broad- x4600 or email [email protected]. Please fax CV to (407) 293-2049 or email to [email protected]. SOUTHERN VERMONT Immediate opening. Established practice. Partnership is offered – no cash required. Experienced staff. Contact Jeff Queen, (866) 488- moving expenses, CME, med school loan payback, and more. Contact us at (304) 529-0900, email: spectrum general derm practice with JUPITER, FLORIDA the option to perform MOHS surgery Dermatology group looking for ethical, and expand into specialty areas of in- hard working general dermatologist in terest. Fully staffed and managed of- beautiful office. Excellent compensa- fice. Excellent earnings potential with tion package and benefits. Please email outstanding guaranteed salary plus resume to [email protected] generous quarterly performance bonus or call (561) 346-6900. and full benefits. Excellent recruitment You Spoke. We Listened. incentives include: signing bonus, paid interview and moving expenses, loan SUNRISE, FLORIDA repayment up to $50k, $30k reloca- Immediate opening. Established tion stipend and more. Visit our web- practice. Partnership is offered – no site: www.allegiancehealth.org. Please cash required. Experienced staff. contact Michelle Spielberg at (800) Contact Jeff Queen, (866) 488- 547-1451 or E-mail: mspielberg@ 4100 or [email protected]. sourceonestl.com. www.mydermgroup.com. SALES INFORMATION UPCOMING DEADLINES FOR FUTURE ISSUES: August .............................July 1 September ...................August 1 October ................. September 1 November .................. October 3 December ............... November 1 54 DERMATOLOGY WORLD //June 2011 PRINCETON, NEW JERSEY • Well-established practice looking to expand • Vibrant university town close to Philadelphia & Manhattan • State-of-the-art facility opened in July 2010 • Competitive salary & benefits Contact Jayme at (609) 924-7690 www.princetondermatology.com Your feedback is critical to the success of the programs and services the AAD offers to members. Because of your comments, the AAD’s flagship publication, Dermatology World, has been enhanced to provide even more trustworthy information to help you navigate practice, policy, and patient care. As a member you can move mountains. Your feedback today can help us generate ideas for future issues of Dermatology World as we continue to strive to serve you better. We are still listening. Tell us what you think about the new Dermatology World and be entered for a chance to win a $500 Visa Gift Card. Visit the June digital edition at www.aad.org/dw and look for this ad to enter. www.aad.org classifieds ad index PROFESSIONAL OPPORTUNITIES We gratefully acknowledge the following advertisers in this issue: Company Product/Service American Society for Mohs Surgery ..CME ....................................................... 33 Amgen Inc ...........................................Enbrel.................................... 48A-48D, 49 Avantik ................................................Laboratory Services................................ 8 Associates in Dermatology, Inc. located in Hampton, VA, is seeking to add a BC/BE Dermatologist to our successful and rapidly growing practice. Patient volume for a full-time physician is immediately available. We are medically, surgically and cosmetically oriented and located in a state-of-the-art practice owed facility. Physicians are supported by stable staff that includes a physician assistant, aesthetician and 10 MAs. Well staffed with medical assistants maximizing efficiency by providing patient preparation, EMR data entry, and post-visit paperwork and patient notification. Care Credit ..........................................Credit Services...................................... 39 We are looking for someone who is interested in being a vested contributor to our growth and the long-term direction of the practice. The position offers flexibility with either full or part time employment, competitive salary, incentive bonus, partnership potential, medical benefit package, malpractice insurance, paid vacation, 401(k)/pension plan, EMR, and excellent support staff. Nextech ...............................................EHR Software ..................................... BC Please contact Dana Cobb, Office Manager at (757) 838-8030 or email [email protected] Centocor Ortho Biotech ......................Stelara................................... 8A-8D, 9-10 Coria Laboratories..............................Acanya ..............................................29-30 Dermpath Lab of Central States ........Corporate ................................................ 5 Ederm Systems ..................................EHR Software...................................... IFC Graceway Pharmaceuticals................Zyclara .............................................43-44 Innovative SkinCare ............................IS Clinical .............................................. 37 Leo Pharma ........................................Taclonex ...........................................21-22 Leo Pharma ........................................Taclonex No-Pay Copay ..............32A-32B Merz ....................................................Mederma............................................... 51 OCuSOFT, Inc ......................................Zytaze .................................................... 25 Officite .................................................Website Services................................. IBC Pacific World .......................................Bio Oil .................................................... 41 Stiefel, a GSK Company ......................Duac .................................................13-14 Stiefel, a GSK Company ......................Panoxyl .................................................... 3 Recruitment Advertising Associates in Dermatology................................................................................ 55 Beebe Medical Center ....................................................................................... 53 Dermatology Associates of Wisconsin .............................................................. 55 Practice Dermatology the way it was meant to be…. with friendly colleagues, a great supportive staff, and no bureaucratic headaches. Dermatology Associates of Wisconsin is a rapidly growing, single-specialty dermatology practice with thirteen clinics located throughout Wisconsin. It is our goal to provide dermatologists with a practice environment where they can provide excellent patient care, integrate subspecialty interests, and benefit from a focused practice environment. Our collegial thirty-one member team consists of twenty-three board certified dermatologists, including six Mohs surgeons, five dermatopathologists, and eight mid-level providers. We pride ourselves on the use of the latest technology and treatment protocols for optimal surgical and treatment outcomes. Our approach to clinical practice is to work smarter, not harder, by utilizing RNs, LPNs, and MAs to streamline our practice. With this philosophy, we are able to dedicate more time to patient care, less time to paperwork, and spend more time with families and friends. We maximize YOUR income with a combination of excellent insurance reimbursement rates, efficient billing and collections, and effective overhead management. Get to know us on line at www.dermwisconsin.com. Join our rapidly growing team! Geisinger Health System ................................................................................... 53 FOR ADVERTISING INFORMATION, CONTACT: ELSEVIER 360 Park Avenue South, New York, NY 10010 REPRESENTATIVES: Roxana Aldea PHONE: (212) 633-3160 FAX: (212) 633-3820 E-MAIL: [email protected] Aileen Rivera PHONE: (212) 633-3721 FAX: (212) 633-3820 E-MAIL: [email protected] ADVERTISING STATEMENT: The American Academy of Dermatology and AAD Association does not guarantee, warrant, or endorse any product or service advertised in this publication, nor does it guarantee any claim made by the manufacturer of such product or service. THE AD INDEX IS PROVIDED AS A COURTESY TO OUR ADVERTISERS. THE PUBLISHER IS NOT LIABLE FOR OMISSIONS OR SPELLING ERRORS. DERMATOLOGY WORLD // June 2011 55 facts at your fingertips data on display MELANOMA AND INDOOR TANNING F or years, dermatologists suspected that indoor tanning increased the risk of developing melanoma. A study published in the June 2010 issue of Cancer Epidemiology, Biomarkers & Prevention, “Indoor Tanning and Risk of Melanoma: A Case-Control Study in a Highly Exposed Population,” finally confirmed the connection. The study calculated the association between a history of indoor tanning and the risk of developing melanoma. The resulting odds ratios indicated how many more times likely a person was to develop melanoma given a variety of tanning behaviors than without them. The study found that those who had indoor tanned at all, or fell into the category of “ever use,” were 1.74 times more likely to develop melanoma. The charts below show other factors that increased the likelihood of developing melanoma. – RICHARD NELSON dw Frequency of use Duration of use 1.68 25-100 2.45 10+ 2.72 100+ 1.85 6-9 NUMBER OF SESSIONS YEARS 1.80 11-24 1.34 ≤ 10 0 1.64 2-5 1.47 1 1 3 2 0 1 2 3 TIMES MORE LIKELY TO DEVELOP MELANOMA TIMES MORE LIKELY TO DEVELOP MELANOMA Device used 1.85 Sun lamp 4.44 High pressure DEVICE High speed/ high intensity 2.86 1.46 Conventional 0 1 2 3 4 5 TIMES MORE LIKELY TO DEVELOP MELANOMA All odds ratios were adjusted for age, gender, eye color, natural hair color, skin color, freckles, moles, income, education, family history of melanoma, routine sun exposure, outdoor activity sun exposure, outdoor job exposure, mean sunscreen use, and number of lifetime painful sunburns. Full study doi: 10.1158/1055-9965.EPI-09-1249. 56 DERMATOLOGY WORLD //June 2011 www.aad.org Your Referred Patients are Searching for You Online... 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