Comparison of pathology code billing in the context of evaluation and management (EM) codes (Current Procedural Terminology [CPT] 99202-99205 and 99212-99215). Proportions were calculated by dividing the service code count of pathology codes by the sum of the service code counts for pathology codes and EM codes. Puerto Rico was excluded from the analysis given a low number of practitioners. Middle lines represent medians; upper and lower ends of the boxes, IQRs; and curved lines, relative frequency of practitioners billing different proportions of pathology codes.
aP < .05.
bP < .001.
cP < .01.
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Chen HW, Vuong VA, Adamson AS, Nguyen KD. Billing Patterns and Geographic Distribution of Dermatologist-Dermatopathologists in the US From 2013 to 2017. JAMA Dermatol. 2022;158(5):581–583. doi:10.1001/jamadermatol.2022.0073
Physicians who are dual board-certified in dermatology and dermatopathology (dermatologist-dermatopathologists) serve an important role in the diagnosis and management of skin disease, merging experiences with the clinical and histopathologic presentations of disease.1 There have been concerns about decreasing numbers of dermatologists opting to pursue dermatopathology fellowship training.2,3 Little is known about the geographic distribution and practice patterns of dermatologist-dermatopathologists and non–dermatologist-dermatopathologists, which may be obscured by their employment in larger pathology practices. However, many dual-trained dermatologist-dermatopathologists in the US bill Medicare independently for their services, permitting an analysis of their billing patterns and geographic distribution. In this study, we characterized the distribution and billing patterns of dermatologist-dermatopathologists in the US.
This cross-sectional study used data from the Medicare Physician and Other Supplier Public Use Files from 2013 to 2017 in conjunction with publicly available information from the American Board of Medical Specialties and websites of individual medical practices to identify dual board-certified dermatologist-dermatopathologists. Because the study used publicly available data sets, it was not considered human participant research; thus, the University of Texas Southwestern Medical Center exempted it from the need for approval and informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Using Current Procedural Terminology (CPT) codes, we calculated the percentage of dermatologist-dermatopathologists who billed Medicare for outpatient evaluation and management (EM) services (CPT codes 99202-99205 and 99212-99215), total Medicare reimbursement, and total Medicare reimbursement for pathology services (CPT codes 88302-88309). We excluded physicians who billed for Mohs micrographic surgery (CPT code 17311/17313). The cohort analyzed was grouped into different geographic regions of practice in the US and was compared using pairwise Kruskal-Wallis tests. Data were analyzed from June 2020 to December 2021. Two-tailed P < .05 was considered significant. Data analysis was performed using R, version 3.6.2 (R Project for Statistical Computing).
The number of dual board-certified dermatologist-dermatopathologists who billed Medicare for surgical pathology services from 2013 to 2017 ranged from 446 to 463 (equivalent to 40.5% to 42.1% of the 1100 active dermatopathologists in the US in 20194), with most practicing in the South or West regions (Table). Of these dermatologist-dermatopathologists, most were male (range: 254 [57.0%] to 291 [63.3%]), and more than 89% billed for EM services. Those practicing in the South and Northeast regions of the US consistently accounted for a larger proportion of billed pathology services compared with those in the West and Midwest regions (Table). Dermatologist-dermatopathologists in the western US (compared with those in other US regions) consistently had a billing mix composed of a smaller proportion of pathology codes (Figure).
This cross-sectional study used population-based data to examine the billing patterns and geographic distribution of dermatologist-dermatopathologists, which to our knowledge have not been assessable with past survey studies.5,6 Of note, most dermatologist-dermatopathologists billing for dermatopathology services also continued to provide office-based and/or outpatient care. The practice mix of dermatologist-dermatopathologists in the western US showed a greater proportion of outpatient visits than in other regions. Regional variation in the practice mix for pathology and EM services may be associated with the density of dermatopathologists and characteristics of the regional patient population (including regional differences in Medicare coverage rates), among other health care market factors; however, an evaluation of these factors was beyond the scope of this study. Of note, billing trends were stable during the observation period, suggesting the presence of a specific population of dual-trained physicians.
Several limitations may affect the generalizability of these findings. The data set prevented the study of dermatopathologists not trained in dermatology, whose geographic distribution and pathology billing patterns may differ from those of dermatologist-dermatopathologists. Also, this analysis was limited to dermatologist-dermatopathologists who billed Medicare independently. Their practice patterns may differ from those reimbursed by other means. In addition, we may not have completely captured the billing patterns of physicians who may also have been employed by group pathology practices. Although our investigation focused on a narrow subset of the dermatology and dermatopathology workforce, it is, to our knowledge, the only study that has examined the dermatopathology billing patterns in the past decade.
Further work is needed to understand the heterogeneity in dermatopathologist billing patterns and the degree to which dual-trained dermatologist-dermatopathologists practice both specialties. Our findings may be used as a baseline from which to study the effects of future changes in reimbursement and dermatopathology training on the dermatologist-dermatopathologist workforce.
Accepted for Publication: January 11, 2022.
Published Online: April 6, 2022. doi:10.1001/jamadermatol.2022.0073
Corresponding Author: Khang D. Nguyen, MD, MS, Department of Dermatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9069 (firstname.lastname@example.org).
Author Contributions: Mr Chen and Dr Nguyen had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chen, Nguyen.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: Chen, Nguyen.
Statistical analysis: Chen, Nguyen.
Administrative, technical, or material support: Nguyen.
Conflict of Interest Disclosures: Dr Nguyen reported being the chair of the American Academy of Dermatology’s Health Information Technology committee. No other disclosures were reported.
Disclaimer: Dr Adamson is an Associate Editor for JAMA Dermatology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.