Characterizing trends in the delivery of dermatologic care is important to understanding how the practice of dermatology evolves.1 We aimed to assess recent changes and geographic variations in the utilization of outpatient evaluation & management services (E&M) billed by dermatologists for Medicare beneficiaries.
This study did not require institutional review board approval. The number of new outpatient E&M (Healthcare Common Procedure Coding System codes 99201-99205) and established (99211-99215) E&M billed by dermatologists were obtained from the Medicare Part B Physician/Supplier Procedure Summary Master Files.2 Utilization rates per 100,000 Medicare beneficiaries were normalized using Medicare Part B enrollment figures. The numbers of distinct dermatologists billing outpatient E&M per year were summarized. Changes in the absolute count, utilization rate, and aggregate payments from 2013 to 2018 were analyzed.
The number of new patient E&M decreased −10.3% (Average Annual Growth Rate [AAGR], −2.1%). Level 1 to Level 5 new patient E&M changed by −42.1% (AAGR, −10.3%), −17.9% (−3.9%), +2.2% (+0.5%), −27.3% (−6.1%), and −23.7% (−5.2%), respectively. The number of established patient visits increased by +5.6% (AAGR, +1.1%) . Level 1 to Level 5 established patient E&M changed by −41.6% (AAGR, −10.1%), −33.0% (−7.7%), +7.2% (+1.4%), +83.2% (+13.0%), and +24.7% (+4.6%), respectively (Figure 1). Between 2013 and 2018, the number of distinct dermatologists billing outpatient E&M increased from 10590 to 11512 (+8.7%; AAGR, +1.7%). In 2018, aggregate payments for dermatology outpatient E&M amounted to $872.5 million ($2.6 million per 100,000 beneficiaries). Declines in new outpatient E&M and increases in established outpatient E&M billed by dermatologists between 2013 and 2018 were notable in >80% of US states (Figure 2).
Figure 1.
Service counts of established outpatient visits for dermatology by HCPCS Code per 100,000 Medicare beneficiaries between 2013 and 2018
Figure 2.
Geographic distribution of percent changes in outpatient visits billed by dermatologists per 100,000 Medicare beneficiaries between 2013 and 2018
Consistent with decreases in new hospital-based dermatologic consults,1 our study highlighted outpatient trends of decreasing new dermatologic consultations – despite an increase in number of billing dermatologists – for Medicare beneficiaries. However, substantial growth was observed in established patient E&M, particularly among Level 4 encounters. While our provider-level data lacked patient-level detail on visit diagnoses, disease severity, or treatments, future research should clarify contributors to increasing levels of E&M billing among outpatient dermatologic visits. Potential causes may include increasing overall burden of chronic skin diseases3, expanding use of systemic and biologic treatments that require monitoring,4 expanding use of electronic medical records, or other changes in medical documentation, coding practices, reimbursement, or payment models. E&M coding has been revised in 2021 to reduce administrative burden and increase E&M reimbursements; its effects on dermatologic E&M utilization and aggregate payments should be monitored.5
Study limitations included potential misclassification of emergency department consultations, which were billed as inpatient or outpatient E&M depending on disposition. Medicare censored data from providers billing <10 codes per year; our high-volume of outpatient E&M data is unlikely to be affected. Use of biopsies and other procedural services that often accompany dermatologic E&M, as well as trends in non-Medicare patients, were not analyzed.
Trends in outpatient dermatologist visits include declines in new patient visits and rises in increasingly complex established patient visits. These trends should be monitored with the implementation of new E&M coding changes.
Acknowledgments
Funding Sources: Dr. Yeung is supported by the Dermatology Foundation and NIAMS K23 AR075888 and L30 AR076081. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Department of Veterans Affairs.
Abbreviations and Acronyms
- E&M
evaluation and management services
- AAGR
average annual growth rate
Footnotes
Conflict of Interest Disclosure: None.
This work has not been previously published. Preliminary results of this work were presented at the 2020 Winter Clinical Meeting.
References
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