Analysis of dermatologic procedures billed independently by nonphysician practitioners in the United States

doi:10.1016/j.jaad.2018.08.047

Journal of the American Academy of Dermatology

Volume 88, Issue 5, May 2023, Pages e203-e209

https://doi.org/10.1016/j.jaad.2018.08.047 Get rights and content

Background

Nonphysician practitioners (NPPS), including nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice outside of primary care and performing more procedures in dermatology.

Objective

To understand the scope and geographic pattern of practice by NPs and PAs in dermatology in the United States.

Methods

Cross-sectional retrospective cohort analysis of dermatology practices in the 2014 Medicare Physician/Supplier Procedure Summary master file, which reflects Part B carrier and durable medical equipment fee-for-service claims in the United States.

Results

Over 4 million procedures were billed independently by NPs and PAs, which accounted for 11.51% of all procedures. Injection, simple repair, and biopsy were the most commonly billed by the nonphysician practitioners, but complex procedures were also increasingly billed independently by NPs and PAs. Proportions of their claims are higher on the East Coast, Midwest, and Mountain states.

Limitations

Data were collected at the state level and limited to Medicare beneficiaries, and did not include billing incident to physicians.

Conclusions

This study demonstrated the increasing scope of practice of NPs and PAs in dermatology; this increase is alarming because of their limited training and the lack of uniform regulations guiding their practices. To ensure quality and safety of care, it is prudent to set benchmarks for proper supervision and utilization of procedures in dermatology.

Section snippets

Methods

We obtained the 2014 Medicare Physician/Supplier Procedure Summary (PSPS) master file, which is a 100% summary of Part B carrier and durable medical equipment regional contractor claims processed through the common working file and stored in the National Claims History Repository.¹² Data was received with all patient and provider identifiers removed. Therefore, with all data deidentified, the study was exempt from review by an institutional review board. The main outcome variable was the

Results

CPT codes representing 12 major dermatologic procedures were selected: simple repair, intermediate repair, complex repair, skin graft, adjacent tissue transfer, destruction of premalignant lesions, destruction of malignant lesions, biopsy, shaving of skin lesions, excision of malignant lesions, excision of benign lesions, and injection. These CPT codes were the most commonly billed and, thus, most representative of dermatologic services provided in different clinical settings.¹⁰ These

Discussion

NPPs have mostly increased their range of services. As the results show, significant proportions of dermatologic procedures were billed independently by NPs and PAs. From 2012 to 2014, the number has increased significantly, by 32%-95% depending on the procedure group. Among all procedures, simple procedures (such as simple repair, injection, and biopsy) were the most commonly billed by NPs and PAs. More concerning is that significant proportions of more complex procedures, including

Conclusion

NPs and PAs bill independently for a wide range of services in dermatology. These even include some complex procedures including skin grafts and tissue transfers. The pattern varies by state, potentially depending on state regulations and also density of dermatologists. The increasing scope of practice and expanding numbers of procedures independently billed by NPs and PAs in dermatology call into question proper supervision and utilization of CPT codes. It might also contribute to

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: Funding sources: Supported by the National Institutes of Health National Cancer Institute with a Small Business Innovation Research grant (R44CA162561), the National Institutes of Health National Institute of Biomedical Imaging and Bioengineering (grant no. R01EB020029), and the American Society for Dermatologic Surgery with a Cutting Edge Research Grant.

: Conflicts of interest: None disclosed.

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Online-only original articleAnalysis of dermatologic procedures billed independently by nonphysician practitioners in the United States

Background

Objective

Methods

Results

Limitations

Conclusions

Section snippets

Methods

Results

Discussion

Conclusion

Mayo Clinic Proc

J Am Acad Dermatol

J Am Acad Dermatol

The Future of Nursing: Leading Change, Advancing Health

Report to Congress: Reforming the Delivery System

Analysis of trends in geographic distribution and density of US dermatologists

JAMA Dermatol

State practice environment

Scope of physician procedures independently billed by mid-level providers in the office setting

JAMA Dermatol

Centers for Medicare and Medicaid Services. Physician/Supplier Procedure Summary master file

Zip Code to Carrier Locality file

Online-only original article
Analysis of dermatologic procedures billed independently by nonphysician practitioners in the United States