On January 24, 2013 Dr. Harry Goldsmith
presented the annual “Simply Coding Seminar” at
the NYSPMA Clinical Conference. There were
excellent lectures on new codes, proper coding ,
charting and audits. New this year, Dr.
Goldsmith invited well-respected podiatrists to
present clinical scenarios for a panel of
codingline experts to review.
Dr. Bryan Markinson presented a number of
dermatology cases, including a case of a patient
with a melanoma on the plantar aspect of the
foot. The presentation started with a shave
biopsy of a suspicious lesion that the
pathologist reported as non-invasive in situ
melanoma. Additional excisions were performed,
culminating with a wide excision and a skin
graft. After the graft healed, a questionable
dark spot developed on the graft site. A biopsy
of the spot on the graft was reported as an
insitu melanoma.
Dr. Markinson is well known for his lectures on
dermatologic foot problems. He is Chief of
Podiatric Medicine and Surgery at Mount Sinai
School of Medicine in New York. The scenario he
presented raised some interesting coding
questions which the panel discussed. The
scenario also posed some serious clinical
questions which I raised during the seminar.
First, why was a shave rather than a punch or
excisional biopsy performed? The National Cancer
Institute states “A biopsy, preferably by local
excision, should be performed for any suspicious
lesions, suspicious lesions should never be
shaved off”
(reference:
http://cancer.gov/cancertopics/pdq/treatment/mela
noma/HealthProfessional)
Second, when the patient, developed a recurrent
melanoma at the graft site why wasn’t the
patient referred to an oncologist who
specialized in melanoma treatment. The National
Cancer Institute states that a patient with
recurrent or new skin melanoma near the primary
melanoma, including in situ melanoma, might
benefit from immunotherapy in addition to
surgical excision.
They also note that failure to aggressively
treat a melanoma that has spread beyond the
first lesion, even if the metastasis remains in
the skin, increases patient mortality.. Over
9,000 people died from melanoma in the United
States last year. Many new treatments have been
developed which have decreased patient
mortality, but it is still a deadly disease.
These treatments have significant side effects.
Neither dermatologists nor podiatrists are
equipped to use them.
Dr. Markinson is on staff of a major teaching
hospital. Most of us are not. My biggest
concern is that some members who came to a
lecture on coding received information on the
management of melanoma that does not follow the
current standard of care.
My advice to all podiatrists is: If you suspect
melanoma take a punch or excisional biopsy; If
your suspicion is correct immediately refer the
patient to a melanoma center or to an oncologist
who specializes in melanoma. Both the patient,
and your malpractice carrier, will be grateful.
Mark Schilansky, DPM, Catskill, NY,
schilansky@mhcable.com
