Non-Physician Practitioners Expanding Scope of Practice in Dermatology

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Investigators sought to determine whether nurse practitioners and physician assistants are expanding their scope of practice outside of primary care to perform dermatologic procedures.

Non-physician practitioners (NPPs) such as nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice into dermatology and performing more procedures, according to a study recently published in the Journal of the American Academy of Dermatology.

Investigators conducted a cross-sectional retrospective cohort analysis of data from dermatological procedures in the 2014 Medicare Physician/Supplier Procedure Summary Master File. They selected Current Procedural Terminology (CPT) codes for the 12 most common dermatologic procedures: simple repair, intermediate repair, complex repair, skin graft, adjacent tissue transfer, destruction of premalignant lesions, destruction of malignant lesion, shaving of skin lesions, excision of benign lesions, excision of malignant lesions, biopsy, and injection. Investigators then determined whether the procedures were performed by a physician or an NPP based on billing.

A total of 36,900,799 dermatologic procedures were billed in the continental US in 2014. Of these, 11.51% were billed by NPPs independently (with NPs performing 3.23% and PAs performing 8.28%). Of the 12 procedures analyzed, simple repair had the highest percentage billed by NPPs (25.73%) trailed by injection (13.42%) and biopsy (13.03%). NPPs also billed more complex procedures such as destruction of premalignant lesions and shaving of skin lesions at relatively high rates (11.94% and 10.32%, respectively). In addition, NPPs also billed advanced procedures including skin grafts and tissue transfers independently. NPPs billed at higher rates in the East Coast (12.22%), the Midwest (13.21%), and in Mountain states (13.99%).  

The study was limited by the fact that data were obtained on a state-by-state basis rather than a county-by-county basis. In addition, the study only accounted for procedures billed to NPPs independently. This means that NPP-performed procedures billed to physicians were not accounted for and the number of procedures performed by NPPs was underestimated. Finally, the data were restricted to Medicare patients. 

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Investigators conclude that this study shows “the increasing scope of practice of NPs and PAs in dermatology, despite limited training and lack of uniform regulations.” In some cases, NPP-performed procedures may contribute to the overutilization of procedures including unnecessary biopsies. As NPPs expand their scope of practice and perform more procedures, it will be important to establish regulations on supervision and more consistent laws regarding NPPs practicing dermatology.

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Qi Q, Hibler BP, Coldiron B, Rossi AM. Analysis of dermatologic procedures billed independently by non-physician practitioners in the United States [published online September 15, 2018]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2018.08.047