Catching Unethical Loopholes in ICD-10 Code Billing: Daniel Siegel, MD

It is important that dermatologists practice honest and ethical documentation and billing practices when applying the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) code for reimbursement, says Daniel Siegel, MD, clinical professor of dermatology, SUNY Downstate Health Sciences University, and former president and honorary member of the American Academy of Dermatology (AAD). During his Maui Derm Hawaii 2026 session, Siegel explained “how to honestly, ethically, not leave money on the table.”

This transcript was lightly edited; captions were auto-generated.

Transcript

Can you describe your approach in helping dermatologists maximize billing effectiveness ethically, especially as reimbursements decline?

In this area of declining reimbursement, what Dr Kaufmann [Mark Kaufmann, MD, associate clinical professor, Icahn School of Medicine at Mount Sinai, New York] and I do in our session is try to tell you how to honestly, ethically, not leave money on the table and not do things that will get you in trouble because you found a loophole. One of the things that I look at with EMRs [electronic medical records] is [that] a lot of times, you can template things. If you're doing surgery, let's say you're doing surgery, have a wound, when you're done, it's X mm long by Y mm wide. And when you close it, if you bring the skin edges together, and you say, “It's too tight,” the way you loosen it is you do what's called undermining. If you are undermining to the width of the wound—that Y mm—it’s the entirety of one side that would count as a complex repair. Other factors can make it complex, but that's the one that's most commonly used.

The way it’s prescribed is you actually do it, and then you measure it. Others will, however, [in] their documentation, they’ll say, “Undermining went to Y mm,” [and] they pull it from the side of it. You look, and you say, “Gee, how often is it exactly the minimum?” Because when you think, do the thought experiment: if you're closing a wound with multiple layers of suture, if it's less than the width of the wound, it's an intermediate repair. If it's more, it's complex. But you would expect a normal distribution where a lot are hovering right around that point, [which] has to do with the biomechanics, but some will tail off, even some maybe 2 or 3 times that amount.

There's a lot of variation. [In] tight places like the scalp, you may undermine a whole scalp, but people's [operative] reports when they template it, it may often say “The width of the wound was Y, the undermining was Y, and 100 consecutive medical records were exactly on that point.” Is that believable?

And of course, some people will say, “Well, gee, how are they going to catch me?” If I were answering the question for the Justice Department, or consulting, I would say, “Well, I'd hire a medical van, I’d get an ostomy wound nurse who can take a dressing down. I’d get an ultrasonographer who can do high-frequency ultrasound, and as someone is walking out of your office with a big, bulky dressing on their face. I would show my badge, I'd walk into the truck, have the ostonomers take the dressing down, have the ultrasonographer look, and you can get a fairly accurate measurement, which is actually larger than reality because it has been stretched a bit. But if you're claiming 3 cm, and they're only finding you've done 3 mm, well, you're going to be writing a big check, or you'll get yourself orange pajamas and chain jewelry.”