Government billing interferes with standards of care

While I might agree with Drs Montgomery and Sadler1 that excisional biopsy is the preferred procedure for pigmented lesions, I would like to point out that provincial insurers (in Ontario) actively discourage this procedure by discriminating between malignant and nonmalignant lesions. If you know the diagnosis for certain (as with results from a punch biopsy), you can book your time and do the adequate excision with appropriate margins and marking and collect the fee. If you are uncertain of the diagnosis but go ahead with excisional biopsy with appropriate margins and marking and it comes out benign, you bill a substantially lower fee (the malignant fee code in Ontario requires pathology results). The fee differential in Ontario is $70.90 for a malignant lesion on the face versus $14.80 for a mole. If you are lucky and the lesion is premalignant (which has a narrow definition), you bill $53.20. All of these require the exact same amount of work and care.

Barriers to optimal care built into the billing schedules must be eliminated or most, like me, will still do punch biopsy before investing substantial time and effort to do the right thing!

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