Dermatology Was Built for Telehealth

Most of what a dermatologist does is look. Pattern recognition, color, border, texture, distribution across the body. A camera handles that about as well as any specialty gets, which is why dermatology was running video and photo visits before most of medicine even bought a webcam.

And still, half the dermatology offices we talk to treat telehealth like an experiment. They dip a toe in, offer it to post-op follow-ups, and never build the workflow out. Meanwhile the practices that figured it out are seeing patients across the state, clearing their rash and acne volume in dedicated video blocks, and keeping their in-person chairs open for biopsies and surgical cases.

This is the working guide. What belongs on video and what belongs on photos sent ahead of time, how to triage without eating your front desk, the workflow that scales to a dozen visits an hour, how to bill it, and the lesions that always get an in-person look no matter what the picture shows.

What Dermatology Visits Actually Work on Video

Start with the easy answer. These are the complaints that resolve in a 10 to 15 minute video visit, often with a photo the patient sends in beforehand.

The Reliable Yes

  • Acne, including routine follow-up, medication adjustments, and new patient starts. You can see distribution, severity, and scarring on video. Isotretinoin counseling and iPLEDGE check-ins work the same way.
  • Rosacea, perioral dermatitis, and seborrheic dermatitis. Distribution and triggers drive the plan more than the exam.
  • Eczema and atopic dermatitis flare management. Patients know their disease; you're adjusting the ladder.
  • Psoriasis follow-up and biologic monitoring. Verify coverage of involved areas on camera, review labs, decide on dose.
  • Warts, molluscum, and other viral skin lesions. Diagnosis is visual. Treatment plan is a conversation.
  • Hair loss, including androgenetic, telogen effluvium, and alopecia areata that's clearly delineated. Have the patient show the scalp in good light, with partings, and send photos ahead.
  • Nail complaints that are chronic, like onychomycosis, where you're confirming history and starting or renewing therapy.
  • Post-procedure follow-up after a biopsy, excision, Mohs case, cryotherapy, or laser. Wound check, suture decisions, scar progress.
  • Established skin cancer survivors getting their quarterly or every-six-month check-in between full-body exams, especially for a specific spot they're worried about.
  • Benign lesion reassurance visits for a cyst, lipoma, seborrheic keratosis, or cherry angioma where you can confirm the diagnosis from a close-up photo.
  • Rash visits that are stable, non-urgent, and not systemic. Contact dermatitis, pityriasis rosea, drug eruption follow-up.

The Lesions You Still Need to See in Person

Say these out loud so your intake rules can route them where they belong.

  • Any pigmented lesion a patient or primary care doc is worried about for melanoma. Photos help triage urgency, but a dermatoscope beats a cell phone every time.
  • Any lesion that bleeds, grows fast, is tender, or looks ulcerated. Camera photos cannot replace palpation and dermoscopy here.
  • Full-body skin exams. Patients cannot photograph their own back, scalp, and plantar surfaces reliably.
  • Suspected skin infection with systemic symptoms: cellulitis with fever, zoster with eye involvement, necrotizing fasciitis red flags.
  • Blistering disorders at onset. Pemphigus and pemphigoid need an exam and biopsy, not a telehealth visit.
  • Severe drug reactions. Stevens-Johnson syndrome and DRESS belong in an ER, not a video appointment.
  • Anything that's going to need a biopsy, excision, cryotherapy, or injection today. Book it in person and skip the video step.

The borderline cases are where good teledermatology earns its keep. A video visit plus two decent photos can get you a provisional diagnosis, a treatment plan, and a scheduled in-person follow-up if the response is wrong. You're not trying to replace the clinic; you're sorting faster.

Store-and-Forward: Make the Photos Do the Work

Dermatology is the specialty where "send me a picture before we talk" is clinically useful, not just a convenience. The term of art is store-and-forward, and it means the patient sends photos and a short history ahead of time, you review it on your schedule, and the visit, if there's a visit at all, is the plan conversation. Build this into every single teledermatology slot and your throughput changes shape.

Ask for Three Photos, Not One

One blurry photo of a mole is a liability. Three good photos is a chart entry. Tell patients exactly what you need:

  • A wide shot showing the body region, so you can see distribution and surrounding skin.
  • A medium shot of the lesion itself with a ruler or coin for scale.
  • A close-up with good natural light, in focus, no filter.

Build those three prompts into your intake form. Reject uploads that are obviously unusable and ask for a redo before the visit. You will spend less time apologizing on video for photos you cannot read.

Pick an Asynchronous Model Where It Fits

Not every teledermatology visit needs to be live. For an acne refill in a stable patient, a wart diagnosis, or a post-op wound check that looks fine, an asynchronous reply saves the patient a scheduled appointment and saves you the live time. The patient submits photos and a short questionnaire, you review and send back a plan, prescription, or next-step instruction through secure messaging.

Draw a line in your scheduler: async for stable, familiar complaints, live video or in-person for everything else. Many practices run both: a $45 async review turnaround under 48 hours, and a $95 live video slot for conversations that need back-and-forth. Patients self-select, your schedule stays sane.

Store the Photos in the Chart, Not Email

Photos are PHI. They need to live in the EHR or the telehealth platform's secure storage, not in a Gmail inbox or a staff member's phone. Pick a tool that lets patients upload directly to a HIPAA compliant portal and attaches the images to the visit record. If your current workflow involves anyone emailing a photo to anyone, fix that this week.

Triage Before the Visit, Not During It

If your medical assistant is deciding who gets video and who gets booked in person, you're setting them up to miss a melanoma and set yourself up to run late every single afternoon. Make the triage rules explicit and let the booking tool enforce them.

Pre-Booking Screening Questions

Before the patient sees an available slot, ask a short set of yes/no questions:

  • Is this a new or changing mole, or a spot you or your doctor are worried about for skin cancer?
  • Is the spot bleeding, painful, or growing quickly?
  • Do you need a full-body skin exam today?
  • Are you here for a procedure, like a biopsy, injection, or wart removal?
  • Do you have a rash with fever, blisters covering a large area, or facial swelling?

Any "yes" routes to an in-person booking page or a same-day call line. Everything else sees your video and async slots. You still catch the misrouted cases on your end, but the booking widget filters out the ones that would obviously fail.

Three Visit Types, Clear Pricing

Dermatology patients care about price more than most specialties because so many of them are self-pay for cosmetic adjacent complaints. List the options plainly:

  • Async photo review. Submit photos and history, get a plan back within 48 hours. Best for stable conditions and medication adjustments.
  • Live video visit. 15 to 20 minutes with a provider. Best for new patient visits and anything that needs a conversation.
  • In-person visit. Required for full skin exams, procedures, and concerning lesions.

Patients self-sort when you show them what each option is for. Over-explain this on your booking page; it saves calls.

The Workflow That Scales to Volume

Teledermatology falls apart when it's bolted on to the regular schedule. Build it as its own operating lane and the economics work.

Cluster the Visits

Pick two or three blocks a week and run video and async-review only in those blocks. Three hours on Tuesday morning, two on Thursday afternoon. You stop context switching between a biopsy and a video acne follow-up every ten minutes, and your average visit time drops. Most dermatology practices that cluster see twice the throughput per hour compared to visits mixed into the day.

Pre-Review All Async Cases in Batches

Open the queue twice a day. Work through five or ten cases in a row. Each one gets a chart review, photos reviewed, assessment and plan documented, prescription sent if needed, patient message out. You'll move through async cases faster than you'd expect, because your brain stays in one mode.

Collect the History Before the Camera Turns On

By the time a live video visit starts, you should already have:

  • Chief complaint and duration
  • Prior treatments tried and current medications
  • Allergies and relevant medical history (immunosuppression, prior skin cancers, pregnancy status)
  • At least one photo, uploaded ahead of the visit
  • Verified identity and current state of residence

Your intake form should do all of this. You join the call ready to look at the specific question, not to collect the history.

Keep a Phone and SMS Fallback Open

Patients sometimes cannot get video working. Older patients especially. Have a dial-in option and an SMS visit option for the complaints where a conversation and a photo are all you need. A rash follow-up on text with photos is a legitimate visit if your documentation and billing match the modality. Choose a platform that gives you all three in one place so you're not maintaining three tools.

Document While You're Looking

Finish the note on the call. Say the assessment and plan out loud to the patient and type it as you go. Confirm the pharmacy. Place the follow-up. You get off the call with a done chart, not a to-do list.

Billing Teledermatology Correctly

Dermatology bills on familiar E/M codes with the right modifiers. The async piece is where most practices leave money on the table, because they do the work and bill a visit code that doesn't match.

The Codes You'll Use

  • 99202 to 99205 for a new patient live video E/M, chosen by medical decision making or total time.
  • 99212 to 99215 for an established patient live video E/M.
  • 99421 to 99423 for an asynchronous online digital E/M, billed by cumulative provider time over seven days. This is the right code for a true store-and-forward photo review when there's no synchronous visit.
  • G2010 for a remote evaluation of a patient-submitted image or video with a follow-up communication, five to ten minutes.
  • G2012 for a brief virtual check-in by phone.
  • 96127 if you're using validated instruments like a dermatology quality of life questionnaire.

Append modifier -95 for real-time audio-video and -93 for audio-only. Use place-of-service 10 when the patient is at home and 02 when they're elsewhere. Medicare's telehealth list and the private payer policies both drift annually; pull your top three payers' fee schedules every quarter.

Document the Modality and the Images

Your note needs the chief complaint, history, exam section (describe what you saw on video and in the submitted photos), medical decision making, assessment and plan, modality (audio-video, audio-only, or asynchronous), the patient's physical location, verbal or written consent to telehealth, and total time if coding by time. For async visits, note the date and time the photos were received, when you reviewed them, and when the response was sent. The photos themselves should be in the chart.

Set Expectations on Price Up Front

Dermatology self-pay is a real segment. Publish your async and video prices on the booking page. If insurance covers the visit, show the expected cost after copay. Patients book faster when they know what they're going to pay, and your front desk fields fewer billing calls.

The Mistakes That Keep Teledermatology From Working

Four patterns show up over and over when a dermatology practice stands up telehealth and it stalls. Watch for them.

Accepting Bad Photos

Blurry, poorly lit, filtered, or wrong-angle photos make the whole model worse. Build a reject-and-redo step into intake and train your front desk to send the "please resubmit with better light and a ruler" message with a one-click template. A photo that cannot be read is not a photo; it's a liability.

Diagnosing Pigmented Lesions on Video

Do not do it. A pigmented lesion the patient is worried about belongs in the clinic with a dermatoscope and the option to biopsy. Route those cases to in-person every time, even if your schedule is tight. Dermoscopy pickups vs. the naked eye are not close, and the one you miss is the one that matters.

Treating Async Like Email

Async teledermatology is a billable visit with documentation requirements. It is not texting with patients between other visits. Build it as its own queue, with its own turnaround SLA, its own templated notes, and its own slot on the schedule. Charge for it. If you're giving it away because you don't want to send a bill, you'll resent the volume within a month.

Picking a Platform That Can't Handle Images

A generic video tool is not a teledermatology platform. You need secure patient-to-provider photo upload, image storage attached to the chart, SMS and phone fallback for patients who cannot do video, in-browser video with no download required for the patient, a signed Business Associate Agreement, and your branding in front of the patient the whole way through. If a vendor can't offer the full set, keep looking. The friction of a weak tool shows up in your no-show rate and your front desk inbox.

Start Small, Measure, Expand

Pick one condition and one block. Acne follow-ups on Tuesday afternoons. Open eight video slots and four async slots. Send the triage questions to your booking widget, publish prices, and run it for a month with one provider. Measure average visit length, async turnaround time, downshift rate to in-person, no-show rate, and revenue per hour.

At the end of the month you'll know which complaint types to add next, where the workflow leaks, and whether your platform is helping or getting in the way. Most dermatology practices that run this honestly discover two things: patients prefer the asynchronous option more than expected, and the in-person schedule relaxes once the low-complexity visits move off of it.

Teledermatology isn't a side feature of the practice. Done right, it's a second operating lane that fits the specialty's strengths and clears space in the clinic for the work that has to happen in person. Build the workflow with intent, pick a tool that handles video, async, phone, and SMS without making the patient download anything, and the volume follows.