Insurance Reimbursement for UV-A and UV-B; Narrow Band Ultraviolet B Light (NB-UV-B) Phototherapy
Phototherapy or light therapy is a first-line treatment for psoriasis and involves exposing the skin to ultraviolet light B (UV-B) or ultraviolet light A (UV-A) on a regular basis under medical supervision. Phototherapy is one of the safest and most cost effective therapies for psoriasis and may be the only therapy option for certain subsets of psoriasis patients, i.e. children, pregnant women, and immuno-suppressed patients. Both treatments work by penetrating the skin and slowing the growth of affected skin cells.
The physician bills on a per treatment basis. Each treatment is billable once per day
Usually, four patients can be seen in an hour if the practice has two light boxes. It is helpful for a physician providing phototherapy to be involved with the maximum amount of managed care plans because it allows patients the best access to care, especially if that physician’s practice is serving the phototherapy needs for the entire community.
The billing document should contain an ICD-9 diagnosis code appropriate to phototherapy (696.1 for psoriasis). There is lack of specificity of the CPT code descriptions for phototherapy.
There may be a request of medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
This list of codes may not be all-inclusive. Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.
Office-Based Phototherapy and Photochemotherapy
The chief Current Procedural Terminology (CPT) codes for reporting phototherapy services are considered Medically Necessary when criteria in the applicable policy statements listed are met:
Current Procedural Terminology (CPT®) ©2018 American Medical Association: Chicago, IL.
96900 Actinotherapy (ultraviolet light)
96910 Photochemotherapy; tar & ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
96912 Photochemotherapy; psoralens and ultraviolet A
96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses
96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm
96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm
96900: Actinotherapy (UV Light Treatment)
Existing coding guidance for phototherapy indicates that actinotherapy (96900) defines the basic service of treating a patient with a UV light unit. Actinotherapy does not involve application of topical medications while the patient is in the office.
The code 96900 provides the least reimbursement and is only used when light treatments are being given without the use of any other drug or topical agent.
96910: Photochemotherapy, Tar, and UVB (Goeckerman Treatment) Or Petrolatum And UVB
The Current Procedural Terminology (CPT®) code 96910 as maintained by American Medical Association, is a medical procedural code under the range - Special Dermatological Procedures.
The Code 96910 is used when light treatments are given in conjunction with mineral oil, tar or the photosensitizing drug, Psoralen. (photoenhancing agents)
The Coder's Desk Reference for Procedures 2017 describes 96910 as "the physician uses photosensitizing chemicals and light rays to treat skin ailments."
Application of light-enhancing topical products should occur within the office by either staff or the patient. Centers for Medicare & Medicaid Services indicate that the 96910 code can include payment for clinical staff time to apply topical products as well as the cost of the topical agent(s).
Because the Relative Value Units (RVUs) for procedure codes 96910 and 96912 takes into account supplies and direct clinical staff involvement, these codes provide for better reimbursement than 96900. However, there are important documentation requirements that must be met to protect your practice in the event of an audit. When billing 96910, it is important that your documentation include a contemporaneous note stating that mineral oil was applied with the direct involvement of a clinical staff member, identifying the staff member in the note. Contemporaneous, by definition, means that you must note it each and every time a treatment is given.
96912: Photochemotherapy and PUVA
The Code 96912 is used when light treatments are given in conjunction with mineral oil, tar or the photosensitizing drug, Psoralen. The PUVA code 96912 is defined by the use of photosensitizing psoralen medication, which can be administered topically or orally, followed by UVA treatment. If application of topical photoenhancing products occurs outside the office, the requirements of photochemotherapy are not met, and 96900 should be reported.
Because the Relative Value Units (RVUs) for procedure codes 96910 and 96912 considers supplies and direct clinical staff involvement, these codes provide for better reimbursement than 96900. However, there are important documentation requirements that must be met to protect your practice in the event of an audit.
96913: Photochemotherapy (Goeckerman and/or PUVA) For Severe Photoresponsive Dermatoses Requiring At Least 4 To 8 Hours Of Care Under Direct Supervision Of The Physician
The 96913 code defines prolonged phototherapy service with intensive topical therapy requirements and multiple phototherapy sessions per day.3 This code is rarely reported (average of fewer than 100 times in the Medicare population per year), and most insurers do not reimburse this service.
CPT code range 96920-96922
Laser treatment for inflammatory skin disease, specifically indicated for psoriasis treatment.
96920 Laser Treatment for Inflammatory Skin Disease (Psoriasis)
Treatment area size: total area less than 250 sq. cm
96921 Laser Treatment for Inflammatory Skin Disease (Psoriasis)
Treatment area size: 250 sq. cm to 500 sq. cm
96922 Laser Treatment for Inflammatory Skin Disease (Psoriasis)
Treatment area size: over 500 sq. cm
96999 Unlisted Special Dermatological Service or Procedure
The Current Procedural Terminology (CPT®) code 96999 as maintained by American Medical Association, is a medical procedural code under the range - Special Dermatological Procedures.
There is no specific CPT code for laser therapy for vitiligo. It should currently be reported using the
unlisted CPT 96999, but the CPT codes for laser therapy for psoriasis (96920-96922) might be used.
96567 Photodynamic Therapy (PDT)
Per the AMA’s CPT 2018: Professional Edition book, 96573 is for PDT by external application of light to destroy premalignant lesions of the Understanding Phototherapy Services skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified healthcare professional, per day. Per the 2018 CPT book published by AMA, they recommend not reporting 96567, 96574 with 96573 for the same anatomic area.
99211 (Nursing Code)
The nursing billing code can be used in addition to the phototherapy code when there is a medical decision being made by the nurse in terms of evaluating burns, new drugs, lapse in treatment or any other problems.
CPT® code 99211 is defined by the 2011 CPT Standard Edition manual as: "Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal.
There is no specific CPT code for laser therapy for vitiligo.
It should currently be reported using the unlisted CPT 96999, but the CPT codes for laser therapy for psoriasis (96920-96922) might be used.
ICD-9-CM Diagnosis Codes that Support Coverage Criteria
696.1 Other Psoriasis and similar disorders
ICD-10-CM Diagnosis Codes that Support Coverage Criteria
L40.0 Psoriasis vulgaris (plaque psoriasis)
Have a written standard operating procedure in place regarding the performance of phototherapy services and how application of topicals will be handled has been helpful in audit defense.
Have detailed documentation or a flowchart in the medical record regarding the topical agent and the light administration. The medical record should include what topical agent was applied, if any; whether the topical agent was applied in the office; where the topical product was applied; and who applied the topical product. Sometimes topical product application by a physician or staff is not feasible because of patient preference or the site of application. If the patient applied the topical, document that assistance was offered and refused, along with what type of UV light was used and the dosage.
Inclusion of these elements in the medical record provides a clear picture of the delivery of the phototherapy service and will aid in responding to medical record audit.
- Progress notes indicative of the following:
- Baseline skin color.
- Treatment history; documented failure of adherent 3-month trial of both:
- high-potency (Class II steroids)
- Extent and distribution of vitiligo to the face, neck and or hand.
- Photographic evidence.