CPT/HCPCS Codes:
96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
96912 Photochemotherapy; psoralens and ultraviolet A (PUVA)
96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings)
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
DESCRIPTION 2014 Total RVUs1 2013 Total RVUs2 Total RVUs % Difference 2014 payment in $ assuming 35.6653 CF3
96900: Ultraviolet light therapy 0.58 0.65 -10.77% $20.69 $22.11 -6.46% 97,972
96910: Photochemotherapy with uv-b 1.10 2.24 -50.89% $39.23 $76.21 -48.52% 383,029
96912: Photochemotherapy with uv-a 1.10 2.87 -61.67% $39.23 $97.65 -59.82% 34,307
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.
Applicable service codes: 96900, 96912, 96913, 96920, 96921, 96922 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. BCBSNC may request 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 neede to make a medical necessity determination is included
How Treatment Codes 96900, 96910, and 96912 are used: Phototherapy or light therapy, is a first-line treatment for psoriasis and involves exposing the skin to ultraviolet light B (UVB) or ultraviolet light A (UVA) on a regular basis under medical supervision. Phototherapy is one of the safest and most costeffective 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.
Why is CMS proposing this change? Where CMS found reimbursements to be higher in a non-facility setting than in a facility setting, non-facility practice expense relative value units (RVUs) were reduced toalign with the Medicare's Hospital Outpatient Prospective Payment System (OPPS) payment for the same service.4
In other words, non-facility RVUs were capped at the OPPS level.5 RVUs are a calculation of physician work, practice expense, and malpractice expense. For services with no work RVUs (including phototherapy), CMS is proposing to compare the total non-facility PFS payment to the OPPS payment rates directly since no PFS payment is made for these services when furnished in the facility setting.
CMS suggests that the unaligned payments are not the result of appropriate payment differentials between the services furnished in different settings. Rather, they believe it is due to anomalies in the data they use under the PFS and in the application of the resource-based practice expense (PE) methodology to the particular services.6
Flaw with CMS rationale: The rationale underlying the phototherapy cuts in the CY 2014 Physician Fee Schedule is fundamentally flawed because the OPPS and ambulatory surgical center (ASC) fee setting does not evaluate the costs of the resources that are used to provide services and fails to recognize the extent to which a hospital or ASC may offset the costs of providing these services. OPPS and ASC fees are grouped into Ambulatory Payment Classifications (APCs) which are intended to cover the costs of providing services in those settings, but which may actually pay more or less than the costs incurred. Hospitals and ASCs are able to offset the underpaid services with those that pay more than costs that are incurred, something physicians are unable to do. There is no evidence that the fees OPPS or ASC fee schedule accurately reflect the cost of providing services, and they certainly do not reflect the cost of providing services in the physician’s office. Using APCs incomplete fees to value services that are performed 90.6% and 91.8% of the time respectively (for codes 96910 and 96912) in a physician’s office is not in the best interest of Medicare beneficiaries.
Likely Patient Impact: There is already a shortage of phototherapy units in the country, and these cuts would likely lead to additional closures of phototherapy units and decreased availability of these treatments, adversely affecting millions of patients. Should this treatment option disappear, many patients would be forced to go without treatment or transition to a systemic therapy that includes biologics, which can cost more than 10 times the expense of phototherapy treatments. (Phototherapy costs approximately $2,000- $3,000 a year.)
References:
[1]. Phototherapy Coding and Documentation in the Time of Biologics
[2]. Phototherapy and Photochemotherapy (PUVA) for Skin Conditions - Medical Clinical Policy Bulletins | Aetna
http://www.cms1500claimbilling.com/2017/03/cpt-code-96910-96912-96920.html