See the light in reporting phototherapy services
Derm Coding Consult
By Cynthia Stewart, CPC, CPMA, COC, CPC-I, Manager, Coding and Reimbursement Resources, May 1, 2022
Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.
AAD/A Coding and Reimbursement staff have received several questions from members regarding the documentation needed to support medical necessity for ultraviolet (UV) light therapy services. While some payers may allow reimbursement for UV light therapy when it is deemed medically necessary to treat conditions such as psoriasis and vitiligo, payers may deny the service if the record does not clearly relay the medical necessity of the treatment based on their policy’s criteria for coverage.
To support medical necessity, payers require that the following information is included in the medical record when UV light therapy services are provided and reported:
Supporting medical necessity
Severity of the skin condition, area(s), and percentage of body surface area affected
The condition being treated is non-responsive to more conventional treatment methods
There is an expected positive response to psoralen and ultraviolet A radiation (PUVA) treatment within a 30-day treatment period
Supportive phototherapy documentation
The form of ultraviolet light (UVB, UVA, or a combination of)
Delivery technique (broad or narrow beam)
Area(s) treated
Light-enhancing agent/shielding
Application of light-enhancing agent documented as occurred in the office, and type of agent applied
Identity of the staff member who applied topical agent
Staff assistance with the application of light-enhancing agents and shielding is assumed if patient self-applied; document if assistance was offered and/or if refused
Session time and strength
Post-procedure or therapy conditions
AADA coding resources
Check out other AADA coding resources.
Examples
Q. We have patients that prefer to apply the topical agent themselves, can we still report the services as photochemotherapy, or should we report this treatment as actinotherapy with code 96900?
A. If the staff/dermatologist offers to apply the topical agent but the patient declines the offer and chooses to apply the emollient themselves while in the office, the provider must document that the patient declined assistance to apply the topical agent. In such an occurrence you can bill 96910 for the time spent supervising the patient applying the emollient while in the room.
Not documenting this key element in the medical record or flow sheet has led to payers reducing photochemotherapy treatment (96910 – 96913) service reimbursement to the same level as actinotherapy (96900).
Q. Is it required that a physician or non-physician clinician (NPC)* be physically on-site when the patient receives treatment in order to bill CPT codes 96910 and 96912?
A. CPT codes 96910, 96912, and all other photochemotherapy codes all have Professional Component/Technical Component (PC/TC) indicator of 5. Codes with PC/TC indicator 5 are incident to codes which indicates that the service provided is "incident to" a dermatologist’s services when performed by auxiliary personnel.
Direct supervision requires that the dermatologist or NPC be present in the office suite and immediately available to provide assistance and direction throughout the performance of the procedure. The service can be reported if a dermatologist or NPC (it does not have to be the dermatologist who prescribed the therapy), is available in case of an emergency.
Quick coding guides
Check out the Academy’s Photodynamic Therapy Quick Coder.
Q. On the patient’s first visit, in addition to photochemotherapy, our nurse collects the intake forms and provides education on the appropriate use of the home unit. Can we charge for a nurse visit in addition to the procedure on that first visit?
Typically, on the first photochemotherapy visit, the nurse will update the medical record, demonstrate appropriate use of the unit, and perform the procedure under the direct supervision of the dermatologist or NPC who orders the therapy treatment.
Additionally, Medicare National Correct Coding Edit (NCCI) procedure-to-procedure bundling edit disallows reporting of nurse visit code 99211 with any of the photochemotherapy codes (96910-96913). As such, a modifier will not override this NCCI edit when the nurse visit is documented as a part of a photochemotherapy encounter. Be sure to check with your private payers as their edits may vary.
It would be appropriate that the patient’s primary dermatologist follow up over a two- to three-week period of treatment and report a low-level E/M on the patient’s status or if changes are needed in the treatment plan.
For additional guidance, visit the AADA Coding Resource Center at staging.aad.org/coding, and check out our Photodynamic Therapy Quick Coder.
Be sure to check out the AADA’s Principles of Documentation for Dermatology for a go-to reference for ensuring the medical record meets coding compliance. * The AADA uses the term non-physician clinician (NPC) to provide greater clarity when services/procedures are provided and reported by a provider such as a PA or NP. Where appropriate, this term is used in place of the American Medical Association’s QHP acronym, which is also used by CMS and private payers, as NPC more clearly conveys these providers’ credentials and differentiates them from physicians.
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