CPT code 96910 precisely defines photochemotherapy involving the topical application of tar or petrolatum in conjunction with ultraviolet B (UV-B) light, commonly known as Goeckerman therapy or Goeckerman treatment. For accurate billing of this essential phototherapy CPT code in 2025, understanding the latest payer updates, coding edits, and comprehensive documentation requirements is crucial. This guide provides an in-depth look at what CPT 96910 entails, recent changes in reimbursement, and practical tips for ensuring coding success and compliant billing for this specific phototherapy treatment.
What Is CPT Code 96910? Understanding Phototherapy CPT Code
CPT 96910 describes photochemotherapy that utilizes the topical application of tar or petrolatum followed by controlled exposure to ultraviolet B (UV-B) light. This specialized Goeckerman therapy is a cornerstone treatment for various chronic skin conditions, especially when standard phototherapy alone (CPT 96900) is insufficient.
- Common diagnoses: While primarily used for severe and refractory psoriasis (ICD-10 L40.x), CPT 96910 may also be considered for other phototherapy-responsive conditions such as certain forms of eczema, vitiligo, and in specific cases, cutaneous T-cell lymphoma (CTCL) when medically indicated.
- Who administers it: This treatment is performed under direct provider supervision, with the topical agents applied by qualified medical personnel (e.g., nurses, medical assistants) and the UV-B light administered by trained staff.
- Treatment duration: Sessions typically last 15–30 minutes, depending on the patient’s skin type and condition, and may occur several times per week following a specific treatment protocol.
Comparison with related phototherapy CPT codes:
| CPT Code | Description | Key Difference |
|---|---|---|
| 96900 | UV-B phototherapy | UV-B light treatment only, without topical agents. |
| 96910 | Photochemotherapy (tar or petrolatum + UV-B) | UV-B light treatment preceded by topical application of tar or petrolatum (Goeckerman therapy). |
| 96912 | Photochemotherapy (UVA + psoralen, PUVA) | Uses UVA light in combination with psoralen (an oral or topical photosensitizer). Often used for more severe psoriasis or CTCL. |
Key 2025 Coding and Billing Updates for CPT 96910
For 2025, the CPT descriptor for 96910, the specific CPT code for phototherapy with tar or petrolatum and UV-B, remains consistent. However, providers should note payment rule adjustments. CMS has updated the Medicare conversion factor to $32.36, a slight decrease from $33.29 in 2024, which will impact overall Medicare reimbursement rates for services including CPT 96910.
Important NCCI Edit: CPT 96910 cannot be billed with 99211 for nurse visits on the same day. Medicare considers the administration of the topical agent and UV-B exposure as components of the bundled phototherapy service. If a physician provides a separate, distinct E/M service on the same day, modifier -25 must be appended to the E/M code to indicate a separately identifiable service.
Medicare National Coverage Determination (NCD) & Local Coverage Determination (LCD) for CPT 96910
Understanding both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) is crucial for accurate billing of CPT 96910, especially when considering Medicare coverage. These guidelines provide the framework for medical necessity and reimbursement.
Medicare National Coverage Determination (NCD) 250.1 for Goeckerman Therapy
Medicare National Coverage Determination (NCD) 250.1 specifically addresses Goeckerman therapy, which is described by CPT 96910. According to NCD 250.1 from cms.gov, Goeckerman therapy for psoriasis is covered when medically necessary. Key criteria often include:
- Diagnosis of severe, recalcitrant psoriasis that has failed to respond to other conventional therapies.
- The therapy must involve the application of tar or petrolatum preparations followed by controlled exposure to UV-B radiation.
- Treatment must be administered by, or under the direct supervision of, a physician.
- Documentation must clearly support the medical necessity, the specific topical agents used, and the parameters of the UV-B exposure.
- Frequency limits may apply, with Medicare typically expecting no more than 30 sessions unless specific clinical improvement is documented to support ongoing care.
Providers should review the complete NCD for all specific requirements, as adherence is essential for compliant billing of CPT 96910.
Local Coverage Determinations (LCDs) for CPT 96910
While NCDs provide national guidelines, Medicare Administrative Contractors (MACs) issue Local Coverage Determinations (LCDs) which offer additional or more specific requirements for services within their geographical jurisdiction. These LCDs address the “medicare96910 lcd” query directly by providing localized coverage criteria, medical necessity statements, documentation requirements, and sometimes even frequency limitations or specific diagnosis codes that are considered payable.
To ensure proper billing for CPT 96910, providers must:
- Identify the MAC responsible for their region.
- Regularly check the MAC’s website or the Medicare Coverage Database on cms.gov for relevant LCDs pertaining to phototherapy services, including CPT 96910. Searching for “96910 LCD” or “phototherapy LCD” can yield specific policy documents.
The Medicare Learning Network (MLN) often publishes articles that summarize or explain these NCDs and LCDs, serving as a valuable resource for understanding policy details related to codes like “mln 96910.”
Roles and Supervision: Who Can Administer and Bill for CPT 96910?
Clarifying the roles of medical personnel and supervision requirements is critical for compliance and accurate billing of CPT 96910, particularly for queries like “cpt code 96910 nursing” or “can a nurse bill for phototherapy.”
- Physician Supervision: The administration of CPT 96910, Goeckerman therapy, requires direct physician supervision. This means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the procedure. The physician is ultimately responsible for the patient’s care plan, prescription of the topical agents, and the phototherapy dosage.
- Qualified Medical Personnel: The hands-on application of tar or petrolatum and the administration of the UV-B light therapy can be performed by qualified medical staff, such as registered nurses (RNs), licensed practical nurses (LPNs), or medical assistants (MAs), provided they are trained and competent in the procedure and acting under the direct supervision of the physician.
- Billing Responsibility: While nursing staff and MAs perform the procedural components, the billing for CPT 96910 is typically submitted under the supervising physician’s (or rendering provider’s) National Provider Identifier (NPI). Nurses generally cannot “bill for phototherapy” independently under their NPI for this service; rather, their services are integral to the physician’s billable service under direct supervision.
Documentation should clearly reflect the level of supervision and the personnel involved in each step of the CPT 96910 service.
Documentation Tips for CPT 96910: Ensuring Compliant Phototherapy Billing
Thorough and accurate documentation is your best defense against claim denials and essential for supporting the medical necessity of CPT 96910. To ensure clean claims and reduce denial risk for photochemotherapy, document the following key elements:
- Medical Necessity and Diagnosis: Clearly state the patient’s diagnosis (e.g., ICD-10 L40.0 for plaque psoriasis, or other specific codes for conditions like CTCL) and explain why Goeckerman therapy is medically necessary and appropriate for the patient’s condition.
- Application of Topical Agent: Provide specific details regarding the application of the tar or petrolatum. This should include:
- The specific agent used (e.g., crude coal tar, refined tar, white petrolatum).
- The body area(s) to which the agent was applied.
- The method of application (e.g., gentle massage, liberal coating).
- The duration the agent remained on the skin prior to UV-B exposure.
- If a patient specifically inquires about “phototherapy with mineral oil cpt code,” clarify that CPT 96910 specifies tar or petrolatum and that mineral oil is not typically the specified agent for this code.
- Details of UV-B Exposure: Document the precise parameters of the UV-B light treatment, including the specific dosage (e.g., joules/cm²), the duration of exposure, and the body area(s) treated.
- Supervision Details: Record the name and credentials of the medical personnel who applied the topical agent and administered the UV-B light, along with confirmation of direct physician supervision.
- Separate E/M Services: If a physician performs a separate and distinct Evaluation and Management (E/M) service on the same day, ensure detailed, separate notes are recorded to justify the use of modifier -25.
For Medicare, treatment exceeding 30 sessions within a given period may require additional documentation of clinical improvement, patient response, and medical rationale to support ongoing care. Be proactive in tracking progress and outcomes to substantiate continued phototherapy.
Reimbursement Considerations in 2025: Navigating CPT 96910 Payer Policies
Reimbursement for CPT 96910 can vary significantly across different payers, including Medicare, Medicaid, and private insurers. A thorough understanding of each payer’s specific policies is paramount for successful phototherapy billing.
Payer-Specific Policies and Coverage
- Medicare: As detailed in NCD 250.1 and various LCDs, Medicare covers CPT 96910 for medically necessary Goeckerman therapy for psoriasis, with specific documentation and frequency requirements.
- Medicaid: Medicaid policies are often state-specific. For instance, some state Medicaid programs, like New York Medicaid, may cover CPT 96910 for conditions such as cutaneous T-cell lymphoma (CTCL) when provided by a licensed physician and adhering to program guidelines. Always verify with the specific state’s Medicaid program.
- Private Insurers: Private payers such as Aetna, Blue Cross Blue Shield (e.g., BCBSTX), Cigna, and UnitedHealthcare typically have their own medical policies for phototherapy. These policies may outline specific diagnostic criteria, step therapy requirements, prior authorization mandates, and frequency limits. Providers are strongly advised to verify coverage and obtain any necessary pre-authorizations directly with each patient’s private insurance plan before initiating Goeckerman therapy to prevent unexpected denials. The American Academy of Dermatology (AAD) guidelines may often be referenced by private payers when developing their coverage criteria for codes like “aad 96910 cpt.”
Common Claim Denials and Prevention Strategies
Despite careful coding, denials for CPT 96910 can occur. Addressing common denial scenarios proactively can improve clean claim rates:
- Lack of Medical Necessity: Denials often result from insufficient documentation to support why Goeckerman therapy was necessary, especially if other treatments were not attempted or failed.
- Prevention: Ensure comprehensive documentation of the diagnosis (e.g., L40.x for psoriasis, or specific codes for CTCL), patient history, previous treatment failures, and the rationale for choosing CPT 96910.
- Missing or Incorrect Modifiers: For instance, claims for an E/M service on the same day as CPT 96910 without modifier -25 will likely be denied.
- Prevention: Apply modifiers correctly and only when appropriate, ensuring robust documentation supports their use.
- Frequency Exceeds Limits: If the number of sessions exceeds payer-specific limits without clinical justification, denials may occur (e.g., denial code “CO-151 – Payment adjusted because the payer deems the information submitted does not support this many services”).
- Prevention: Monitor session counts, track patient progress meticulously, and obtain prior authorization or submit appeals with strong clinical documentation for extended treatment.
- Topical Agent Not Specified/Used: Failure to document the application of tar or petrolatum, or using an agent not covered by the code description, can lead to denials.
- Prevention: Document the specific tar or petrolatum preparation used, the application method, and the body areas treated for every session.
Ensure accurate claim submission by using proper ICD-10 codes in Box 21E of the CMS-1500 form, including CPT 96910 in Box 24, and linking it to the correct diagnosis. Regularly verify payer-specific rules on prior authorization and frequency limits, as these policies are subject to change.
Best Practices for Billing CPT 96910: Maximizing Reimbursement and Compliance
Adhering to best practices is essential for efficient and compliant billing of CPT 96910, the phototherapy CPT code for Goeckerman therapy. Implement these strategies to optimize your reimbursement and reduce audit risks:
- Single Phototherapy Code: Submit only one phototherapy code per patient per session (e.g., 96900, 96910, or 96912). Do not combine these codes for the same treatment encounter.
- Accurate Diagnosis Linking: Always link the most specific and appropriate ICD-10 code (e.g., L40.x for psoriasis) to CPT 96910. The diagnosis must clearly support the medical necessity of the Goeckerman therapy.
- Judicious Use of Modifiers: Apply modifiers like -25 (for distinct E/M services) or -59 (for distinct procedural services) only when clinically and procedurally appropriate, ensuring robust documentation supports their use. Misuse of modifiers is a common audit trigger.
- Stay Updated on Payer Guidelines: Regularly check the Medicare National Coverage Determinations (NCDs) and your specific Medicare Administrative Contractor’s (MAC’s) Local Coverage Determinations (LCDs) for any updates or changes related to CPT 96910. These guidelines, along with private payer policies, are critical for maintaining compliance.
- Internal Audits: Periodically conduct internal audits of your phototherapy billing and documentation practices to identify and correct any potential issues before they lead to denials or external audits.
For additional guidance and to ensure your “phototherapy cpt code” claims are accurate, see our resources on ICD-10 coding tips, common modifiers, and claim denial reasons.
FAQs About CPT 96910: Photochemotherapy Billing Explained
When should CPT 96910 be used for phototherapy?
Use CPT 96910 specifically when tar or petrolatum is applied by a qualified provider or staff, followed by UV-B phototherapy (Goeckerman therapy). If only UV-B light therapy is performed without these topical agents, CPT 96900 should be used instead. For photochemotherapy involving UVA and psoralen, CPT 96912 (PUVA therapy) is appropriate.
Can I bill CPT 96910 with an office visit?
You can only bill CPT 96910 with an office visit if the visit involves a distinct and separately identifiable Evaluation and Management (E/M) service performed by the physician on the same day. In such cases, append modifier -25 to the E/M code and ensure that separate, clear documentation supports the distinct service. Routine nurse visits or elements typically bundled with the phototherapy procedure (like 99211) are generally not separately payable when billing 96910.
Is there a treatment session limit for Goeckerman therapy?
Yes, treatment session limits apply and vary by payer. Medicare typically expects no more than 30 sessions for Goeckerman therapy (CPT 96910) within a given treatment course unless there is clear, documented clinical improvement and a strong medical rationale supporting continued therapy. Always check with individual payers and relevant NCDs/LCDs for their specific policy on frequency limits.
Conclusion
Accurate coding for CPT 96910 in 2025 demands more than just assigning the correct CPT code for phototherapy. It requires a nuanced understanding of Goeckerman therapy, diligent documentation of topical agent application and UV-B light exposure, and continuous vigilance regarding payer-specific policies, including Medicare NCD and LCD guidelines. Be mindful of NCCI edits, appropriate modifier use, and stay updated on reimbursement changes. By implementing these best practices and thoroughly understanding the nuances of CPT 96910, providers can ensure clean claims, optimize reimbursement, and maintain compliance. For more guidance and to keep your photochemotherapy billing clean and compliant, explore our latest resources on cms1500claimbilling.com.