Welcome to our comprehensive billing guide for **CPT codes 96910, 96912, and 96920**, essential codes for phototherapy and laser treatments in dermatology. This article provides detailed definitions, outlines coverage considerations, and clarifies reimbursement specifics for these crucial **phototherapy CPT codes** and **laser treatment CPT codes**, particularly relevant for conditions like psoriasis. As an expert resource for healthcare providers, we aim to demystify the complexities of billing for ultraviolet light therapy and laser procedures, addressing common queries like “**cpt code for laser treatment psoriasis**” and “**cpt 96910 definition**.” Understanding these codes is vital for accurate claims processing and optimal patient care.
Understanding CPT Codes for Phototherapy and Laser Treatment
Accurate coding is the cornerstone of proper medical billing. Below, we provide structured definitions for the primary CPT codes related to phototherapy and laser treatments, including **uv light therapy CPT codes** and those used for inflammatory skin conditions.
Definitions of Key CPT Codes
- 96900: Ultraviolet light therapy
Description: General ultraviolet light therapy, often used for various dermatological conditions. - 96910: Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
Description: This **CPT code 96910** refers to photochemotherapy involving Goeckerman treatment (tar and UVB) or petrolatum and UVB, typically for conditions like severe psoriasis. - 96912: Photochemotherapy; psoralens and ultraviolet A (PUVA)
Description: Photochemotherapy using psoralens and ultraviolet A (PUVA), another common treatment for widespread skin disorders such as psoriasis. - 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)
Description: An extended photochemotherapy service for severe photoresponsive dermatoses, necessitating significant physician supervision and care over several hours. - 96920: Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq. cm
Description: This **CPT code 96920** specifies laser treatment for inflammatory skin diseases, primarily psoriasis, covering a small treatment area. - 96921: Laser treatment for inflammatory skin disease (psoriasis); 250 sq. cm to 500 sq. cm
Description: Laser treatment for inflammatory skin diseases like psoriasis, applied to a medium-sized body surface area. - 96922: Laser treatment for inflammatory skin disease (psoriasis); over 500 sq. cm
Description: Laser treatment for extensive inflammatory skin diseases such as psoriasis, covering a large body surface area.
CPT Code Comparisons for Accurate Billing
Distinguishing between similar CPT codes is crucial for preventing denials and ensuring appropriate reimbursement.
CPT 96910 vs 96900: Understanding the Differences
While both codes involve light therapy, **CPT 96900** represents general ultraviolet light therapy, which might be a simpler, less intensive treatment. In contrast, **CPT 96910** specifically describes photochemotherapy using tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B. This distinction implies a more complex procedure involving a photosensitizing agent or specific preparation, typically requiring more physician resources and potentially yielding different reimbursement rates.
CPT 96920 vs 96910: Distinguishing Laser vs. Photochemotherapy
The key difference between **CPT 96920** and **CPT 96910** lies in the modality of treatment. **CPT 96910** describes photochemotherapy, a treatment that combines light with a photosensitizing drug (like tar or psoralens) to treat a skin condition. On the other hand, **CPT 96920** is specifically for laser treatment for inflammatory skin diseases, such as psoriasis. Lasers offer targeted, high-intensity light delivery, which differs significantly from the broader application of light in photochemotherapy. Providers must accurately document the type of therapy rendered to ensure correct coding.
Historical Context: 2014 CMS Proposed RVU Changes
Understanding past reimbursement policies can offer insight into the current landscape. The following data provides **Historical Context (2014 CMS Proposed Changes)** regarding Relative Value Units (RVUs) for phototherapy services.
DESCRIPTION 2014 Total RVUs 2013 Total RVUs Total RVUs % Difference 2014 payment in $ assuming 35.6653 CF
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
In 2014, CMS proposed significant changes to RVUs for certain services. 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 to align with the Medicare’s Hospital Outpatient Prospective Payment System (OPPS) payment for the same service. In other words, non-facility RVUs were capped at the OPPS level. RVUs are a calculation of physician work, practice expense, and malpractice expense. For services with no work RVUs (including phototherapy), CMS proposed 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 suggested that the unaligned payments were not the result of appropriate payment differentials between the services furnished in different settings. Rather, they believed it was due to anomalies in the data used under the PFS and in the application of the resource-based practice expense (PE) methodology to the particular services.
Critics argued that the rationale underlying the phototherapy cuts in the CY 2014 Physician Fee Schedule was flawed because the OPPS and ambulatory surgical center (ASC) fee setting does not accurately evaluate the costs of the resources used to provide services. They failed 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 was no evidence that the fees OPPS or ASC fee schedule accurately reflected the cost of providing services, and they certainly did 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 was seen as not being in the best interest of Medicare beneficiaries.
This led to concerns about the likely patient impact, as a shortage of phototherapy units already existed, and these cuts would potentially lead to additional closures 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).
Comprehensive Billing and Reimbursement Guidelines
Navigating the complexities of billing and reimbursement requires an understanding of general principles and payer-specific policies.
CMS Coverage for CPT Codes 96910, 96912, 96920
While our client-side search found no specific CMS documents in the database regarding these codes, general Medicare (CMS) billing principles apply. For Medicare coverage, services must be medically necessary and meet specific criteria outlined in national and local coverage determinations (**National Coverage Determinations (NCDs)** and **Local Coverage Determinations (LCDs)**). Providers should consult the official **Medicare Learning Network (MLN)** resources and **CMS guidelines** for the most up-to-date information on appropriate billing for phototherapy and laser treatments.
NCCI Edits and Bundling Rules for Photochemotherapy
The National Correct Coding Initiative (NCCI) edits are vital for preventing improper payments due to incorrect code combinations. NCCI edits clarify when certain codes can be billed together and when one service is considered incidental to another.
- 96912 Incidental to 96910: Based on NCCI edits, code 96912 is often listed as a component code to code 96910. Therefore, if 96912 is submitted with 96910, typically only 96910 will reimburse. For example, **Anthem Central Region bundles 96912 as redundant/mutually exclusive to 96910.**
- 96910 and 96912 Incidental to 96913: Procedure 96910 (Goeckerman treatment) and 96912 (Ultraviolet A (PUVA) treatment) are considered components of the more comprehensive code 96913. Therefore, if 96910 and/or 96912 are submitted with 96913, typically only 96913 will reimburse. **Anthem Central Region bundles 96910 and 96912 as incidental with 96913.**
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