‘Hoo’ Is Performing Photodynamic Therapy? CPT® 2018 Says You’d Better Know

Happy Halloween!

Hope you can forgive that bit of Halloween headline fun before we get down to serious coding business! Maybe “‘Witch’ Team Member” would have been more to your liking than “Hoo.” Either way, I bet you are ready for more CPT® 2018 news now. Here’s what you need to know about the photodynamic therapy update swooping our way Jan. 1.

The procedure: Photodynamic therapy services involve using a photosensitive agent at one or more target areas and then applying a special light to activate the agent. The activation by the light results in a special kind of oxygen that destroys certain cells.  An example service would be removal of a lesion from an eyelid.

Kick Things Off With This 96567 Revision

In CPT® 2017, you have 96567. That code’s descriptor will see a revision in CPT® 2018. The parts that differ are marked below:

  • 2017: Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session
  • 2018: Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug(s), per day.

What’s different? Major 2018 changes include the removal of “and/or malignant” and the switch from “each phototherapy exposure session” to “per day.”

For that last part about the “per day” wording, it’s worth noting that 96567 already has a Medicare date of service medically unlikely edit (DOS MUE) of 1. In other words, Medicare already limits you in Q4 2017 to reporting 96567 once per day.

Here’s Where the ‘Hoo’ Comes Into Play

As the MPFS 2018 proposed rule explains, 96567 describes work by clinical staff and does not include physician work. So 96567 is appropriate when someone other than a physician or other qualified healthcare professional delivers the service.

Term tip: The CPT® definition of “qualified healthcare professional” is someone who is able to perform and independently report a professional service. “Qualified” refers to factors such as education, having the required license, and even facility privilege. CPT® distinguishes qualified healthcare professionals from clinical staff who work under supervision and are not allowed to individually report a professional service.

Use These New Codes for Physician Work

Two new codes that CPT® 2018 will introduce for photodynamic therapy include physician/qualified healthcare professional work.

New code 96573’s descriptor is almost identical to 96567, but 96573 adds the phrase “provided by a physician or other qualified health care professional.”

New code 96574 is a little different, with debridement included, as well. Here’s the descriptor (bold added for emphasis): Debridement of premalignant hyperkeratotic lesion(s) (ie, targeted curettage, abrasion) followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day.

The new codes include physician and qualified healthcare professional work, so unlike 96567, the new codes will have work RVUs. The proposed 2018 MPFS shows 96573 with 0.48 work RVUs and 96574 with 1.01 work RVUs.

Final tip: Don’t report 96567, 96573, and 96574 together for the same treatment area. Choose the one that best describes the service rendered.

What About You?

Do you think these new codes will be helpful? Are you glad to have new options for physician-provided services?

About 

Deborah concentrates on coding and compliance for radiology and cardiology, including the tricky world of interventional procedures, as well as oncology and hematology. Since joining The Coding Institute in 2004, she’s also covered the ins and outs of coding for orthopedics, audiology, skilled nursing facilities (SNFs), and more.

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