Integrating Scar Management into Clinical Practice
Murad Alam
KEY POINTS
In the United States, Current Procedural Terminology (CPT) codes are used to identify medical procedures, including those that may be appropriate for scar treatment. If an appropriate code is available, such as for an injection, laser, excision, or repair, this should be used.
Often, no specific code exists for a particular scar procedure. In this case, an unlisted procedure code may have to be used in combination with appropriate documentation to support the medical necessity of a procedure, whether before the procedure is performed (preapproval) or after the fact. Code updates are indicated to parallel advances in scar management techniques, such as ablative fractional laser treatment for traumatic scars and contractures with functional and symptomatic sequelae.
Treatment of some scars may not be considered medically necessary. For instance, atrophic acne scars may be construed as cosmetic in nature by insurers and require out-of-pocket payment by patients seeking treatment.
Apart from acquiring technical skills and honing the clinical decision making required to treat a scar, a physician interested in scar treatment must learn to incorporate scar treatment into his or her practice in a feasible and cost-effective manner. Important pragmatic considerations include: (1) how to defray the costs of scar treatment; (2) how to promote the availability of scar treatment services; and (3) how to ensure efficient throughput of scar patients that reduces utilization of staff, space, equipment, and time.
Payment for Services: Insurance Reimbursement or Self-Pay in the United States
Although payment is not a comfortable topic, especially in the context of the emotional and physical trauma of scarring, a busy scar treatment practice must be supported by a revenue stream. Regrettably, at this point, there is no wide consensus among third-party payers that treatment of scars is medically necessary. There is also no specific CPT code for treatment of scarring that can be billed to Medicare/Medicaid or private insurers. Although it may still be possible to receive insurance reimbursement for scar treatment services, it should be made clear at the onset to patients that claims may be rejected and that they may be liable for some or all of the cost of treatment.
Governmental and Third-Party Payment
CPT Code Process
CPT codes are updated annually and are five-digit designators that describe medical procedures performed in the United States.1,2 Code descriptors explain the procedure, and so-called code vignettes characterize how it is typically performed. CPT codes, and the definitions for each, are created, updated, and altered three times a year at face-to-face meetings of the CPT Panel, which is managed by the American Medical Association and includes members of medical specialty societies and payer groups. The CPT Panel is the voting body that decides to approve or decline so-called code change proposals (CCPs). At each CPT Panel meeting representatives of major medical professional societies called CPT Advisors who can offer testimony on behalf of particular CCPs and answer panel questions about clinical practice relevant to their specialties before the Panel votes are present. CCPs can be submitted by any interested group, including members of industry or the general public. Most successful CCPs (i.e., those that are approved by Panel vote) are supported and edited by the Advisors of the relevant specialty societies.
CPT codes for medical procedures performed by physicians are typically Category I or Category III codes. Category I codes represent routine, noninvestigational procedures. Once approved, Category I codes are sent to the Relative Value Scale Update Committee (RUC), which determines how much physician work effort and practice expense is required
for completion of the procedure in question. Thereafter, the Centers for Medicare and Medicaid Services (CMS) usually accepts RUC recommendations and uses these to assign a dollar value to the code. The constituents of code value include physician work effort (i.e., the sum of preservice, intraservice, and postservice time, adjusted by the intensity of the effort), practice expense (i.e., the cost of disposable supplies, nonphysician staff time, a small fraction of the cost of durable equipment required, and other space and utilities costs), malpractice expense (i.e., a minute amount that reflects the malpractice risk per procedure), and any additional adjustments that CMS may deem appropriate. The final code values are published by the CMS each year in the Physician Fee Schedule. Private insurers usually use CMS-designated relative values, which they can adjust as they deem appropriate. For instance, a third-party insurer may price most procedures at 80% of Medicare or 120% of Medicare.
for completion of the procedure in question. Thereafter, the Centers for Medicare and Medicaid Services (CMS) usually accepts RUC recommendations and uses these to assign a dollar value to the code. The constituents of code value include physician work effort (i.e., the sum of preservice, intraservice, and postservice time, adjusted by the intensity of the effort), practice expense (i.e., the cost of disposable supplies, nonphysician staff time, a small fraction of the cost of durable equipment required, and other space and utilities costs), malpractice expense (i.e., a minute amount that reflects the malpractice risk per procedure), and any additional adjustments that CMS may deem appropriate. The final code values are published by the CMS each year in the Physician Fee Schedule. Private insurers usually use CMS-designated relative values, which they can adjust as they deem appropriate. For instance, a third-party insurer may price most procedures at 80% of Medicare or 120% of Medicare.
Category III codes are new procedure codes that denote experimental procedures or procedures that have not yet been widely adopted. These codes are not valued by the RUC or priced by CMS. Instead, they are “carrier priced,” meaning individual insurers can choose to cover them, and if they do, they can select a payment amount. Often, procedures associated with Category III codes are redesignated with Category I codes after several years. As code utilization increases and procedures become routine, a CCP may be submitted to the Panel requesting an upgrade to Category I status. Even though Category III codes may not be paid, it is important for practitioners to submit them for consideration so that CMS can track utilization. Increased code use is often a major factor favoring eventual Category I status.
Table 25-1 Current CPT and HCPCS Codes That May Be Appropriately or Inappropriately Used for Scar Treatment | ||||||||||||||||||||||||||||||||||||||||||||
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Current CPT Codes for Scar Treatment
The rule of thumb in selecting CPT codes is that if the right code does not exist, the physician provider should select the code that is the best fit. If no code is a reasonably good fit, then a code ending in -99 that designates an unspecified or miscellaneous service should be submitted, along with detailed documentation regarding the procedure and its medical necessity.
There is currently no CPT code for laser treatment of scars. Scar resurfacing, whether by nonablative or ablative lasers, does not have a specific code. Laser treatment of redness or erythema associated with scar also does not have a code, as the 17106-17018 (Table 25-1) family of laser codes are for treatment of congenital vascular disorders like port-wine stains and hemangiomas. Unless scars are part of congenital malformations or vascular proliferative lesions, these codes do not apply. There is some ambiguity because the CPT code descriptor “vascular proliferative lesion” does not specifically restrict use to lesions that are congenital or lifelong, and it may be argued that hypertrophic scars and keloids are both proliferative and mediated by a growth in underlying vascular network. The relevant local coverage
determination of the Medicare contractor operating in a given region may provide additional guidance as to which ICD-10 diagnosis codes may be used with the code group 17106-17018. In general, atrophic scars, like some acne scars, would not meet the proliferation criterion, and treatment of these could not be described by these codes. Treatment of redness in a scar associated with prior surgery or previous laser treatment to treat a congenital malformation would be covered since the underlying disease process is covered.
determination of the Medicare contractor operating in a given region may provide additional guidance as to which ICD-10 diagnosis codes may be used with the code group 17106-17018. In general, atrophic scars, like some acne scars, would not meet the proliferation criterion, and treatment of these could not be described by these codes. Treatment of redness in a scar associated with prior surgery or previous laser treatment to treat a congenital malformation would be covered since the underlying disease process is covered.
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