Chemosurgical Destruction

Chemosurgical destruction with 5 FU or treatment with 5 FU of actinic keratosis is considered an integral part of a doctor's medical care and is not eligible as a distinct and separate service. The physician does not personally remove the keratosis but gives the patient medication to apply daily under his supervision. If chemosurgical destruction with 5 FU is reported on the same day as a doctor's medical care, and the charges are itemized, combine the charges and pay only the doctor's medical care. Payment for the doctor's medical care performed on the same date of service includes the allowance for the chemosurgical destruction with 5 FU. A participating, preferred, or network provider cannot bill the member for chemosurgical destruction with 5 FU in this case.

If the chemosurgical destruction with 5 FU is performed independently, process it under the appropriate code(s).

Modifier 25 may be reported with chemosurgical destruction with 5 FU to identify it as a significant, separately identifiable service from the doctor's medical care. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Destruction of Pre-malignant Lesions

Actinic Keratoses can also be destroyed with cryosurgery, electrodesiccation, and laserabrasion. If the agent used is not reported or if the lesion is destroyed by an agent other than 5 FU, the claim should be processed under one of the appropriate surgical procedure codes:

17000, 17003, 17004, 67850

Levulan® with BLU-U™ Light Therapy

Levulan® (aminolevulinic acid, ALA, kerastick) is a photosensitizing agent that renders actinic keratosis lesions vulnerable to destruction by the application of the BLU-U™ light which is a fluorescent light source. This treatment is typically performed on individuals who have multiple lesions.

The application of Levulan® followed by the application of the light source requires two visits to the physician's office. During the first visit, the photosensitizing solution is applied. Fourteen to sixteen hours later, the Blu-U™ light is applied to the treated areas. Levulan® with BLU-U™ light does not have FDA approval for any skin condition other than actinic keratosis of the face and scalp, 702.0. Therefore, the use of this treatment for diagnoses other than actinic keratosis will be denied as experimental/investigational, and is not covered. A participating, preferred, or network provider can bill the member for the denied service. Also, application of this treatment to body areas other than the face and scalp will also be considered experimental/investigational.

When photodynamic therapy with Levulan® is reported for conditions other than actinic keratosis or the Levulan® is applied to areas other than the face and scalp, the office visit during which the Levulan® is applied will be denied. A participating, preferred, or network provider can bill the member for the denied service.

Levulan® used with photodynamic therapy should be submitted on a single claim for the complete service. The first stage (application of the Levulan® Kerastick™) should be reported under the appropriate level of E/M service rendered in addition to code J7308 (for the Levulan®). For the second stage (the illumination procedure) only 96567 should be reported. Codes 17000, 17003, or 17004 should not be reported for this procedure.

All suspected lesions should be treated at the same time and should not be performed separately. An additional treatment may be necessary to achieve complete clearing of the lesions. Therefore, a second treatment may be performed within 6-8 weeks of the original treatment.

Description

Actinic keratoses are sun-induced, premalignant lesions that appear primarily on the forehead, scalp and temples of light complected individuals who have experienced years of sun exposure. Since many actinic keratoses eventually transform into squamous cell carcinoma, early removal of these lesions can reduce the morbidity and mortality associated with such malignant transformation.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PRN References

06/2001, Levulan with BLU-U Light used to treat actinic keratosis

First Drug Device to Treat Actinic Keratoses, JAMA, Volume 283, No 5, February 2000

Topical Aminolevulinic Acid HCl Photodynamic Therapy, American Journal of Clinical Dermatology, Volume 1, No 2, March 2000

FDA Approves BLU-U Blue Light Photodynamic Therapy for Non-Hyperkeratotic Actinic Keratosis, www.pslgroup.com/dg/1e292a.htm, March 2001

Destructive Procedures are the Standard of Care for Treatment of Actinic Keratoses, Journal of the American Academy of Dermatology, Volume 40, No. 1, January 1999

Patients Urged to Seek Treatment for Actinic Keratoses, Recommends the American Academy of Dermatology, The American Cancer Society, and the Skin Cancer Foundation, Cutis, Volume 63, No. 6, June 1999

Selective Inflammatory Effect of Systemic Fluorouracil in Actinic Keratosis, Cutis, Volume 64, No. 1, July 1999