96910

Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

Photochemotherapy, specifically the Goeckerman regimen or its clinical variants, is an intensive, specialized dermatological treatment involving the synergistic use of a topical photosensitizing or therapeutic agent (such as crude coal tar or petrolatum) and targeted ultraviolet B (UVB) phototherapy. This code, 96910, represents a single comprehensive treatment session combining these two distinct modalities. Initially developed in the 1920s by dermatologist William Goeckerman, the regimen remains a highly effective cornerstone for managing severe, recalcitrant, or generalized inflammatory skin conditions. It is predominantly utilized for generalized plaque psoriasis, but is also highly beneficial for severe atopic dermatitis (eczema), cutaneous T-cell lymphoma (such as mycosis fungoides), and prurigo nodularis that have failed to respond adequately to conventional systemic or topical therapies. The procedure begins with the meticulous application of the topical agent (coal tar or petrolatum) to the affected skin areas or the entire body surface. Coal tar possesses inherent anti-inflammatory, antipruritic, and anti-proliferative properties, which suppress the rapid turnover of epidermal cells characteristic of psoriatic plaques. Furthermore, it acts as a potent photosensitizer, significantly enhancing the skin's receptivity and responsiveness to subsequent ultraviolet irradiation. The topical agent is typically left on the skin for a specified duration, sometimes several hours or overnight in an inpatient or specialized day-treatment setting, to allow for optimal absorption and cellular interaction. Following this incubation period, the excess agent is gently removed to prevent physical blocking of the light rays, leaving only a microscopically thin, therapeutically active layer. The patient is then precisely positioned in a specialized, calibrated light booth or targeted with a focused light device to deliver a carefully calculated dose of broad-band or narrow-band Ultraviolet B (UVB) radiation. The exact dosage of UVB is determined by the patient's Fitzpatrick skin phototype, the thickness and scaling of the cutaneous plaques, and their documented previous response to phototherapy, aiming to maximize therapeutic efficacy while strictly minimizing the risk of erythema, blistering, or phototoxic burns. The synergistic combination of tar and UVB produces a robust therapeutic effect, profoundly inhibiting DNA synthesis in the hyperproliferative epidermal cells and modulating the local cutaneous immune response. This protocol is typically administered frequently, often three to five times a week, over a period of several consecutive weeks to achieve complete clearance or substantial clinical improvement of the cutaneous lesions. Rigorous clinical monitoring is absolutely essential throughout the entire treatment course to continually adjust the UVB dosimetry based on skin response and to promptly manage any localized adverse effects, ensuring both the safety and the success of the therapeutic intervention.

Clinical Indications

  • Severe, generalized, or recalcitrant plaque psoriasis
  • Atopic dermatitis (severe eczema) unresponsive to standard topical therapy
  • Cutaneous T-cell lymphoma (e.g., mycosis fungoides) in early stages
  • Vitiligo with extensive body surface area involvement
  • Prurigo nodularis
  • Lichen planus (widespread)

Procedure Steps

  1. Evaluate the patient's skin to determine the current severity of lesions and assess for any signs of phototoxicity or excessive erythema from prior treatment sessions.
  2. Calculate the appropriate Ultraviolet B (UVB) dosimetry based on the patient's skin type, prior exposure, and current clinical response.
  3. Prepare the skin by gently removing any thick, adherent scales if clinically necessary to improve light penetration.
  4. Apply the prescribed topical agent (crude coal tar preparation or petrolatum) generously and evenly to the affected skin areas or the entire body surface.
  5. Allow the topical agent to remain on the skin for the designated contact time (ranging from hours to overnight) to ensure adequate cutaneous absorption and photosensitization.
  6. Carefully remove the excess tar or petrolatum prior to UVB exposure to prevent a physical barrier effect, leaving only a thin, active residue on the epidermis.
  7. Protect sensitive and unaffected areas, including shielding the eyes with UV-blocking goggles and covering the male genitalia.
  8. Expose the patient to the carefully calibrated dose of broad-band or narrow-band Ultraviolet B (UVB) light within a specialized phototherapy booth.
  9. Monitor the patient continuously during the light exposure for safety, compliance, and comfort.
  10. Assist the patient post-exposure with cleansing the skin to remove remaining topical agents, apply soothing emollients, and meticulously document the treatment parameters (agent used, UVB dose in Joules or millijoules, and patient tolerance) in the medical record.

Coding Guidelines

  • Report CPT 96910 once per treatment session, regardless of the number of lesions treated or the total body surface area exposed to the therapy.
  • Do not report 96910 in conjunction with standard phototherapy codes (e.g., 96900) or PUVA codes (e.g., 96912, 96913) for the same treatment session.
  • Evaluation and Management (E/M) services are generally considered inclusive and are not reported on the same day unless a significant, separately identifiable E/M service is performed, which necessitates appending modifier 25 to the E/M code.
  • Medical documentation must clearly specify the concurrent use of BOTH the topical agent (tar or petrolatum) AND the ultraviolet B (UVB) light to support billing 96910.
  • If only ultraviolet light (UVB) is administered without the topical photosensitizing agent, report CPT 96900 instead of 96910.

Associated ICD-10 Codes