Summary & Overview
CPT 96574: Photodynamic Therapy for Precancerous Skin Lesions
CPT code 96574 describes combined removal of hyperkeratotic, precancerous skin lesions followed by photodynamic therapy (PDT) using a photosensitizing drug and a light source to destroy abnormal cells. The code is limited to one use per patient per day and applies to procedures performed by a physician or other qualified health care professional. Nationally, this code is relevant because PDT is an established, minimally invasive option for treating actinic keratoses and other superficial precancerous lesions, with implications for utilization, coverage policies, and outpatient procedural billing.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical intent and service setting, payer coverage considerations, common modifiers used in billing, and where CPT 96574 fits within dermatologic procedural coding. The publication provides benchmarks and policy context relevant to both clinicians and revenue cycle professionals, including reporting constraints (one per day) and typical ambulatory settings where the service is delivered. Data not available in the input for specific associated taxonomies, ICD-10 diagnoses, and payer-specific reimbursement levels are noted where applicable.
Billing Code Overview
CPT code 96574 reports removal of hyperkeratotic skin lesions that appear precancerous followed by photodynamic therapy (PDT). The procedure involves application of a photosensitizing drug to the lesion and subsequent exposure to a specific wavelength of light to destroy precancerous cells of the skin and adjacent mucosa. This code is reported only once per day.
Service type: Procedure — lesion debridement followed by photodynamic therapy
Typical site of service: Outpatient dermatology clinic or ambulatory surgical center, where a physician or other qualified health care professional performs the lesion removal and PDT under appropriate clinical settings.
Clinical & Coding Specifications
Clinical Context
A 68-year-old male with a history of chronic sun exposure presents to a dermatology clinic with multiple hyperkeratotic, scaly patches on the dorsal hands and forearms diagnosed clinically and by shave biopsy as actinic keratoses with confluent areas suspicious for extensive field change. The physician applies a topical photosensitizing agent to the affected areas, waits the required incubation period, then performs photodynamic therapy (PDT) using a specific wavelength light source to activate the drug and destroy dysplastic keratinocytes. The procedure is performed in an outpatient dermatology procedure room under topical anesthesia; the patient is monitored briefly for pain and local reaction and discharged with wound care instructions and follow-up scheduled.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Primary procedure | When this PDT is the primary service rendered on the date of service |
22 | Increased procedural services | When work, time, or complexity substantially exceeds usual for PDT |