Baseline	After 2 Weeks	After 4 Weeks
This patient received a course of broadband UVB phototherapy in conjunction with topical tar treatment. Within 4 weeks of 5 times a week treatment, near clearing is seen. Top: the patient at baseline; middle: after 2 weeks (10 treatments); bottom: after 4 weeks (20 treatments)

Training to Provide Phototherapy
Exposure to phototherapy begins during a physician’s dermatology residency. In residency, an individual should pay particular attention to the differing doses of light given to varied skin types. The National Psoriasis Foundation (NPF) and American Academy of Dermatology (AAD) offer courses that help physicians learn more about phototherapy and its use in psoriasis.

An efficient phototherapy unit is highly dependent on the phototherapist. An experienced phototherapist can handle the supervision of two light boxes at a time. The degree requirement for a phototherapist varies from state to state, ranging from none to R.N.  A well-trained phototherapist will be able to put patients at ease, educate them about phototherapy, and administer treatment following physician-directed protocols with a high level of safety. The phototherapist will also assess patients for signs of phototoxicity (burning, redness) prior to each session.  The physician is primarily responsible for training the phototherapist. Often, dermatologists with well-established phototherapy units will gladly host and help educate another practice’s new phototherapist.

Clinic Operations
The philosophy of phototherapy is to achieve clearing and remission for a certain time period. The two most common forms of light therapy are narrow-band ultraviolet B (UVB) and psoralen plus ultraviolet A (PUVA). Broad-band UVB is still used by many dermatologists, but narrow-band has generally replaced broad-band for those starting new phototherapy units. In narrow-band UVB, the wavelengths of light found most effective in the treatment of disease, 311 nm, is given to the patient.

For PUVA, 8-methoxypsoralen is given 1.5 hours before light therapy. The patient is then exposed to UVA between 320 nm to 400 nm.

Purchasing equipment for a phototherapy unit. The equipment needed for a phototherapy unit are light boxes that emit UVA and UVB. The light boxes cost about $15,00 0 each. The replacement cost of the bulbs for the light boxes must be considered as well. For narrow-band UVB, the unit usually has 42 bulbs. Each bulb costs around $125 each and lasts about 6 months. The replacement of the bulbs will cost around $6,00 0 every 6 months in a busy phototherapy practice. PUVA bulbs, on the other hand, are less expensive, costing $25 each and lasting 9 months. The other equipment option is to purchase a unit that emits both UVA and UVB. The drawback of this method is that treatments will take twice as long. In order to maintain patient flow in a busy phototherapy clinic, it’s best to purchase two of both UVA and UVB light boxes. This practice allows for an alternative in case a light box isn’t functioning. Furthermore, if patients miss a few weeks of therapy, they often need to start the whole process again.

Other items needed are protective wear for patients, including protective eyewear, jockstrap for men and zinc oxide for sensitive areas, such as nipples and lips.

Allotting enough space in your practice for phototherapy units. Assuming that you’ll probably want to start out with a couple of light boxes, you’ll need to dedicate one patient exam room to the equipment. One 10-foot by 12-foot room should be adequate enough, and you can expand from there as necessary.

Getting the word out. If you already have a lot of psoriasis patients in your practice, you won’t have to do much to promote phototherapy services. As soon as patients know you offer phototherapy, the word gets out, and you’ll find that you not only have interest among your own patients but that you get referrals from family practitioners as well as other dermatologists who don’t have large psoriasis patient populations in their practices.

Reimbursement Issues
The physician bills on a per treatment basis. The billing document should contain an ICD-9 diagnosis code appropriate to phototherapy (696.1 for psoriasis). The different CPT codes used are 99211 (nursing code), 96910 (UVB therapy), 96912 (PUVA), and 96913 (physician code). The nursing billing code can be used in addition to the phototherapy code when there is a medical decision being made by the nurse in terms of evaluating burns, new drugs, lapse in treatment or any other problems.

The average reimbursement is about $60 per patient. Usually, four patients can be seen in an hour if the practice has two light boxes. In the overall scheme of things, it’s helpful for a physician providing phototherapy to be involved with the maximum amount of managed care plans because it allows patients the best access to care, especially if that physician’s practice is serving the phototherapy needs for the entire community. Because of the numerous visits to the office even within a week, patients may find it prohibitively expensive to pay for an entire course of therapy out-of-pocket.

Offering this Service
With all the excitement about new treatments for psoriasis, now is a great time to consider adding phototherapy. Equipment is generally quite affordable and minimal space and staffing are needed to keep a phototherapy unit up and running. In addition, with its long record of safety and efficacy, phototherapy is a valuable treatment resource for many dermatology patients — and one that patients may utilize several times each year for multiple courses of therapy.