Photobiomodulation (PBM) of the retina, a novel treatment for early- to intermediate-stage dry age-related macular degeneration (AMD), has demonstrated good results in clinical trials.^1,2 [“Rapid Developments in Geographic Atrophy,” p. 14] In November 2024, LumiThera’s Valeda Light Delivery System received FDA authorization to treat dry AMD and its later stage, geographic atropy.^3,4 Physicians are excited to finally offer a treatment plan other than lifestyle changes^5,6,7 and intravitreal injections of pegcetacoplan (SYFOVRE, Apellis) or avacincaptad pegol (IZERVAY, Astellas Pharma). The latter only slow disease progression for advanced AMD, while PBM improves vision.^8,9

Where Is PBM Performed?

PBM does not require anesthesia or other medication, such as dilating agents. Therefore, the procedure is not performed in an ambulatory surgery center or operating room, but rather in a medical clinic, in a dedicated suite under physician supervision. In teaching institutions affiliated with a hospital, PBM may be performed in unregulated space.¹⁰

Who Administers PBM?

Check with Your State

State laws and regulations define the roles and responsibilities of healthcare workers. Interpretation of those laws is performed by one of the following:

• a medical board for physicians and surgeons;
• a medical board for medical assistants;
• a physician assistant board for physician assistants;
• a board of optometry for optometrists;
• a board of nursing for registered nurses and
• a board of nursing for licensed vocational nurses; or
• a board of nursing for nurse practitioners and advanced-practice nurses.

Nationwide, there are differences in laws and their interpretation; check your state boards for specific information. Also, be aware of limitations on scope of practice for optometrists, physician assistants, nurse practitioners, and medical assistants. Some examples follow.

Of Optometrists and Allied Health Professionals

In California, under the Business and Professional Code §3401(a)(5)(F)(xii), optometrists are permitted to: “Use of noninvasive devices delivering intense pulsed light therapy or low-level light therapy that do not rely on laser technology, limited to treatment of conditions of the adnexa.”

Significantly, PBM is applied to the retina and not the adnexa.

The California Physician Assistant Practice Act provides that they may perform procedures if all of the following conditions are met:

• The physician assistant (PA) is supervised by a physician;
• Procedures are defined within a PA practice agreement;
• The PA is trained on the procedure and has competency;

and

• The therapy is for a patient-specific procedure ordered by a physician.

The Act does not authorize PAs to perform refractions, prescribe glasses or contact lenses, or do routine visual screening.

Article 8 of the California Business and Professional Code pertains to nurse practitioners (NP). It requires that:

• The NP is a licensed registered nurse with a graduate degree in nursing;
• The NP has completed an NP training program approved by the Board of Nursing;
• The NP adheres to Board of Nursing standards;
• The NP has established clinical competency;
• The NP follows standardized procedures;
• The physician is available by telephone.

Within CPT, PAs and NPs are referred to, along with some other healthcare professionals, as “qualified healthcare professionals” (QHPs). The characterization is important to identify providers who can be credentialed with healthcare plans and submit claims for reimbursement.

The California Medical Board has carefully described the limitations of medical assistants (MA). It states: Medical assistants are unlicensed, and may only perform basic administrative, clerical and technical supportive services as permitted by law. An unlicensed person may not diagnose or treat or perform any task that is invasive or requires assessment. The responsibility for the appropriate use of unlicensed persons in health care delivery rests with the physician.¹¹ Table 1 summarizes what medical assistants can and cannot do. 

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Most states share this point of view, which means that a medical assistant cannot treat patients using PBM even if directly supervised by a physician. Research on this point found considerable disagreement about what medical assistants may do, so the reader is encouraged to carefully investigate the matter and not blithely proceed. Significantly, payors are oriented to reimburse services personally performed by a physician or QHP while services performed by an MA under supervision of a physician are not equivalent.

Coding and Billing for PBM

On January 1, 2025, Category III CPT code 0936T (photobiomodulation of retina, single session) was inaugurated. The term “session” refers to a treatment on a single day, whether of 1 or 2 eyes. Your claim will report 1 unit; do not use modifier -50. This code reports a procedure that was personally performed by an ophthalmologist, optometrist, or QHP in compliance with state laws and regulations.

In 2019, 0552T (low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other QHP) was added to the CPT manual. The term “laser” does not apply to PBM of the retina, which uses low-intensity, non-coherent, multi-wavelengths of light, so this code cannot be used to report it. HCPCS code S8948 (Application of a modality requiring constant provider attendance to one or more areas; low-level laser; each 15 minutes) has the same difficulty and likewise cannot be used. 

In 2024, 97037 (Application of a modality to 1 or more areas; low-level laser therapy ie, nonthermal and nonablative for postoperative pain reduction) was added to the CPT manual. The phrase “postoperative pain reduction” as well as the term “laser” do not apply to PBM, so this code cannot be used on a claim. It is noteworthy that one Medicare Administrative Contractor, National Government Services, published a policy that defines these codes as not reasonable and necessary and not payable by Medicare.^12,13

Importantly, recent experience with 0936T in 2025 has been favorable and many claims have been paid.

Since PBM is a minor procedure, the modifier -25 rules for examinations on the same day apply.¹⁴ In the majority of cases, an eye exam is not billed on the same day as 0936T. An exception exists when the eye exam is performed for a separate and distinct reason unrelated to the minor procedure.

For example, your patient returns for re-evaluation of vitreous floaters and posterior vitreous detachment. During the eye exam, you find several drusen indicative of early dry AMD and reduced BCVA of 20/40 OU. With the patient’s consent, you perform PBM OU. A claim for an eye exam with modifier -25 is supported in this case by the floaters and PVD—not early dry AMD.

In the situation where PBM is performed by a QHP, CMS’ regulation on “incident to” services is germane.¹⁵ When a service satisfies the conditions for “incident to” billing, it is reimbursed based on 100% of the allowed amount for the procedure in the MPFS. Those conditions require the following:

• The QHP is credentialed with CMS;
• The QHP is employed by the entity billing for services;
• The procedure is ordered by a physician;
• There is direct supervision by a physician on the premises; ordering and supervising physician may be different;
• The services are provided in a non-institutional setting;
• They are performed on an established patient of the practice (not a new patient);
• The claim is filed with the PIN of the supervising physician.

If the “incident to” requirements are not satisfied, the reimbursement is reduced to 85% of the allowed amount. Significantly, the 2025 MPFS does not have an assigned value; it is carrier priced.

Chart Documentation

Foundation Tests

Before a physician orders PBM, an eye exam with dilation is required to 
establish medical necessity for the procedure. Determination of best-corrected visual acuity also must be made. And ancillary diagnostic tests are usually performed, which might include: fundus photography, fundus autofluorescence, optical coherence tomography (OCT), or OCT angiography.

Patient Education

During the process of getting the patient’s informed consent to proceed with the therapy, the physician and/or office staff must explain that coverage of PBM by health insurance plans is uncertain and the patient might be financially responsible for the procedure. This is accomplished with a financial waiver. For Medicare Part B, an Advance Beneficiary Notice of Noncoverage (ABN) is used; for Medicare Part C, a pre-determination of benefits is made; for other payors, a Notice of Exclusion from Health Plan Benefits is used.

For Complete Documentation

A minor procedure, such as PBM, is documented in the medical record with a report that includes:

• Date of service
• Patient nameDiagnosis
• Proceduralist’s name
• Title of procedure
• Indication for the procedure
• Description of the procedure
• Discharge instructions
• Signature per payor guidelines

Payor Coverage

The directions for use for the Valeda Light Delivery System (LumiThera)¹⁶ provide the needed information to establish which ICD-10 codes would support payment for PBM (Table 2).

All other diagnoses do not fall within the indications for PBM. At the present time, payors have not published a local coverage policy that formally declares where, when, why, and how often they will pay for PBM, so providers must file claims to obtain a determination. Table 2 is a good estimate for a future coverage policy.

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Payment for PBM

Within the 2025 Medicare Physician Fee Schedule, CMS did not assign an allowed amount to Category III CPT code 0936T. That is not oversight, but the expected action since Medicare Administrative Contractors typically make a determination on a claim-by-claim basis for temporary codes.

Table 3 is Corcoran’s calculation of estimated relative value units (RVUs) for physician expense, practice expense, and malpractice expense for 0936T.

Using the 2025 Medicare conversion factor $32.3465, we calculated a low value of $159.14, a high value of $244.22, and an average value of $201.84. These amounts are only approximations but provide the reader with a point of reference based on realistic expenses for PBM. 

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Conclusion

PBM provides physicians with a means to effectively treat early and intermediate dry AMD; that’s exciting. Until now, there wasn’t much to recommend other than vitamins, dietary changes, and weight loss. With this diagnosis, patients were seriously frightened by the threat of vision loss, so they are understandably enthused by a therapy that may mitigate the problem to some degree.

Some essential practice management requirements for providing this service are already in place: FDA authorization, a CPT code, some early paid claims, and a mechanism for patient payment of noncovered claims. In the United States, there are an estimated 16.8 million patients with early- or intermediate-stage dry AMD,¹⁷ so PBM represents a major advance for eye care. OM

References

1. Valters K, Tedford SE, Eells JT, Tedford CE, Photobiomodulation use in ophthalmology – an overview of translational research from bench to bedside. Ophthalmol., 14 Aug 2024 Sec. Retina, V 4. https://www.frontiersin.org/journals/ophthalmology/articles/10.3389/fopht.2024.1388602/full Accessed June 16, 2025.
2. Munk MR, Valter K. Photobiomodulation as an Innovative and Promising Treatment for Retinal Disease. Retinal Physician. April 2022. 19;4:36-39. https://retinalphysician.com/issues/2022/april/photobiomodulation-as-an-innovative-and-promising-treatment-for-retinal-disease/. Accessed June 16, 2025.
3. DEN230083, November 4, 2024. https://www.accessdata.fda.gov/cdrh_docs/pdf23/DEN230083.pdf. Accessed June 16, 2025.
4. FDA Authorizes Light Therapy for Dry AMD. Jan. 21, 2025. https://www.aao.org/eye-health/news/light-therapy-photobiomodulation-dry-amd-ga. Accessed June 16, 2025. 
5. Brzostowicki D. New Therapy Brings Hope for Dry AMD Vision Loss. January 7, 2025. https://www.webmd.com/eye-health/macular-degeneration/news/20250107/new-therapy-brings-hope-for-dry-amd-vision-loss. Accessed June 16, 2025.  
6. Rosen RB. Photobiomodulation: Innovation on the Horizon for dry AMD. Retina Today. May/June 2024. https://retinatoday.com/articles/2024-may-june/photobiomodulation-innovation-on-the-horizon-for-dry-amd. Accessed May 6, 2025.
7. Chican H, Aldujaly IH, Michalakis K, Kanal L. Photobiomodulation in ocular therapy: current status and future perspectives. Int J Ophthalmol 2025 Feb 18;18(2):351-357. https://pubmed.ncbi.nlm.nih.gov/39967973/. Accessed May 6, 2025. 
8. Photobiomodulation: A New Approach to Retinal Disease. The Ophthalmologist. Mar 2021. Accessed June 16, 2025. 
9. Kaymak H, Schwahn H. Photobiomodulation as a treatment of dry AMD. Retina Today May/June 2020. https://retinatoday.com/articles/2020-may-june/photobiomodulation-as-a-treatment-in-dry-amd. Accessed May 6, 2025.
10. HOPD and ASC Final Rule (CMS-1809-FC) 2025 NFRM Addendum B. 0936T is not covered in hospital outpatient setting. 
11. California Medical Board. Is Your Medical Assistant Practicing Beyond their Scope of Training? https://www.mbc.ca.gov/Licensing/Physicians-and-Surgeons/Practice-Information/Medical-Assistants.aspx. Accessed May 6, 2025. 
12. LCD L33631. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33631&ver=51. Accessed May 6, 2025. 
13. LCA A56566. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56566. Accessed May 6, 2025. 
14. Medicare Claims Processing Manual Chapter 12, §40.2(A)(8). https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf.  Accessed June 16, 2025.
15. Medicare Benefit Policy Manual Chapter 15, §60. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf. Accessed June 16, 2025.
16. Valeda Light Delivery System Directions for Use. https://www.manualslib.com/manual/1831158/Valeda-Light-Delivery-System.html#manual. Accessed June 16, 2025.
17. Prevent Blindness. Prevalence of Age-related Macular Degeneration. https://preventblindness.org/amd-prevalence-vehss. Accessed June 16, 2025.

Kevin J. Corcoran, COE, FNAO, Principal, Corcoran & Corcoran, Las Vegas. Contact him at: KCorcoran@Corcoran2.com.