From the clinician's perspective, starting a laser practice, dedicated to the treatment of burn patients with hypertrophic scar formation, can be quite daunting. These patients may have significant medical comorbidities and must have a comprehensive medical work-up, as some medical conditions, such as diabetes, nicotine dependency, history of deep venous thrombosis, and neuropathic pain, may impact healing and recovery from laser treatments. On the other hand, these patients are largely grateful for even small, incremental improvements in their burn scars, especially if such symptoms as pruritis and dysesthesia can be alleviated. Nevertheless, managing expectations and providing a realistic perspective on final outcomes are critical to optimizing both patient and provider satisfaction.
Almost all of the patients require treatment in the operating suite because of the following reasons: (1) patients may have difficult airways from previous tracheostomies or limited cervical extension due to their burn scars, (2) treatments are quite painful and many patients have pre-existing difficulties with chronic pain and posttraumatic stress disorder, (3) large areas approaching several hundred cm2 may need to be treated, which exceeds the ability to safely pretreat scars with topical anesthetics, (4) a large percentage of our patients are children, who do not have the cognitive maturity to remain still during a procedure, (5) treatments in the head and neck, where patients would be at risk for ocular complications from an errant laser pulse, also mandate a level of sedation that cannot be provided in the clinic, and (6) the surgeon can focus on providing the treatment, while the anesthesiologist or anesthetist can focus on providing anesthesia.
Before the first patient is treated, the clinician must obtain access to the laser. In addition to taking a laser safety course and working closely with the institution's laser safety officer, the clinician must obtain institutional privileges to perform these procedures. Furthermore, the provider must develop intellectual competency in the physics, indications, treatment parameters, complications, safety protocols, and perioperative management of laser therapy. Acquiring the laser platforms may be done through rental, lease, or purchase, but the capital requirement can be considerable, as the value of the equipment, with the extended warranties, can easily approach $500,000
US. We recommend initially renting the equipment and transitioning to a lease, when demand for the procedures can be determined. Leasing also provides the opportunity to upgrade equipment as new technologies are developed and added to the platform. A final consideration that must be addressed, even before the first session, is who can operate the laser. This is often determined by institutional guidelines and state regulations. At our center, any midlevel provider or upperlevel provider can treat patients, but a physician must be in the operating suite at all times during the procedure. Furthermore, two individuals are required, at our ambulatory surgery center, to actually perform the procedure: the operator, who actually discharges the laser and aims the pulse at the targeted tissue, and the technician, who manages the settings of the laser and is immediately available to assist with any emergency situations, such as OR fire, device malfunction, or inadvertent discharge of the laser.
The ability to collect revenue from these procedures is absolutely essential for the sustainability of the practice. Insurance companies legitimately do not cover most laser treatments for asymptomatic scars, especially when patients present with cosmetic concerns. However, we have found that almost all of the third-party payers do reimburse for laser treatment of burn scars, when functional problems such as contracture, stiffness, pruritis, and dysesthesia can be documented. We seek preauthorization and submit the results of our clinical consultation, combined with photographic documentation, for review. Direct, personal communication with medical directors at the insurance companies has facilitated this process; we have found that these individuals are quite helpful and interested in helping this group of patients. Because specific CPT codes for the laser treatment of burn scars do not exist, we use 17106, 17107, and 17108 (laser destruction of cutaneous vascular proliferative lesion, <10
, and >10
), which serve as a proxy for what we do. The rationale for using these codes is that burn scars are hypervascular, hypertrophic, and hyperpigmented, all of which are due to a proliferative, neovascular, and hyperplastic response of the injured tissues. While not hemangiomas or vascular malformations, burn scars act like these lesions, due to similar pathophysiologic mechanisms, resulting in similar endpoints. Also important for documentation is using the correct ICD-9 diagnosis terminology, to signify that these scars are due to burn injury: 701.4, keloid or hypertrophic scar; 709.2, fibrosis of skin; 906.5–906.9, late effects of burn.
One element that is particularly attractive to all stakeholders, patients, providers, and third-party payers, is that laser therapy for hypertrophic burn scars has the potential to dramatically reduce the cost of care. The surgical approach to management of burn scars can range from relatively simple laser treatments to very complex free flap reconstructions, depending upon the degree of contracture, pliability of the wound, and presence of such mitigating factors as ulceration and folliculitis. Allowable professional fees, for North Carolina Medicaid, range from $361 for a laser session to $2493 for the free flap reconstruction, the latter of which would consume 4–6 hours of OR time, 1-2 days of intensive care, and several additional days of step-down care before hospital discharge. The laser cases take one hour, including anesthesia induction/emergence, surgical procedure, transport time, and room turnover. Of course, patients with neck contractures may not be adequately treated with laser therapy alone. However, 1-2 laser sessions may preclude the need for any invasive surgery in patients with mild to moderate contractures and may permit less aggressive, and less costly, procedures, such as tissue rearrangement or skin graft, to be utilized in patients with moderate to severe contractures. For patients who suffer from severe pruritis, debilitating paresthesias, and chronic pain, laser treatment of hypertrophic burn scars almost always decreases pharmacologic requirements and allows some patients to discontinue many or all of their medications, such as narcotics, anxiolytics, antihistamines, and antidepressants. Patients who can wean off of these complex regimens faster require less clinic followup and are more successful with rehabilitative efforts and return to work faster.