By Melody W. Mulaik
Artificial intelligence (AI) has been around for many years in radiology. From a clinical to an efficiency perspective, it has and continues to be a hot topic for discussion. It is natural then that the question of reimbursement should enter into the conversation.
In the 2023 Edition of the CPT® Manual, the American Medical Association (AMA) added Appendix S: Artificial Intelligence Taxonomy for Medical Services and Procedures, which is new and dedicated to AI. This appendix provides guidance to classify AI applications into three categories with stated primary objectives: (1) Assistive – detects clinically relevant data (e.g., CAD imaging), (2) Augmentative – analyzes and/or quantifies data in a clinically meaningful way (e.g., external processing of imaging data sets), and (3) Autonomous – interprets data and independently generates clinically meaningful conclusions (retinal imaging is currently the only recognized procedure by the CPT® code set). The inclusion of an appendix does not guarantee payment for AI codes and procedures but rather indicates a recognition of the need to address the technologies in a meaningful and productive way.
In radiology, for a number of years, there have been codes for AI technology either as stand-alone procedures or as part of a code definition. Computer-assisted detection (CAD) for mammography is good example. Initially separate add-on codes were created but ultimately the mammography code definitions were changed to reflect the industry standard of utilizing CAD. A similar update was made for breast MRI as well though there are still code options that do not contemplate CAD.
The majority of current AI codes are Category III procedure codes. The AMA developed Category III CPT® procedure codes to track the utilization of emerging technologies, services and procedures. Category III codes are five digits as well, but the last digit is always a “T.” For example, 0042T (Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time) is a Category III code. These codes are temporary codes intended for data collection to substantiate widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. Their scheduled sunset date, which is typically 5 years after creation, is now listed in the CPT® Manual. These code descriptions do not establish a service or procedure as safe, effective or applicable to the clinical practice of medicine. Unlike Category I codes, which are released only once a year, Category III codes are released in January and July.
There are no assigned Relative Value Units (RVUs) or established payments for Category III codes. They will typically be denied as not medically necessary by Medicare and commercial payers, unless a Local Coverage Decision (LCD) or coverage article specifically extending coverage to a particular Category III code has been published. Historically no Category III codes were assigned to an Ambulatory Payment Classification (APC) for outpatient hospital reimbursement; however, this changed for 2023. Two (2) of the new augmentative technologies, quantitative CT tissue characterization (0721T-0722T) and quantitative MRCP (0723T-0724T) were assigned to APCs (1508 and 1511 respectively) so hospitals should see reimbursement for these procedures if allowed by their local Medicare Administrative Contractor (MAC). This is a positive sign of potential things to come in terms of reimbursement for AI procedures.
Coding and reimbursement for AI technologies will continue to be a growing area that we should all watch carefully. Make sure to obtain accurate information when performing return on investment (ROI) analysis on new technologies to ensure appropriate expectations are set for all stakeholders. Some technologies will become industry standard, like breast CAD, while others will appear and not survive in the market for any myriad of reasons. Stay tuned!
Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle Coding Strategies LLC.
