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What Category?

billing

By Melody Mulaik

When you hear the word category, especially at this time of year, most people will immediately think of the strength of a hurricane, but this word does have its place in coding. Just because there is a procedure code for a service does not mean that it is accepted and/or reimbursed for all payers.

Category I CPT® codes are five-digit numeric codes developed by the American Medical Association (AMA) that identify a procedure or service that is approved by the Food and Drug Administration (FDA), performed by health care professionals nationwide, and clinically proven to be effective. For example, 71045 (Radiologic examination, chest; single view) is a Category I. Most services are submitted with these codes.

The American Medical Association (AMA) developed Category III CPT® procedure codes to track the utilization of emerging technologies, services and procedures. Category III codes are 5-digits as well, but the last digit is always a “T.” For example, 0559T (Anatomic model 3D-printed from image data set(s); first individually prepared and processed component of an anatomic structure) is a Category III code. These codes are temporary codes that are intended for data collection to substantiate widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. 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.

I frequently refer to Category III codes as “Pinocchio” code – they want to be real codes, but they aren’t yet. Sometimes these codes are ultimately granted Category I status. As an example, the “virtual colonoscopy” CT codes (74261-74263) have their origins as Category III codes.

In recent years there has been a substantial increase in the number of Category III codes for radiology or radiology-related services. In most cases these codes reflect emerging technologies and create a way to bill for services that previously either were submitted with an unlisted procedure code (e.g., 76498) or not billed at all. Current examples of Category III codes that have been in place for many years include: 0042T (CT Cerebral perfusion), 0075T-0076T (Extracranial vertebral stent placement), 0174T-0175T (CAD for chest X-ray), 0200T-0201T (Sacroplasty), 0234T-0238T (Atherectomy). Newer codes include 0213T-0218T (US guided facet joint injections) and 0559T-0562T (3-D printing) but there are many more that may apply depending upon your organization’s scope of service.

There are no assigned Relative Value Units (RVUs) or established payments for Category III codes and 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. That said, it may be possible to be reimbursed for certain procedures if medical necessity can be proven to the payer. Each payer has their own requirements to justify medical necessity. Each organization needs to evaluate their volume of Category III procedures and determine if it is worth the time and effort to seek reimbursement from the payers.

Melody Mulaik, CRA, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle Coding Strategies.

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