As wonderful as new technology can be for our patients and practice, it’s often frustrating when a new procedure doesn’t come to market with reimbursement from third-party insurances. But that doesn’t mean we shouldn’t embrace new technology. On the contrary, with careful coding—and a good dose of patience—we can help new technologies mature into full CPT-coded options.
The Path to Coverage and Reimbursement
When new innovation is brought to market, the owners of that technology have to decide whether or not they want to pursue a formal code that allows health care providers to submit for insurance reimbursement. This path begins with the application for a Category III code. The following criteria are used by the CPT/HCPAC Advisory Committee and the CPT Editorial Panel for evaluating Category III code applications:1
• The procedure or service is currently or recently performed in humans and at least one of these additional criteria has been met:
(1) The application is supported by at least one CPT or HCPAC advisor representing practitioners who would use this procedure or service.
(2) The actual or potential clinical efficacy of the specific procedure or service in question is supported by peer-reviewed literature that is available in English for examination by the CPT Editorial Panel.
(3) There is an Institutional Review Board approved protocol of a study of the procedure or service being performed; a description of a current and ongoing United States trial outlining the efficacy of the procedure or service; or other evidence of evolving clinical use.
The Codes & Their Process
In the United States, we operate under the umbrella of the Health Care Procedural Coding System (HCPCS). Within this system, there are three distinct subsets of CPT codes used to describe ophthalmic services and products:
Category I. Most commonly referred to as the CPT codes, these have descriptors that correspond to a procedure or service. Codes range from 00100 to 99499 and are generally ordered into sub-categories based on procedure/service type and anatomy. These codes are always five digits.
Category II. Referred to as HCPCS Level II codes, these supplemental tracking codes are typically used for materials, some services and quality or performance measurements. Using them is optional and not required for correct coding. They always start with a letter (A-V) followed by four digits.
Category III. These are temporary codes for new and developing technology, procedures and services. They were created for data collection, assessment and, in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code. These are denoted by four digits followed by the letter T.
Category III codes generally have no coverage or reimbursement by third party carriers; instead, they are created to track the use of emerging technologies, services and procedures. They generally have five years of use before they move to a Category I, or CPT, code.
Although coverage and payment for performing a Category III-coded procedure is not common when the code is initially released, physicians are required to use the most appropriate code to describe the service provided. Thus, reporting a Category III code for a service accurately described by the code is appropriate. In fact, the correct reporting of a Category III service is essential to that code moving up to a CPT code, as carriers track use of Category III codes.
Ocular Surface Tech
As an example, let’s look at two Category III codes recently established for evaluation and treatment of the ocular surface:
0507T: Near-infrared dual imaging (i.e., simultaneous reflective and trans-illuminated light) of meibomian glands, unilateral or bilateral, with interpretation and report.2
This was changed in July of 2018 to specifically define meibography and separate it from anterior segment photography. This is generally considered a patient-pay code and will “sunset” or expire in 2024 (five years past the official listing in the CPT of January 2019).
0563T: Evacuation of meibomian glands using heat delivered through wearable, open-eyelid treatment devices and manual gland expression, bilateral.2
This code is specific to the TearCare device (Sight Sciences), materials and procedure. It was first included in the CPT reference in January 2020 and will sunset in 2025. When performing meibomian gland expression with the TearCare device, you must use this code and submit to the carrier, even though you know it will likely be denied. The patient should pay the day of the procedure in accordance with a properly adjudicated ABN form.
New technology will continue to come to market, and not all of it will be covered by third-party insurance. For companies that want coverage and reimbursement, it all starts with a Category III code. Understanding the importance of these codes is critical to both the compliance and financial health of your practice.
Send your coding questions to firstname.lastname@example.org.
1. American Medical Association. Criteria for CPT Category I and Category III codes. www.ama-assn.org/practice-management/cpt/criteria-cpt-category-i-and-category-iii-codes. Accessed October 1, 2020.
2. www.CodeSAFEPLUS.com. Accessed October 1, 2020.