Background
Category III “emerging technology” codes were introduced in 2002 as a way to collect data on new procedures, but some payors also recognize some of these codes for reimbursement purposes.
Category III codes are found in a tabbed section following the Category I and II codes in the 2009 CPT Professional Edition. They are listed in numeric order and not by anatomic location. These codes are usually formatted as four numerals plus a letter; for example, “1234T.”
Application
When a Category III code exists, it is not appropriate to use an unlisted procedure code or Category I CPT code. Category III codes are temporary. If, after five years, the code is not accepted for placement in Category I, it is either renewed for another five years or removed from the CPT book. A new symbol — the hollow circle (○)—in the CPT book applies to Category III codes that have been recycled or reinstated.
CMS leaves it up to each Medicare carrier to decide whether or not to pay for Category III procedures and how much payment should be. Medicare does not publicize a fee schedule for these codes. So, before billing a particular payor for a particular Category III code, the practice should contact the private payor and obtain written prior authorization of the code. Medicare does not pre-authorize surgical cases.
If the payor does not cover a particular code, obtain a waiver (private patients) or ABN (Medicare) from patients indicating that they have been informed that they have financial responsibility for the procedure if the payor denies as experimental or not medically necessary. Make sure all processes for claims management are in place as it is not uncommon to expect close to a six-week delay in processing and/or paying/rejecting this claim. It could take months to get paid.
Practices should appeal all denials where prior authorization was obtained or when the bill was denied because a Category III code was used.
Newly added Category III CPT codes are released twice a year — on Jan. 1 and July 1 — and are implemented six months afterwards.
New codes
The following three new Category III codes were released Jan. 1 and became effective July 1. They will be found in CPT 2010.
1. 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device (if utilized), one or more needles
2. 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device (if utilized), two or more needles. For radiological supervision and interpretation, see 72291, 72292. If bone biopsy is performed, see 20220, 20225.
3. 0202T Posterior vertebral joint arthroplasty (such as facet joint replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine. Do not report 0202T in conjunction with 22521, 22524, 22840, 22851, 22857, 63005, 63012, 63017, 63030, 63042, 63047, 63056 at the same level.
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The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
