Category I CPT Codes
Category I CPT codes describe a procedure or service identified with a five-digit CPT code and descriptor nomenclature. The inclusion of a descriptor and its associated specific five-digit identifying code number in this category of CPT codes is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.
In developing new and revised regular CPT codes the Advisory Committees and the Editorial Panel require:
• that the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
• that the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States;
• that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature;
• that the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and
• that the suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.”
Requirement for Category I CPT Codes
All Category I codes have been reviewed by the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel and have met the following criteria:
• the service/procedure necessary for the procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
• the suggested procedure/service is a distinct service performed by many physicians or other qualified health professionals across the United States;
• the suggested service/procedure and clinical efficacy of the service/procedure is well established and documented in peer review literature that meets the requirements set in the code change proposal form;
• the suggested service/procedure is performed with the frequency consistent with the intended clinical use;
• the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and
• the procedure or service is consistent with current medical practice.
Therefore, when a physician provides such a service or procedure and has documented his or her work properly and according to payer guidelines, the payer should not deny reimbursement for that service or procedure by claiming it is experimental or investigational.
Basic Code Sets
99201-99499 Evaluation and Management
80047-89356 Pathology and Laboratory
Modifiers usage on Category I CPT Codes
• Modifiers are used to “modify” the code that is chosen for a given procedure.
• These are listed in the front cover of the CPT book with a description
51 Multiple Procedure
52 Reduced Service
“Who maintains CPT?
The CPT Editorial Panel is responsible for maintaining the CPT code set. This panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is comprised of 17 members. Of these, 11 are physicians nominated by the National Medical Specialty Societies and approved by the AMA Board of Trustees. One of the 11 is reserved for expertise in performance measurement. One physician is nominated from each of the following: the Blue Cross and Blue Shield Association, America’s Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for two members of the CPT Health Care Professionals Advisory Committee (one co-chair “full seat” and one “rotating seat” member at-large).”
Comparison: Category I Versus Category III Codes
Category III CPT codes are a set of temporary codes for emerging technology, services, and procedures. These codes are intended to be used to track the usage of these services, and the data collected may be used to substantiate widespread usage in the Food and Drug Administration (FDA) approval process. However, Category III codes are not given an automatic designation for services or procedures, as the CPT Editorial Panel determined that they did not meet the requirements for a Category I code.
Category I CPT codes are restricted to clinically recognized and generally accepted services, and not emerging technologies, services, and procedures. Category III CPT codes are not required to conform to the CPT Category I code requirements but instead are for reporting services or procedures that must have a relevance for research, either ongoing or planned, or the need to be tracked to evaluate the frequency of use.
Another important consideration in the development of Category III codes was the elimination of local codes under the Health Information Portability and Accountability Act (HIPAA). The local codes were temporary codes used by third-party payers as a mechanism to identify services and supplies such as services and procedures that had not yet been substantiated through research. Thus, Category III codes have, in part, taken the place of these local codes. As with Category I CPT codes, inclusion of a descriptor and its associated code number in CPT nomenclature does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Additionally, inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy.
To expedite the availability of CPT Category III codes and to reflect the need to more quickly establish tracking mechanisms, the new CPT Category III codes are released semiannually via electronic distribution on the AMA CPT Web site (www.ama-assn.org/go/cpt ). The codes are effective six months after they are first posted. (Category III codes that are posted in July become effective the following January 1, and Category III codes that are posted in January become effective the following July 1.) The full set of Category III codes is then included in the next published edition of the CPT codebook for that CPT cycle. Such an early release is possible for Category III codes because the codes are not reviewed by the Relative Value Update Committee (RUC) for valuation by the Centers for Medicare and Medicaid Services (CMS). The AMA’s CPT Web site features updates of the CPT Editorial Panel actions and early release of the Category III codes on July 1 and January 1 in each CPT cycle