CPT Category III Codes
The following CPT codes are an excerpt of the CPT Category III code set, a temporary set of codes for emerging technologies, services, procedures, and service paradigms. For more information on the criteria for CPT Category I, II and III codes, see Applying for Codes.
To assist users in reporting the most recently approved Category III codes in a given CPT cycle, the AMA’s CPT website publishes updates of the CPT Editorial Panel (Panel) actions of the Category III codes in July and January according to the Category III Code Semi-Annual Early Release Schedule. This was approved by the CPT Editorial Panel as part of the 1998- 2000 CPT-5 projects. Although publication of Category III codes through early release to the CPT website allows for expedient
dispersal of the code and descriptor, early availability does not imply that these codes are immediately reportable before the indicated implementation date.
Publication of the Category III codes to this website takes place on a semiannual basis when the codes have been approved by the CPT Editorial Panel. The complete set of Category III codes for emerging technologies, services, procedures, and service paradigms are published annually in the code set for each CPT publication cycle.
As with CPT Category I codes, inclusion of a descriptor and its associated code number does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy
1. What is a Category III CPT code?
Category III CPT Codes are temporary codes for emerging technology, services and procedures that allow for specific data collection associated with those services and procedures. There are no assigned RVU’s or established payment for the Category II CPT codes. When these procedures become more commonly adopted and established, the societies will work with the American Medical Association (AMA) to move these codes from Category III to Category I CPT status.
Physicians will report the WATCHMAN LAA Closure procedure with Category III CPT Code: 0281T. The code descriptor for 0281T is:
Percutaneous transcatheter closure of the left atrial appendage with implant. Includes fluoroscopy, transseptal puncture, catheter placements, left atrial angiography, left atrial appendage angiography, radiologic supervision and interpretation.
2. How do Category III CPT Codes differ from Category I CPT Codes?
Category I codes have assigned relative value units (RVUs) or work values and have an associated payment amount. A Category III CPT code does not have assigned RVUs and therefore, there is no payment rate established and reimbursement is at the payer’s discretion. In addition, a Category III code does not require FDA approval whereas; procedures described by a Category I CPT code must have FDA approval.
3. In the interim, how do physicians work with payers in establishing an appropriate payment rate for the WATCHMAN LAA Closure procedure when they are reported with Category III CPT Codes? For physician services reported with a Category III CPT Code, providers will reference or crosswalk a procedure code with similar or equivalent resources (i.e., RVUs) as the WATCHMAN LAA Closure implant (i.e., suggested CPT codes include but are not limited to: 93580: transcatheter closure of atrial septal defect with implant or 93581: transcatheter closure of ventricular septal defect with implant). It will be important for the provider to document the services provided in regards to resources and time for appropriate consideration of the payment for the professional component of the procedure.
Recommended items to support your claims submissions include the following:
* Copy of operative report
* Letter of medical necessity
* Copy of the FDA approval letter (Boston Scientific can supply electronic copy)
Copy of relevant published clinical literature supporting the use of the WATCHMAN LAA Closure System If physicians are employed by the hospital and their compensation is based on productivity from an RVU tracking methodology, it is important to work closely with the hospital administrators in benchmarking WATCHMAN LAA closure procedures to a procedure with established RVU’s utilizing similar resources, time, competency and risk. These discussions should happen in advance of a WATCHMAN implant being performed.
Guidelines for using Category III Codes
Unless an NCD, LCD or coverage article is published to address coverage for a specific Category III CPT code, UnitedHealthcare considers all services and procedures listed in the current and future Category III CPT code list as not proven effective and will deny submitted claims as not medically necessary. Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meeting all technical requirements for coverage, but are determined to be any of the following:
** Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used
** Not proven to be safe and effective based on peer review or scientific literature
** Experimental
** Not medically necessary in the particular case
** Furnished at a level, duration or frequency that is not medically appropriate
** Not furnished in accordance with accepted standards of medical practice, or
** Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician’s office or home care) appropriate to the patient’s medical needs and condition.
** Items and services must be established as safe and effective to be considered medically necessary. That is, the items and services must be:
** Consistent with the symptoms or diagnosis of the illness or injury under treatment;
** Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental or investigational);
** Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier;
** Furnished at the most appropriate level that can be provided safely and effectively to the patient.
Example Category III Codes
CPT Code Description Noncovered
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
0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)
0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for
primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)
0058T Cryopreservation; reproductive tissue, ovarian
0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue
0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue
0085T Breath test for heart transplant rejection (Not Covered by Medicare) [See the Medicare Advantage Policy Guideline titled Heartsbreath Test for Heart Transplant
Rejection (NCD 260.10)]
0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy [See the Medicare Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]
0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle [See the Medicare
Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]
0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation
0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation
0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia
0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia
0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation
0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes