The American Medical Association (AMA) published changes to Current Procedural Terminology (CPT) Category III codes, which take effect July 1. Category III codes govern clinical efficacy, safety, coverage, and reimbursement for new and emerging technologies, services, and procedures, and should be used when appropriate to ensure accurate data collection.
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The American Medical Association (AMA) has published new Current Procedural Terminology (CPT) Category III codes, which take effect July 1, 2023. The new codes will be published in the AMA CPT Professional 2024 codebook and are available for review now within Vitalware® by Health Catalyst products.
Category III codes facilitate data collection and analysis to determine the clinical efficacy, safety, and utilization of new and emerging technologies, services, and procedures. Unlike Category I codes, which are permanent and finalized, the AMA updates Category III codes semi-annually and evaluates their utility after a period of five years. At the end of the five years, the AMA reviews the data and determines whether to assign the code permanent Category I status, modify or extend the existing Category III code, or discontinue the code.
Healthcare organizations must remember that the creation of a new code does not guarantee health insurance coverage or reimbursement for the service.
A novel therapy utilizing gamification and semi-immersive virtual reality to simulate motor-cognitive challenges encountered in daily life can be billed under code 0791T. Code 0791T should be used in conjunction with CPT code 97116: Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing).
GaitBetter, a medical technology company, offers AI-based gait tracking software that projects a patient’s foot movements into a VR environment displayed on a TV screen. In this entertaining and secure game, patients overcome virtual obstacles to improve gait while performing complex tasks requiring attention, memory, motor planning, and execution to enhance motor-cognitive skills.
Code 0793T describes a procedure in which extreme heat is applied through a catheter with a probe to destroy the nerves of the pulmonary arteries. This procedure includes right heart catheterization, pulmonary artery angiography, and all imaging guidance.
Code 0794T represents a rules-based algorithm that ranks monotherapies and drug combinations according to their ability to target a patient’s specific cancer biomarkers. The rankings are based strictly on current Food and Drug Administration (FDA)-approved drugs but include on- and off-label uses for targeted therapies. The rankings also provide information about potential active clinical trials that may be suitable for the patient. The new code accounts for the time spent by physicians, qualified health professionals, or clinical staff in submitting the patient’s clinical and existing molecular, laboratory, or pathology findings for the algorithmic assessment.
Silver diamine fluoride (SDF) is a liquid substance used to help prevent tooth cavities from forming, growing, or spreading. Most dentists use a liquid form of SDF that contains at least 38% of this solution, and it is applied topically directly on the surface of the teeth. The AMA created code 0792T for the application of this solution.
Several new codes were established for inserting, removing, and replacing dual-chamber leadless pacemakers. A dual-chamber pacemaker system includes two pulse generators with a built-in battery and electrode. Implantation of this system is performed using a catheter under fluoroscopic guidance via transvenous access. One pacemaker is implanted in the right atrium, and one in the right ventricle. Code 0795T describes the insertion of the complete dual-chamber leadless pacemakers.
A complete dual-chamber leadless pacemaker system can be done in stages, with one pacemaker implanted into the right ventricle at the initial procedure and the other implanted into the right atrium during a subsequent appointment. For these cases, two codes were created to correctly code for each instance — code 0796T for insertion of the right atrial pacemaker component and code 0797T for insertion of the right ventricular pacemaker component.
New codes were also generated for the following:
AMA also established a code for programming and device evaluation of a dual-chamber leadless pacemaker system (0804T). This code includes any analysis, review, or report by a physician or qualified healthcare professional, along with iterative adjustment of the implantable device to test its function and choose optimal permanent programmed values.
The TricValve® – Transcatheter Bicaval Valves System is a minimally invasive system of two self-expanding biological valves for treating patients with hemodynamically relevant tricuspid insufficiency and caval reflux. The prostheses are implanted percutaneously or through an open approach into the superior and inferior vena cava without disturbing the native tricuspid valve. This procedure helps eliminate peripheral venous congestion and reduce right heart failure symptoms. Two codes were created for the percutaneous femoral vein approach (0805T) and the open femoral vein approach (0806T).
The purpose of pulmonary tissue ventilation is to evaluate lung function and ensure air reaches all parts of the lung. The XV Lung Ventilation Analysis Software calculates lung tissue’s ventilation in a 4-dimensional (4D) manner by measuring lung tissue motion during all phases of the breath. Two new codes (0807T and 0808T) summarize the use of the software to analyze pulmonary ventilation using data captured from separate cinefluorograph images, compared to a computed tomography (CT) image. Code 0807T applies when a previously obtained CT image is used for the evaluation, whereas code 0808T applies when a CT image is obtained at the same time as the analysis.
There are two types of procedures for the sacroiliac joint: one uses transfixing devices placed laterally through a transiliac approach (crossing the joint), while the other uses the intra-articular placement of bone allograft products or devices within the joint. Previously, if both types of devices were used in an arthrodesis of a sacroiliac joint, coders had to use code 27299: Unlisted pelvis, or hip joint procedures. However, a new code (0809T) accounts for using a transfixing device and an intra-articular implant during an arthrodesis of the sacroiliac joint procedure.
Subretinal injections deliver therapeutic suspension or pharmacological agents directly under the sensory retina into the subretinal space — a virtual space between the photoreceptors and the retinal pigment epithelium. To describe this injection method, a new code (0810T) was created and includes vitrectomy and one or more retinotomies, which would typically be used when delivering ocular gene and cellular therapy.
GSK, a biopharma company, created a new RSV vaccine called Arexvy, which has been assigned the code 90679. This code is retroactively effective from May 3, 2023. Arexvy is a single-dose intramuscular injection approved for adults 60 years and older. RSV is a respiratory virus that usually causes mild, cold-like symptoms. It is common among small children but can be dangerous in senior citizens, particularly if they have underlying heart conditions, lung disease, or weakened immune systems
The AMA recognizes the swift evolution of healthcare technology and has introduced Category III codes to enable providers and health systems to properly document and report emerging technology, services, procedures, and service paradigms. While the existence of a CPT code does not warrant coverage for a procedure, it is necessary to assign Category III codes when appropriate to ensure accurate data collection.
Category III codes are temporary but can be archived and reach permanent status sooner if sufficient data is available. In the meantime, stay informed about forthcoming coding and reimbursement changes through Vitalware.
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