Last month, several new Category III codes took effect — including codes for the Argus II retinal prosthesis implant and CyPass micro-stent. The American Medical Association routinely creates these temporary codes for emerging technology, services and procedures. Here are some tips on using these codes to bill properly.
Background: What Are Category III Codes?
The AMA introduces new Category III codes each July to track physician use of emerging techniques and technology. Data collected help the AMA decide if it should add Category III codes to the permanent set of CPT codes (also called Category 1 codes).
- Category III codes are presented as four numeric characters followed by the letter “T.”
- They cannot be used alone — you must attach them to a Category 1 CPT code
- Each code remains in use for five years. After this period, the AMA either give the code CPT status or retires it. When the latter occurs, physicians will need to use an unlisted code.
Payment and Category III Codes
Because they exist to collect usage data, Category III codes have no assigned relative value units nor a global period. In addition, they may not have an assigned allowable for insurance, making the patient responsible.
For patients with Medicare Part B, the Academy recommends you obtain an advance beneficiary notice from patients, informing them that they may have to pay out of pocket. In that case, be sure to append modifier -GA, which indicates you have the ABN on file. Other commercial payers may require a prior authorization.
What’s New in 2017
Each of the following Category III codes expire in January 2022.
1. 0469T Retinal polarization scan, ocular screening with onsite automated results, bilateral
Retinal birefringence scanning is a new approach to vision screening that involves bilateral, simultaneous laser scans of the retina to detect the binocular alignment of the two eyes. The technology generates a “binocularity score” and is thus inherently bilateral.
Because the AMA has not assigned any CCI edits or published any payment policies, no listing of typically covered ICD-10 codes exists for this scan. However, amblyopia and strabismus diagnoses are the most applicable for this service.
2. 0472T Device evaluation, interrogation, and initial programming of intraocular retinal electrode array (e.g., retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified healthcare professional
3. 0473T Device evaluation and interrogation of intraocular retinal electrode array (e.g., retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified healthcare professional
Use both of these two codes for the programming and subsequent reprogramming associated with the Argus II retinal prosthesis implant — as well as any necessary patient education. This service is inherently bilateral. Use code 0100T for the actual implantation of the Argus II device.
Note: So far, CMS has only approved payment of these implants for ambulatory surgery centers, not physicians. Because the AMA has not assigned any CCI edits or published any physician payment policies, no listing of typically covered ICD-10 codes yet exists..
4. 0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space
This code is for the CyPass Micro-Stent, a minimally invasive glaucoma surgical device. It’s used to treat patients with mild to moderate primary open-angle glaucoma in conjunction with cataract surgery.
This service is unilateral. If you perform it bilaterally, be sure to check payer requirements regarding modifiers. Medicare Part B prefers that you submit one line with modifier -50. Other payers may require that you submit two lines with -RT and -LT.
Note: So far, CMS has only approved payment of these implants for ASCs, not physicians. Because the AMA has not assigned any CCI edits or published any physician payment policies, no listing of typically covered ICD-10 codes yet exists. However, ICD-10 codes for treating mild to moderate POAG are the most applicable.
5. 0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space: initial device
6. 0450T Each additional device: list separately and be sure to code for the primary procedure)
This code was released in January 2017; however, most payers, including Medicare, did not start accepting it until last month. Use this code for the XEN Glaucoma Treatment System (XEN 45 Gel Stent preloaded into an XEN Injector). This device is indicated for the management of refractory glaucoma, including cases in which previous surgical treatment failed; POAG; and pseudoexfoliative or pigmentary glaucoma with open angles that are unresponsive to maximum-tolerated medical therapy.
This service is unilateral. If you perform it bilaterally, be sure to check payer requirements regarding modifiers. Medicare Part B prefers you submit one line with modifier -50. Other payers may require that you submit two lines with -RT and -LT.
Because the AMA has not published any physician payment policies, no listing of typically covered ICD-10 codes exists. However, ICD-10 codes for treating POAG, refractory glaucoma and pseudoexfoliative or pigmentary glaucoma are most applicable for this service.
- Use 92499 for the removal of an aqueous drainage device without extraocular reservoir, placed into the subconjunctival space via internal approach.
- Use add-on code +0450T only in conjunction with 0449T.
The AMA has assigned the following CCI edits for use of the XEN stent:
- 0376T, 12011, 12013, 12014, 12015, 12016, 12017, 12018, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13151, 13152, 13153, 65800, 65810, 65815, 66020, 66030, 67500, 67515, 92012, 92014, 92018, 92019, 99211, 9212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99334, 99335, 99336, 99337, 99347, 99348, 99349, 99350, 99374, 99375, 99377, 99378
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.