Coding Q&A By Julie C. Bulman, MD, RPVI
Category III codes Q What is a Category III CPT® code and
should I be using them? A In Current Procedural Terminology (CPT®), Category III
codes are temporary codes for emerging technology, services or procedures. This category of codes was first developed in 2001 to track utilization of these services and be used in the approval process for the U.S. Food and Drug Administration (FDA) process. Category III codes are underutilized in interventional radiology and because of this, these procedures fail to convert to Category I codes, which are typically better paid and reflective of the entirety of procedural work. Because the underutilization is harming IR as a specialty, in this article I will review for informational purposes pertinent IR-related Category III codes. Even though some Category III codes are not reimbursed by all payers, use of these codes is essential to working towards appropriate payment for the work being performed by IR.
The underutilization of Category III codes is harming IR as a specialty.
Category III codes are not valued by the Relative Value Update Committee (RUC) for the Centers for Medicare and Medicaid Services (CMS). However, CMS still establishes payments in the facility (hospital) setting and allows each Medicare Administrative Contractor (MAC) to establish appropriate reimbursement within their jurisdiction under the Medicare Physician Fee Schedule (MPFS). Private payers may also reimburse for Category III codes and providers should review their payer contracts and/or payer policies.
Figure 1: Requirements for a Category III Code2 The procedure or service is currently or recently performed in humans;
AND At least one of the following additional criteria has been met:
• The application is supported by at least one CPT® or HCPAC adviser representing practitioners who would use this procedure or service; OR
• The actual or potential clinical efficacy of the specific procedure or service is supported by peer-reviewed literature that is available in English for
examination by the editorial panel; OR
• There is a) at least one Institutional Review Board–approved protocol of a study of the procedure or service being performed, b) a description of
a current and ongoing U.S. trial outlining the efficacy of the procedure or service, or c) other evidence of evolving clinical utilization.
Category III code updates are released for utilization twice yearly, on Jan. 1 and July 1, and providers should pay close attention to updates. As the Category III codes effective July 1 of each year are not published in the CPT® manual until the next year’s edition (January), it is possible for a code to be available 6 months before it is officially published by the AMA.
The criteria for establishing a Category III code are less stringent than for Category I codes, which are reserved for well-established, well-studied and generally accepted services (Figure 1). Category III codes do not require FDA approval, nor do they require peer- reviewed evidence. Category III codes
will sunset after 5 years, unless criteria for Category I status can be met or an extension is granted to continue the Category III status.
In IR, there are currently 43 Category III codes active in 2023 (See Table 1 starting on page 34). According to CPT®, the choice of a CPT® code must accurately describe the service performed. For this reason, it is best practice to classify new or emerging procedures using the designated Category III code if a Category I CPT® code does not exist. One should not report a CPT® code for a “similar” procedure, nor use an “unlisted” code, if a Category III code exists.
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