Coding Q&A

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.

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. 

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 (Table 1). 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.

Reference:

1. American Medical Association. CPT® Category III Codes: The First Ten Years. 2010.
2. “Guidance for CPT®/HCPAC Advisors—Appendix A.” American Medical Association. Dec. 6, 2019.

Disclaimer: SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2023/CPT®). It is not comprehensive and does not replace CPT®. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service. Please refer to 2023 CPT® for full and complete guidelines.

Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT® billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.