There are certain conditions discussed in this review that enable the reader to determine how to use Current Procedural Terminology (CPT) Category III codes in ASC coding for Medicare reimbursement. If these parameters are not followed, the Category III code cannot be used. The issuance or existence of the code in and of itself does not guarantee reimbursement. Obtaining reimbursement for coverage of minimally invasive glaucoma (MIGS) surgery devices has been a huge challenge to the companies who manufacture them and the physicians and facilities who use them. This review discusses various aspects of this problem in the context of ASC reimbursement.

OBTAINING A CATEGORY III CODE

Category III codes are issued twice a year — in early January and then again in the beginning of July each year. Implementation occurs 6 months after publication by the CPT Editorial Panel. So, codes may fail to appear in the CPT coding book if they miss the cycle deadline.^1,2

The following excerpt from the CPT Editorial Panel of the American Medical Association provides excellent background information on the guidelines for these codes.

Background Information for Category III Codes

CPT Category III codes are a set of temporary codes that allow data collection for emerging technology, services, procedures, and service paradigms. These codes are intended to be used for data collection to substantiate widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. The CPT Category III codes may not conform to one or more of the following CPT Category I code requirements:

• All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service.
• The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
• The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
• The procedure or service is consistent with current medical practice.³

OBTAINING MEDICARE PAYMENT FOR CATEGORY III CODES

The issuance of a Category III code is not a guarantee of Medicare payment for the procedure. There is a national fee schedule; however, the pricing is set by the individual Medicare Administrative Contractor (MAC), of which there are eight nationwide. An ASC may bill and be paid by Medicare if it is listed on the national fee schedule issued annually by CMS and the MAC has sanctioned payment for the code.²

Other insurers may make independent decisions on coverage and amounts. Frequently, Medicare covers these types of procedures, whereas other insurers often categorize them as experimental and may deny reimbursement.

QUESTIONS & ANSWERS

Q. Can an ASC bill the patient for insertion of multiple stents performed at the same session? Can we bill for the use of an iStent (Glaukos) as a standalone procedure?

A. No. If you look at the national fee schedule, you will notice that Category III codes for insertion of an additional stent carries an Indicator of “N1 Packaged service/item; no separate payment made.” This applies to Category III code +0376T, an add-on code for 0191T used for iStent - (each additional device insertion; list separately in addition to code for primary procedure). The same applies to Category III code +0450T for each additional device for XEN Gel Stent (Allergan). A plus sign indicates that it is an add-on code (one that cannot be coded independently). At press time, XEN Gel Stent has not received reimbursement approval by any MAC, although there is a national ASC facility payment listing; thus, the code cannot be used for obtaining Medicare payment nor can another CPT code be substituted.

Q. Are we able to perform the iStent surgery without the cataract surgery if the patient understands it is not covered and will sign an ABN form? The patient is pseudophakic (the surgeon was not able to implant the iStent during the cataract surgery) and already had surgery for the cataract with the iStent on the opposite eye.

A. The FDA has approved iStent for use in conjunction with cataract surgery in patients with mild to moderate glaucoma currently on hypotensive medication — and only for the initial insertion. The following procedures would be considered an off-label use: using Category III code +0376T (each additional device insertion), using the device as a standalone procedure without cataract surgery, and use of the device in multiples.

In this case, the insertion would be considered a standalone device for use of the iStent, a clinical scenario that does not currently have FDA approval, thus, making it an off-label use. This means the surgeon is responsible for obtaining a special informed consent for off-label use and adhering to all other regulations involving the use of a device that is FDA approved, but not for that specific use. I suggest the surgeon contact his or her malpractice carrier regarding this. Nothing can be billed to Medicare from the ASC side (facility fee, anesthesia) or from the physician’s side (surgery fees, office fees).⁴

Q. Please clarify why we were not paid for CyPass (Alcon) when the code was issued, and why XEN Gel Stent is not paid, even though it has a code.

A. For CyPass, the code was issued Jan. 1, 2017, with an implementation date of July 1, 2017. There was misleading information issued by various sources that alternate CPT codes could be used. CyPass was not eligible for reimbursement before the July 1, 2017 implementation date, and then only with the Category III code as issued (0474T).

Many physician practices and ASCs have used 0253T and received reimbursement. Medicare does not permit using substitute codes when a code is assigned to a given procedure, and could circle back later to reclaim the reimbursement.

The issue with XEN is different and based on the type of FDA submission: Although there is a national payment fee on the Medicare ASC fee schedule, no physician compensation is available from the MACs for Medicare cases.

Q. There are codes for removal of certain MIGS devices that are associated with the insertion code as listed in CPT. They are not priced on the national fee schedule and my MAC does not cover them. How should I code for removal of one of these devices?

A. When a parenthetical instruction follows a given CPT code, as is the case with 0450T - (For removal of aqueous drainage device without extraocular reservoir, placed in the subconjunctival space via internal approach, use 92499), it is best to ignore this instruction based on two important facts:

1. This is an unlisted code (those ending in “99”) and is not paid by Medicare in an ASC when it is the site of service because there is no mechanism in place to evaluate payment for the code. Unlisted codes do not carry any Relative Value Units (RVUs) on which to base payment.
2. There is a correct Category I CPT code for the removal of material that has been inserted into the anterior segment of the eye: CPT Code 65920 - Removal of implanted material from the anterior segment of the eye.⁵

Furthermore, it is Medicare policy to pay for complications following any procedure, even if that procedure may be a Category III code or if it was originally noncovered for any reason, including being a cosmetic procedure.

Q. Our MAC has lowered the amount of reimbursement for the iStent. How should we fill out our bills now that the cataract surgery reimburses higher than the iStent procedure?

A. Medicare regulations for payment of multiple procedures specifies that the highest-paying procedure should be listed first and subsequent procedures should be listed in declining order of reimbursement. This is in accordance with Medicare Part B Claims Payment instructions.

Because the method of calculation of ASC reimbursement for devices/procedures deemed “device intensive” was effective Jan. 1, 2017, it is highly unlikely that the cataract reimbursement will exceed the MIGS procedure reimbursement.

However, for physician payment, when a Category III code is used in conjunction with a Category I code, as is the case here, there is no reduction in payment for the Category III code because no mechanism to do so is present due to the Category III codes not being based on Medicare using a system based on RVUs.

If your MAC will process the claim when submitted in this fashion, the best way to optimize reimbursement is to list the cataract first and MIGS second. ■

CPT codes copyright 2016 and 2017 by the American Medical Association

References

1. American Medical Association. CPT® Category III Codes Code Descriptors. Available at https://www.ama-assn.org/sites/default/files/media-browser/public/cpt/cpt-category3-codes-descriptors.pdf . Last accessed Aug. 31, 2017.
2. Asbell RL. Coding for Current Concepts in Glaucoma Surgery. The Ophthalmic ASC; May 2016.
3. Centers for Medicare & Medicaid Services. Addenda Updates. Available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html . Last accessed Aug. 31, 2017.
4. Asbell RL. 2015 ASC Coding Update for Glaucoma Surgery. The Ophthalmic ASC; May 2015.
5. Asbell RL. Coding for Complications of MIGS Surgery. The Ophthalmic ASC; May 2017.