Dispelling myths of billing codes

There has been a new development in the way Current Procedural Terminology (CPT) Category III codes, also known as T-codes, are viewed, reimbursed, and treated in the means of medical billing and coding. In the past, there have been many myths and rumors regarding "temporary" code reimbursements. At one time, T-codes carried the cache of a less-than-sterling endorsement of a procedure or technology.

The American Medical Association (AMA) set up T-codes to allow data collection specific to newer services and procedures, since the use of an unlisted code did not facilitate product-specific data collection. These codes are assigned in order to track where and how frequently a service or device is being used and to what extent. The data was combined to help payers decide whether services or devices should be considered effective and "medically necessary."

Because Category I CPT code assignments are finite and adoption patterns could not be predicted, new technology services could not be incorporated under the existing Category I CPT codes. As a result, the AMA has implemented increasing numbers of Category III T-codes. Regarding this, services reported under ***99 Codes mandate hard-copy claim submission with documentation. On the other hand, services reported under T-codes can generally be adjudicated electronically. In short, T-codes are a welcome evolution of our coding systems and a recognition of valid technologies.

Over the years, there have been many technologies relating to glaucoma surgery. The mini-glaucoma shunt (Ex-PRESS, Optonol Ltd.) is an example of a new ophthalmic technology associated with a Category III CPT T-code. In the case of the mini-shunt, the procedure was initially billed using codes assigned to other surgical glaucoma procedures, such as trabeculectomies or other drainage devices. Acknowledging the rapid adoption of the device, the AMA assigned the mini-shunt procedure an exclusive Category III Code: 0192T, effective July 1, 2008. This isolation has differentiated the device from other aqueous shunt procedures.

The mini-shunt's manufacturer immediately hired a vice president of reimbursement and an outside consultant to assist physicians and facilitate billers with appealing denied claims. By doing so, they addressed the reimbursement challenges faced with the new assignment. The company's goal was to provide professional assistance to its customers in directing the T-code reimbursement process. Results were positive, with coverage determinations and support regarding 0192T from the majority of Medicare carriers as well as many commercial carriers. Where medical necessity has been documented and the use of the mini-shunt is in the best clinical interest of the patient, the company encourages physicians to appeal negative benefit determinations.

Experience with authorizing and coding surgical procedures with T-codes has shown that there is increased success in coverage, and the appeal process is reasonably simple if a claim happens to be denied. CPT Category III 0192T is generally electronically adjudicated and processed regularly for benefits. Providing further documentation of medical necessity can result in reimbursement without further difficulties.

With ophthalmologists being able to recognize the clinical value in performing procedures currently identified with a T-code for their patients benefit, it is vital that they also recognize that all new technologies must be reviewed for medical benefits. While the major payor obligation is to provide benefits for services that are the standard of care, it is also reasonable to expect payors to cover services that are medically necessary, as long as the FDA has approved them.

The mini-shunt has been available to surgeons for 6 years. During that time, more than 20,000 implants have been performed in the United States by more than 500 ophthalmologists.

Medicare and private carriers are paying for the procedure; 0192T is covered as well.

Experience has shown that once billing staffs become comfortable with the specifics of T-code use, the reimbursement process becomes routine, predictable, and successful. If ophthalmologists want to continue performing a T-code procedure because they believe in the procedure and that it's the right procedure for their patients, then they need to recognize that-like any new technology product-it just requires a little extra work.

Dr. Noecker did not indicate a proprietary interest in the subject matter. noeckerrj@upmc.edu

Mary Corkins is president of The Reimbursement Group. maryc@trgltd.com