The Life and Times of a T Code

Clinical Scorecard: The Life and Times of a T Code

At a Glance

Category	Detail
Condition	Category III CPT codes (temporary codes for emerging technologies, services, procedures, and service paradigms)
Key Mechanisms	Category III codes support specific utilization and outcomes data collection; they do not have nationally assigned relative value units, so reimbursement is largely payer-driven.
Target Population	Healthcare practices billing for services or technologies represented by Category III CPT codes
Care Setting	Clinical practice billing and reimbursement, including eyecare practices and Medicare Part B

Key Highlights

Category III codes may convert to Category I codes, be revised or extended, or be archived; generally, they are archived five years after publication or extension unless the archival date is modified.
Reimbursement varies by payer; Medicare pricing for code 0563T is determined locally by each CMS Medicare administrative contractor.
Some payers may consider a service investigational or noncovered, while others may cover it under their own policies and fee schedules.
Practices should provide an appropriate advance notice when coverage is unknown, establish a usual and customary fee, and follow applicable payer contract terms.
The AMA is moving from two annual Category III code releases to three; code details and payer policies can change.

Guideline-Based Recommendations

Diagnosis

Management

When coverage is unknown, provide the appropriate advance notice before performing the service, such as an advance beneficiary notice for Medicare Part B or an applicable notice of noncoverage.
Establish a usual and customary fee for the service and charge it consistently rather than adjusting the charge based on a particular payer's reimbursement.
For contracted payers, follow contract terms, including filing the claim and accepting the contracted rate when applicable.

Monitoring & Follow-up

Regularly review current CPT guidance and payer policies, including code descriptors, instructions, effective dates, coverage, and reimbursement.
Update billing expectations for Category III codes, particularly those used frequently.

Risks

Coverage and reimbursement may vary significantly among payers; some may treat a service as investigational or noncovered, leaving the patient responsible for out-of-pocket costs.
Category III codes may be revised, extended, archived, or converted to Category I codes, and code information and payer policies may change.

Patient & Prescribing Data

Patients receiving services or technologies billed under Category III CPT codes.

If a payer considers a service noncovered, it may be an out-of-pocket expense. When coverage is unknown, the article recommends providing the applicable advance notice before the service.

Clinical Best Practices

Check current CPT guidance and payer policy before billing Category III services.
Give patients the appropriate advance notice when coverage is uncertain.
Use a consistent usual and customary fee while complying with payer contract requirements.
Keep billing expectations current as Category III codes and release schedules change.