What are CPT Category III Codes?

One of my passions has always been to advocate on behalf of our patients to have access to optometric services to the highest scope of training and licensure. To that end, I think it is critical for optometric physicians to understand the value of the care we are providing. It is also important for us to understand how to effectively communicate the level of services we are providing to payers. That is why I developed EyeCode Education.

The challenge with limited scopes of practice and more specifically "inclusionary optometric practice acts" (inclusionary language) is that everytime a new procedure is introduced if it is not explicitly contained within the practice act, our profession must return to the legislature to be granted the new authority. This means that when we rely on inclusionary language we may have to send our patients to other professionals for the most cutting edge treatments and procedures. It is for this reason, we are seeing states move away from inclusionary language to pass legislation with exclusionary language, practice acts that essentially say that the scope of practice includes everything EXCEPT... With exclusionary language as long as a new treatment or procedure is not something specifically excluded it would be included and a new law would not need to be passed to grant the new authority. This is basically how MDs, DPMs, and DDSs laws are written.

So when new treatments and procedures are developed that ARE in our scope of practice, how do we report them to payers if they don't have a definitive CPT code?

That is where CPT Category III Codes come in. These codes are used to track the utilization (See IPA article) of new and emerging technologies, services and procedures. Essentially payers use these codes to determine the utility of a procedure, however, they will often not reimburse anything for those procedures. Additionally, most payers will take the position that procedures in this category have not been established as "safe, effective or applicable to the clinical practice of medicine." Usually, payer will deny reimbursement to a physician for these codes unless there has been a published Local Coverage Determination by CMS to extend coverage for one of these services.

So what are some new emerging procedures and technologies that we may be using currently (or may soon be using) in our practices include:

  • 0198T Ocular blood flow measure

  • 0207T Clear eyelid gland w/ heat/intermittent pressure

  • 0329T Monitoring of IOP for 24 hours or longer- report

  • 0330T Tear film imaging, unilateral or bilateral-report

  • 0333T Visual evoked potential, screening of acuity-auto

  • 0464T Visual evoked potential testing for glaucoma

  • 0341T Quantitative pupillometry with interpretation and report

  • 0356T Insertion of drug-eluting implant into lacrimal canaliculus, each

  • 0378T Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional

  • 0379T Technical support and patient instructions, surveillance, analysis, and transmission of daily + emergent data reports prescribed by a physician or other qualified health care professional

  • 0380T Computer-aided animation + analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report

  • 0444T Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral

  • 0445T Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral

Bottom Line

There are always new technologies that are on the horizon for us to better serve our patients, optometrists need to have

  • The authority to provide these services

  • An understanding as to how/when we will be reimbursed for these services.