Using Category III Codes
Five tips to help improve accuracy, payment, and compliance.
Matthew Baugh, MHA, COT, OCS, OCSR
Retina Today 
Accurate coding for emerging retinal technologies requires more than familiarity with the standard American Medical Association (AMA) Current Procedural Terminology (CPT) Category I and Healthcare Common Procedure Coding System (HCPCS) codes; it also requires understanding CPT Category III codes. These temporary tracking codes, or “T” codes, are increasingly common in retina as innovation accelerates, yet they remain a frequent source of confusion, denials, and compliance risk. CPT Category III codes consist of four numeric characters followed by the letter “T.” Although they are valid CPT codes, they do not have assigned relative value units (RVUs) or national Medicare payment rates. As a result, coverage and carrier pricing for reimbursement are determined by the Medicare Administrative Contractor (MAC) or the individual payer. The following five practical tips outline how retina practices can use CPT Category III codes correctly to improve payer outcomes and position emerging services for future CPT Category I promotion. TIP NO. 1: DON’T DEFAULT TO PATIENT PAY A common misconception is that Category III codes are inherently noncovered and should automatically be billed to the patient. However, Category III status does not always mean investigational or noncovered. Rather, when a procedure is best described with a Category III code, it should be billed as such on the claim. Coverage decisions are based on medical necessity and payer policy—not the code category alone.
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