Category II & Category III The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 12 Category II & Category III Coding McGraw Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes 12-2 Interpret the guidelines for using category II codes. Identify the guidelines for using category III codes. Apply the guidelines to determine the best category II code.

Learning Outcomes 12-3 Utilize the guidelines to ascertain the best category III code. Correct use category II code modifiers. Correctly follow notational instructions with category III codes.

Introduction 12-4 Category II codes are used for statistical purposes, including the new Physician Quality Reporting Initiative. Category III codes report the use of new, emerging technologies.

Category II Codes 12-5 Used in conjunction with Appendix H Alphabetic Index of Performance Measures by Clinical Condition or Topic Report specific protocols accomplished during a patient encounter

Category II Codes Category II codes are not used for reimbursement 12-6 Category II codes are not used for reimbursement CMS uses category II codes in determining physician bonus payments under the PQRI program. They are reported on the CMS-1500 claim form with a charge of $0.00.

Category II Codes 12-7 Each category II code has 5 characters: 4 numbers followed by the letter F Example: 3006F

Category II Codes Compiled in 8 categories Composite measures 12-8 Compiled in 8 categories Composite measures Patient management Patient history Patient examination Diagnostic/screening processes Therapeutic, preventive & interventions Follow-up Patient safety

Category II Codes 12-9 Appendix H provides additional detail to assist with the assigning of the correct Category II code.

Category II Modifiers 1P Due to medical reasons 12-10 Explain why a protocol was not provided. 1P Due to medical reasons 2P Due to patient reasons 3P Due to system reasons

PQRI Participation Identify Medicare-covered patients who qualify. 12-11 Identify Medicare-covered patients who qualify. Document fulfillment of measure in notes for the encounter. Select appropriate Category II code. Submit codes on CMS-1500.

Category III Codes 12-12 Emerging technology and procedures not yet accepted as standard of care Some insurance carriers may consider these experimental procedures.

Category III Codes 12-13 Category III codes have 5 characters: 4 numbers followed by the letter T Example: 0016T

Category III Codes A regular CPT code is not appropriate. AND 12-14 Use a Category III code when: A regular CPT code is not appropriate. AND A Category III code is appropriate.

Category III Notations 12-15 When a procedure is accepted into regular clinical practice, the procedure gets a regular CPT code, and its Category III code is deleted. Example: (0023T has been deleted. To report, use 87900)

Category III Notations 12-16 Category III codes may be reported with regular CPT codes. Example: (Use 0068T in conjunction with 93000)

Category III Notations 12-17 Some Category III codes are not permitted to be reported with some CPT codes. Example: (Do not report 0065T in conjunction with 99172 or 99173)

Category III Notations 12-18 Some Category III notations will direct you to a CPT code that may be more accurate. Example: (For diagnostic epidurography, use 64999)

Chapter Summary 12-19 Use category II codes for statistical purposes. Use category III codes for the use of new, emerging technologies. Both category II and category III codes are updated twice a year: January 1st and June 1st.