T-Codes (Category III)
Beginning in CPT 2003, the American Medical Association (AMA) began publishing category III codes. These are commonly referred to as T-codes since they contain four numerical digits and end with a capital "T". These are temporary codes for emerging technology, services and procedures. Category III codes allow data collection for these services/procedures. Use of unlisted codes does not offer the opportunity for the collection of specific data. Unlisted codes can be used for many different procedures and data analysis is meaningless. If a category III code is available, this codes must be reported instead of a category I unlisted code. The use of the T-codes allows physicians and other qualified health care professionals, insurers, health services researchers, and health policy experts to identify emerging technology, services, and procedures for clinical efficacy, utilization and outcomes.
The inclusion of a service or procedure in the category III section neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice by the AMA or other organizations. The codes in this section do not conform to the usual requirements for CPT category I codes established by the Editorial Panel of the AMA. For category I codes, the Panel requires that the service/procedure be performed by many health care professionals in clinical practice in multiple locations and that FDA approval, as appropriate, has already been received. The nature of emerging technology, services, and procedures is such that these requirements may not be met. Please note that FDA approval in no way promises Medicare coverage of a service or procedure.
Since Category III codes were first introduced in 2003, many services have been analyzed by the American Medical Association, by Centers for Medicare and Medicaid Services, by various insurance companies, and by Medicare carriers. A number of these codes have been replaced by category I codes (the "typical" five digit CPT codes). Others have not had their clinical efficacy and safety established. Thus, they still remain T-codes.
WPS normally pays for the professional component of T-codes when these services are performed in an approved Investigational Device Exception (IDE) trial. If, in time, a given T-code proves to be safe and effective based on clinical trials, it will be paid with minimal medical review after a decision to cover the procedure has been made. However, under all other circumstances, claims for T-codes (category III) will be denied as experimental/investigative and, therefore, not medically necessary. Under federal law, [Title XVIII of the Social Security Act section 1862 (a) (1) (A)] coverage and payment are only allowed for those services that are considered medically reasonable and necessary.
