CPT Category III Codes, definition, guidelines and examples

CPT Category III Codes

The following CPT codes are an excerpt of the CPT Category III code set, a temporary set of codes for emerging technologies, services, procedures, and service paradigms. For more information on the criteria for CPT Category I, II and III codes, see Applying for Codes.

To assist users in reporting the most recently approved Category III codes in a given CPT cycle, the AMA’s CPT website publishes updates of the CPT Editorial Panel (Panel) actions of the Category III codes in July and January according to the Category III Code Semi-Annual Early Release Schedule. This was approved by the CPT Editorial Panel as part of the 1998- 2000 CPT-5 projects. Although publication of Category III codes through early release to the CPT website allows for expedient
dispersal of the code and descriptor, early availability does not imply that these codes are immediately reportable before the indicated implementation date.

Publication of the Category III codes to this website takes place on a semiannual basis when the codes have been approved by the CPT Editorial Panel. The complete set of Category III codes for emerging technologies, services, procedures, and service paradigms are published annually in the code set for each CPT publication cycle.


As with CPT Category I codes, inclusion of a descriptor and its associated code number does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy



1. What is a Category III CPT code?

Category III CPT Codes are temporary codes for emerging technology, services and procedures that allow for specific data collection associated with those services and procedures. There are no assigned RVU’s or established payment for the Category II CPT codes. When these procedures become more commonly adopted and established, the societies will work with the American Medical Association (AMA) to move these codes from Category III to Category I CPT status.

Physicians will report the WATCHMAN LAA Closure procedure with Category III CPT Code: 0281T. The code descriptor for 0281T is:

Percutaneous transcatheter closure of the left atrial appendage with implant. Includes fluoroscopy, transseptal puncture, catheter placements, left atrial angiography, left atrial appendage angiography, radiologic supervision and interpretation.


2. How do Category III CPT Codes differ from Category I CPT Codes?

Category I codes have assigned relative value units (RVUs) or work values and have an associated payment amount. A Category III CPT code does not have assigned RVUs and therefore, there is no payment rate established and reimbursement is at the payer’s discretion. In addition, a Category III code does not require FDA approval whereas; procedures described by a Category I CPT code must have FDA approval.

3. In the interim, how do physicians work with payers in establishing an appropriate payment rate for the WATCHMAN LAA Closure procedure when they are reported with Category III CPT Codes? For physician services reported with a Category III CPT Code, providers will reference or crosswalk a procedure code with similar or equivalent resources (i.e., RVUs) as the WATCHMAN LAA Closure implant (i.e., suggested CPT codes include but are not limited to: 93580: transcatheter closure of atrial septal defect with implant or 93581: transcatheter closure of ventricular septal defect with implant). It will be important for the provider to document the services provided in regards to resources and time for appropriate consideration of the payment for the professional component of the procedure.

Recommended items to support your claims submissions include the following:

* Copy of operative report
* Letter of medical necessity
* Copy of the FDA approval letter (Boston Scientific can supply electronic copy)

Copy of relevant published clinical literature supporting the use of the WATCHMAN LAA Closure System If physicians are employed by the hospital and their compensation is based on productivity from an RVU tracking methodology, it is important to work closely with the hospital administrators in benchmarking WATCHMAN LAA closure procedures to a procedure with established RVU’s utilizing similar resources, time, competency and risk. These discussions should happen in advance of a WATCHMAN implant being performed.




Guidelines for using Category III Codes
Unless an NCD, LCD or coverage article is published to address coverage for a specific Category III CPT code, UnitedHealthcare considers all services and procedures listed in the current and future Category III CPT code list as not proven effective and will deny submitted claims as not medically necessary. Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meeting all technical requirements for coverage, but are determined to be any of the following:


** Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used
** Not proven to be safe and effective based on peer review or scientific literature
** Experimental
** Not medically necessary in the particular case
** Furnished at a level, duration or frequency that is not medically appropriate
** Not furnished in accordance with accepted standards of medical practice, or
** Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition.
** Items and services must be established as safe and effective to be considered medically necessary. That is, the items and services must be:
** Consistent with the symptoms or diagnosis of the illness or injury under treatment;
** Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental or investigational);
** Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier;
** Furnished at the most appropriate level that can be provided safely and effectively to the patient.




Example Category III Codes

CPT Code Description Noncovered


0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)

0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for
primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)

0058T Cryopreservation; reproductive tissue, ovarian

0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue

0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume greater or equal to 200 cc of tissue

0085T Breath test for heart transplant rejection (Not Covered by Medicare) [See the Medicare Advantage Policy Guideline titled Heartsbreath Test for Heart Transplant
Rejection (NCD 260.10)]

0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy [See the Medicare Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]

0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle [See the Medicare
Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]

0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation

0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation

0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia

0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia

0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation

0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes

what is Medicare as secondary payer - different situation

Medicare Second Payer

Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment.)

The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program.

Precedence of Federal Law

Federal law takes precedence over State law and private contracts. Thus, for the categories of people described below, Medicare is the secondary payer regardless of state law or plan provisions. These Federal requirements are found in Section 1862(b) of the Social Security Act {42 USC Section 1395y(b)(5)}. Applicable regulations are found at 42 CFR Part 411 (1990).

More information on MSP laws and regulations is available through the CMS Laws and Regulations Portal. The link to the CMS Laws and Regulations Portal is located below.

Responsibilities of Beneficiaries Under MSP

As a beneficiary, we advise you to:
  • Respond to Initial Enrollment Questionnaire (IEQ) and MSP claims development letters in a timely manner to ensure correct payment of your Medicare claims,
  • Be aware that changes in employment, including retirement and changes in health insurance companies may affect your claims payment,
  • When you receive health care services, tell your doctor and other providers and the Coordination of Benefits (COB) Contractor about any changes in your health insurance due to you, your spouse, or a family member's current employment or coverage changes,
  • Contact the COB Contractor if you take legal action or an attorney takes legal action on your behalf for a medical claim,
  • Contact the COB Contractor if you are involved in an automobile accident, and
  • Contact the COB Contractor if you are involved in a workers' compensation case.

Responsibilities of Providers Under MSP

As a Part A institutional provider (i.e. hospitals), you should:
  • Obtain billing information prior to providing hospital services. It is recommended that you use the Centers for Medicare & Medicaid Services' (CMS') questionnaire, or a questionnaire that asks similar types of questions; and
  • Submit any MSP information to the intermediary using condition and occurrence codes on the claim.
As a Part B provider (i.e. physicians and suppliers)
  • Follow the proper claim rules to obtain MSP information such as group health coverage through employment or non-group health coverage resulting from an injury or illness;
  • Inquire with the beneficiary at the time of the visit if he/she is taking legal action in conjunction with the services performed; and,
  • Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process an MSP claim.

Responsibilities of Employers Under MSP

As an employer, you must:
  • Assure that your plans identify those individuals to whom the MSP requirement applies;
  • Assure that your plans provide for proper primary payments where by law Medicare is the secondary payer;
  • Assure that your plans do not discriminate against employees and employees' spouses age 65 or over, people who suffer from permanent kidney failure, and disabled Medicare beneficiaries for whom Medicare is secondary payer; and,
  • Accurately complete and submit Data Match reports timely on identified employees.

Group Health Plans (GHP)

An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual's insurance company, the GHP policy is the primary payer to Medicare.

Responsibilities of Attorneys Under MSP

As an Attorney, you must:
  • Immediately, upon taking a case, that involves a Medicare beneficiary, inform the COB Contractor about a potential liability lawsuit, and
  • Contact the assigned lead contractor regarding Medicare's interest in a liability, auto/no-fault, or workers' compensation lawsuit.

Responsibilities of Insurers Under MSP

As a GHP insurer, you must:
  • Report to the COB Contractor if you find that CMS has paid primary when you are primary to Medicare (i.e. 411.25).
As a Non-GHP Auto/Liability Insurer, you must:
  • Contact the COB Contractor immediately when the individual you insure is a Medicare beneficiary.

MEDICARE SECONDARY PAYER (MSP) summary list


Until 1980, Medicare was the primary payor for all Medicare covered services except for services covered by Workers Compensation or Black Lung benefits or paid for by the Department of Veterans Affairs or Other Government Entities. Since 1980, a series of changes in the Medicare law has shifted costs from the Medicare program to private sources of payment.

Federal regulations require healthcare providers to know when they can bill Medicare as the primary or secondary payer. Failure to properly determine the primary payer is a violation of the provider agreement with Medicare. Medicare considers it a fraudulent and abusive practice when a provider regularly submits claims that are the responsibility of another insurer under the MSP provision
.
Presently, Medicare is the secondary payer for individuals

Ø Who are aged 65 or older and currently working with coverage under an employer-sponsored or employee organization group health plan,

Who are aged 65 or older and are covered by a working spouse’s EGHP or employee organization group health plan,

Ø Who are under age 65, disabled, and are covered by a LGHP due to their own or other family members current employment status,

Ø Who receive services covered under Workers Compensation, Federal Black Lung, Automobile, No-Fault, or Liability insurance plans

Ø Who receive services covered under the Veteran Administration

Beneficiaries entitled to Medicare solely on the basis of ESRD, during a 30 month coordination period

Ø Working Aged

CPT Category II codes, why and what is the purpose,description, example


What is the purpose of CPT II codes?

CPT II codes help define nationally established performance measures by facilitating data collection regarding the quality of care rendered.


CPT II codes describe:

• Clinical components, such as those typically included in evaluation, management, or other clinical services;
• Results from clinical laboratory or radiology tests and other procedures;
• Identified processes intended to address patient safety practices; or
• Services reflecting compliance with state or federal law.


Why use CPT Category II codes?

CPT Category II codes can relay important information related to health outcome measures such as

** BMI
** CVD cholesterol management
** Controlling blood pressure
** Comprehensive diabetes care
** Tobacco cessation

What do we hope to achieve?

Amerigroup Kansas strives to ensure that we promote the most efficient processes for our providers while continuously improving the quality of care and services that our members receive. By increasing the use of CPT Level II codes, we hope to:

** Improve the health status of our members
** Monitor and ensure our members receive seamless, continuous and appropriate care throughout the continuum of care
** Improve the provider experience



How do I identify a CPT II code?

CPT II codes contain five characters – the first four numerical characters are followed by an alphabetical fifth character, the letter ‘F’.

The current set of CPT II codes contains the following sub-categories:

• Composite Measures 0001F – 0015F
• Patient Management 0500F – 0575F
• Patient History 1000F – 1220F
• Physical Examination 2000F – 2050F
• Diagnostic/Screening Processes or Results 3006F – 3573F
• Therapeutic, Preventive, or Other Interventions 4000F – 4306F
• Follow-Up or Other Outcomes 5005F – 5100F
• Patient Safety 6005F – 6045F
• Structural 7010F – 7025F


Why should my organization use CPT II Codes?


Not only can using CPT II codes ease the administrative burden of chart review for many HEDIS™ performance measures, use of these codes enables organizations to monitor internal performance for key measures throughout the year, rather than once per year as measured by health plans and Pay for Performance. By identifying opportunities for improvement, interventions can be implemented to improve performance during the service year.

How should my organization bill CPT II Codes?

CPT II codes are billed in the procedure code field; just as CPT Category I codes are billed. CPT II codes describe clinical components usually included in evaluation and management or clinical services and are not associated with any relative value. Therefore, CPT II codes are billed with a $0.00 billable charge amount.


NOTE: Once the lab results are received, please submit the appropriate Category II Code to PSHP.


Where can I find a list of CPT II Codes?

CPT II codes are released annually as part of the full CPT code set and are updated semi-annually in January and July by the AMA. The current listing of CPT II codes can be found on the AMA Web site at:

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billinginsurance/cpt/about-cpt/category-ii-codes.page.



Category II Modifiers
 Four Category II modifiers (1P, 2P, 3P, and 8P) are used to report services that were considered but not provided because of medical reason(s), patient choice, or system reasons. Modifier 1P (performance measure exclusion modifier due to medical reasons) is used to report that one of the performance measures was not performed, because it was not indicated (eg, already performed) or was contraindicated (eg, because of a patient's allergy).


Modifier 2P (performance measure exclusion modifier due to patient choice) is used to report that the performance measure was not performed because of a patient's religious, social, or economic reasons; the patient declined (ie, noncompliance with treatment); or other specific reasons.

Modifier 3P (performance measure exclusion modifier due to system reasons) is used to report that the performance measure was not performed because the payer does not cover the service, the resources to perform the service are not available, or other reasons attributable to the health care delivery system. These modifiers are only used with Category II codes and only when allowed based on the specific reporting instructions for each performance measure.


Modifier 8P (performance measure reporting modifier—action not performed, not otherwise specified) is used as a reporting modifier to allow the reporting of circumstances when an action described in a measure’s numerator is not performed and the reason is not otherwise specified


CPT Category II code short list HEDIS/Other measure Indicator description CPT Category ll codes*

Adult BMI BMI assessed/documented 3008F

CVD cholesterol management LDL test & level 3048F, 3049F, 3050F


Controlling blood pressure Blood pressure readings 3074F, 3075F, 3077F, 3078F, 3079F, 3080F


Comprehensive diabetes care  A1c test & A1c level 3044F, 3045F, 3046F

Eye Exam 2022F, 2024F, 2026F
LDL test & level 3048F, 3049F, 3050F
Nephropathy screening 3060F, 3061F, 3062F, 4009F, 3066F
Blood pressure readings 3074F, 3075F, 3077F, 3078F, 3079F 3080F
Tobacco cessation Screening, counseling, intervention 1031F, 1032F, 1033F, 1034F, 1035F, 1036F, 4001F, 4004F
Fall risk assessment Assessment, plan of care 0518F, 1100F, 1101F



F code Code descriptor(s) From AMA


4010F Angiotensin converting enzyme (ACE) inhibitor or Angiotensin receptor blocker (ARB) therapy prescribed or currently being taken
3080F Most recent diastolic blood pressure 90 mm Hg
3079F Most recent diastolic blood pressure 80 – 89 mm Hg
3078F Most recent diastolic blood pressure < 80 mm Hg
3077F Most recent systolic blood pressure 140 mm Hg
3075F Most recent systolic blood pressure 130 to 139 mm Hg
3074F Most recent systolic blood pressure < 130 mm Hg
3072F Low risk for retinopathy (no evidence of retinopathy in the prior year)
3066F Documentation of treatment for nephropathy (e.g. patient receiving dialysis, patient being treated for ESRD, CRF, ARF or renal insufficiency, any visit to a nephrologist)
3062F Positive macroalbuminuria test result documented and reviewed
3061F Negative microalbuminuria test result documented and reviewed
3060F Positive microalbuminuria test result documented and reviewed
3050F Most recent LDL -C 130 mg/dL
3049F Most recent LDL -C 100-129 mg/dL
3048F Most recent LDL -C < 100 mg/dL
3046F Most recent hemoglobin A1c (HbA1c) level > 9.0%
3045F Most recent hemoglobin A1c (HbA1c) level 7.0% to 9.0%
3044F Most recent hemoglobin A1c (HbA1c) level < 7.0%
2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed
2024F Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed
2022F Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed
1170F Functional status assessed
1160F Review of all medications by a prescribing practitioner or clinical pharmacist (such as, prescriptions, OTCs, herbal therapies and supplements) documented in the medical
1159F Medication list documented in medical record
1158F Advance care planning discussion documented in the medical record
1157F Advance care plan or similar legal document present in the medical record
1126F Pain severity quantified; no pain present
1125F Pain severity quantified; pain present
1111F Discharge medications reconciled with the current medication list in outpatient medical record
0503F Postpartum care visit

Category I CPT Codes, requirements and basics and comparison vs Category III Codes

Category I CPT Codes

Category I CPT codes describe a procedure or service identified with a five-digit CPT code and descriptor nomenclature. The inclusion of a descriptor and its associated specific five-digit identifying code number in this category of CPT codes is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.

In developing new and revised regular CPT codes the Advisory Committees and the Editorial Panel require:

•    that the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
•    that the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States;
•    that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature;
•    that the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and
•    that the suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.”




Requirement for Category I CPT Codes

All Category I codes have been reviewed by the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel and have met the following criteria:

• the service/procedure necessary for the procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;

• the suggested procedure/service is a distinct service performed by many physicians or other qualified health professionals across the United States;

• the suggested service/procedure and clinical efficacy of the service/procedure is well established and documented in peer review literature that meets the requirements set in the code change proposal form;

• the suggested service/procedure is performed with the frequency consistent with the intended clinical use;

• the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and

• the procedure or service is consistent with current medical practice.

Therefore, when a physician provides such a service or procedure and has documented his or her work properly and according to payer guidelines, the payer should not deny reimbursement for that service or procedure by claiming it is experimental or investigational.

Basic Code Sets
99201-99499 Evaluation and Management
00100-01999 Anesthesia
10021-69990 Surgery
70010-79999 Radiology
80047-89356 Pathology and Laboratory
90281-99607 Medicine


Modifiers usage on Category I CPT Codes


• Modifiers are used to “modify” the code that is chosen for a given procedure.

• These are listed in the front cover of the CPT book with a description

Example:
51 Multiple Procedure
52 Reduced Service


“Who maintains CPT?

The CPT Editorial Panel is responsible for maintaining the CPT code set. This panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is comprised of 17 members. Of these, 11 are physicians nominated by the National Medical Specialty Societies and approved by the AMA Board of Trustees. One of the 11 is reserved for expertise in performance measurement.   One physician is nominated from each of the following: the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for two members of the CPT Health Care Professionals Advisory Committee (one co-chair "full seat" and one "rotating seat" member at-large).”


Comparison: Category I Versus Category III Codes

Category III CPT codes are a set of temporary codes for emerging technology, services, and procedures. These codes are intended to be used to track the usage of these services, and the data collected may be used to substantiate widespread usage in the Food and Drug Administration (FDA) approval process. However, Category III codes are not given an automatic designation for services or procedures, as the CPT Editorial Panel determined that they did not meet the requirements for a Category I code.
Category I CPT codes are restricted to clinically recognized and generally accepted services, and not emerging technologies, services, and procedures. Category III CPT codes are not required to conform to the CPT Category I code requirements but instead are for reporting services or procedures that must have a relevance for research, either ongoing or planned, or the need to be tracked to evaluate the frequency of use.

Another important consideration in the development of Category III codes was the elimination of local codes under the Health Information Portability and Accountability Act (HIPAA). The local codes were temporary codes used by third-party payers as a mechanism to identify services and supplies such as services and procedures that had not yet been substantiated through research. Thus, Category III codes have, in part, taken the place of these local codes. As with Category I CPT codes, inclusion of a descriptor and its associated code number in CPT nomenclature does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Additionally, inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy.

To expedite the availability of CPT Category III codes and to reflect the need to more quickly establish tracking mechanisms, the new CPT Category III codes are released semiannually via electronic distribution on the AMA CPT Web site (www.ama-assn.org/go/cpt ). The codes are effective six months after they are first posted. (Category III codes that are posted in July become effective the following January 1, and Category III codes that are posted in January become effective the following July 1.) The full set of Category III codes is then included in the next published edition of the CPT codebook for that CPT cycle. Such an early release is possible for Category III codes because the codes are not reviewed by the Relative Value Update Committee (RUC) for valuation by the Centers for Medicare and Medicaid Services (CMS). The AMA’s CPT Web site features updates of the CPT Editorial Panel actions and early release of the Category III codes on July 1 and January 1 in each CPT cycle

W series CPT code list

W series CPT codes Introduction


Current Procedural Terminology (CPT) codes are used for reporting medical services and procedures performed by physicians.  Their purpose is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services, thereby providing an effective means for reliable nationwide communication among physicians, patients, and third parties.  This system of terminology is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs.

CPT V. 6.0 provides the software to update the CPT files.  The software includes all CPT codes to code outpatient services for reimbursement and workload purposes (as determined by the American Medical Association) and the Common Procedure Coding System from the Health Care Financing Administration (HCPCS).  These codes may also be utilized to report inpatient services in certain instances.

In addition to the National CPT and HCPCS codes, the VA also uses the following VA specific HCPCS format codes.  These codes are not included in the HCPCS or CPT manuals.

W-CODES (VA NATIONAL CODES)



CPT Code Service Description Billing Unit Rate as of July 1, 2016 Max Daily Unit/ Service Limit Place of ServiceW5014 Art Therapy Individual - certified 45-50 min $63.43 1 11,99
W5026 Art Therapy Individual - certified 75-80 min $82.47 1 11,99
W5027 Art Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5028 Art Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5015 Art Therapy Group - certified 45-60 min $24.64 1 11,99
W5029 Art Therapy Group - certified 75-80 min $32.04 1 11,99
W5030 Art Therapy Group - licensed 45-60 min $27.74 1 11,99
W5031 Art Therapy Group - licensed 75-80 min $36.07 1 11,99
W5012 Dance Therapy Individual - certified 45-50 min $63.43 1 11,99
W5032 Dance Therapy Individual - certified 75-80 min $82.47 1 11,99
W5033 Dance Therapy Individual - licensed 45-60 min $69.78 1 11,99
W5034 Dance Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5013 Dance Therapy Group - certified 45-60 min $24.64 1 11,99
W5035 Dance Therapy Group - certified 75-80 min $32.04 1 11,99
W5036 Dance Therapy Group - licensed 45-60 min $27.74 1 11,99
W5037 Dance Therapy Group - licensed 75-80 min $36.07 1 11,99
W5010 Equine Assisted Therapy Individual -certified 45-50 min $63.43 1 99
W5044 Equine Assisted Therapy Individual -certified 75-80 min $82.47 1 99
W5045 Equine Assisted Therapy Individual - licensed 45-50 min $69.78 1 99
W5046 Equine Assisted Therapy Individual - licensed 75-80 min $91.41 1 99
W5011 Equine Assisted Therapy Group - certified 45-60 min $24.64 1 99
W5047 Equine Assisted Therapy Group - certified 75-80 min $32.04 1 99
W5048 Equine Assisted Therapy Group - licensed 45-60 min $27.74 1 99
W5049 Equine Assisted Therapy Group - licensed 75-80 min $36.07 1 99
W5020 Horticultural Therapy Individual - certified 45-50 min $63.43 1 99
W5050 Horticultural Therapy Individual - certified 75-80 min $82.47 1 99
W5051 Horticultural Therapy Individual - licensed 45-50 min $69.78 1 99
W5052 Horticultural Therapy Individual - licensed 75-80 min $91.41 1 99
W5021 Horticultural Therapy Group - certified 45-60 min $24.64 1 99
W5053 Horticultural Therapy Group - certified 75-80 min $32.04 1 99
W5054 Horticultural Therapy Group - licensed 45-60 min $27.74 1 99
W5055 Horticultural Therapy Group - licensed 75-80 min $36.07 1 99
W5022 Face to face caregiver peer to peer support 15 min $16.29 8/11 hrs per month 11,12,99
W5023 Collateral (telephonic) caregiver peer to
peer support
15 min $8.14 8/16 hrs per month 11,12,99
W5024 Mobile Crisis and Stabilization 15 min $26.13 12 hrs 12,99
W5025 Crisis Assessment 1 $313.54 1 12,99
W5016 Music Therapy Individual - certified 45-50 min $63.43 1 11,99
W5038 Music Therapy Individual - certified 75-80 min $82.47 1 11,99
W5039 Music Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5040 Music Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5017 Music Therapy Group - certified 45-60 min $24.64 1 11,99
W5041 Music Therapy Group - certified 75-80 min $32.04 1 11,99
W5042 Music Therapy Group - licensed 45-60 min $27.74 1 11,99
W5043 Music Therapy Group - licensed 75-80 min $36.07 1 11,99
W5018 Drama Therapy Individual - certified 45-50 min $63.43 1 11,99
W5056 Drama Therapy Individual - certified 75-80 min $82.47 1 11,99
W5057 Drama Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5058 Drama Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5019 Drama Therapy Group - certified 45-60 min $24.64 1 11,99
W5059 Drama Therapy Group - certified 75-80 min $32.04 1 11,99
W5060 Drama Therapy Group - licensed 45-60 min $27.74 1 11,99
W5061 Drama Therapy Group - licensed 75-80 min $36.07 1 11,99
W5000 Respite Care In Home/Commuinty Based 1 Hour $25.66 6/6 hrs per day 12,99
W5001 Respite Care Residential/Out of Home 1 overnight stayminimum of 12 hours $203.43 1/24 units per waiver year 12,99
W5062 Intensive In Home Services (EBP) Weekly $253.88 1 12
W5063 Intensive In Home Services weekly $201.42 1 12
W5066 Customized Goods and Services Billed Charges $2000.00 max 99

CPT CODE    DESCRIPTION


W0100    GENERAL MEDICAL EXAM, VA FACILITY
W0105    PSYCHIATRY EXAM, PER HOUR, VA FACILITY
W0110    NEUROLOGICAL EXAM, VA FACILITY
W0115    ENT EXAM, VA FACILITY
W0120    OPTHOMOLOGY EXAM, VA FACILITY
W0125    AUDIOLOGY EXAM, VA FACILITY
W0130    ORTHOPEDIC EXAM, VA FACILITY
W0135    CARDIOLOGY EXAM, VA FACILITY
W0140    DERMATOLOGY EXAM, VA FACILITY
W0145    NEUROSURGICAL EXAM, VA FACILITY
W0150    GU EXAM, VA FACILITY
W0155    GI EXAM, VA FACILITY
W0160    PULMONARY EXAM, VA FACILITY
W0200    POW EXAM, VA FACILITY, PER HOUR
W0210    AGENT ORANGE EXAM, VA FACILITY
W0220    SOCIAL/INDUSTRIAL SURVEY, PER HOUR
W0230    PTSD EXAM, VA FACILITY, PER HOUR
W5000    GENERAL MEDICAL EXAM, NON-VA FACILITY
W5010    PSYCHIATRIC EXAM, NON-VA FACILITY
W5015    NEUROLOGICAL EXAM, NON-VA FACILITY
W5020    ENT EXAM, NON-VA FACILITY
W5025    OPTHOMOLOGY EXAM, NON-VA FACILITY
W5030    AUDIOLOGY EXAM, NON-VA FACILITY
W5035    ORTHOPEDIC EXAM, NON-VA FACILITY
W5040    CARDIOLOGY EXAM, NON-VA FACILITY
W5045    DERMATOLOGY EXAM, NON-VA FACILITY
W5050    NEUROSURGICAL EXAM, NON-VA FACILITY
W5055    GU EXAM, NON-VA FACILITY
W5060    GI EXAM, NON-VA FACILITY
W5065    PULMONARY EXAM, NON-VA FACILITY
W5220    SOCIAL/INDUSTRIAL SURVEY, PER HOUR, NON-VA FACILITY
W5230    PTSD EXAM, NON-VA FACILITY

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