TRICARE Manuals - Display Chap 1 Sect 11.1 (Change 46, Apr 30, 2019)

Administration

Chapter 1

Section 11.1

Category III Codes - Temporary Codes For Emerging Technology, Services And Procedures

Issue Date: March 6, 2002

Authority: 32 CFR 199.2(b) and 32 CFR 199.4(g)(15)

Revision: C-46, April 30, 2019

1.0 DESCRIPTION

Category III codes are a set of temporary codes for emerging technology, services, and procedures. These codes are used to track new and emerging technology to determine applicability to clinical practice. When a Category III code receives a Category I code from the American Medical Association (AMA) it does not automatically become a benefit under TRICARE. However, the codes that may have moved from unproven to proven must be forwarded to the Office of Medical Benefits and Reimbursement Section (MB&RS) for coverage determination/policy clarification.

2.0 POLICY

2.1 Category III codes are to be used instead of unlisted codes to allow the collection of specific data. TRICARE has not opted to track Category III codes at this time.

2.2 Category III codes are excluded from coverage since clinical safety and efficacy or applicability to clinical practice has not been established.

3.0 EXCEPTIONS

3.1 U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) (Category B) clinical trial. See Chapter 8, Section 5.1.

3.2 Category III code 0073T is a covered service as listed in Chapter 5, Section 3.1.

3.3 Category III codes 0075T and 0076T are covered codes as outlined in Chapter 4, Section 9.1.

3.4 Category III codes 0099T and 0308T are covered codes as outlined in Chapter 4, Section 21.1.

3.5 Category III codes 0184T and 0249T are covered services as listed in Chapter 4, Section 13.1.

3.6 Category III code 0346T is a covered service as listed in Chapter 5, Section 1.1.

3.7 Category III codes 0446T-0448T are covered services listed in Chapter 8, Section 5.3.

3.8 Category III codes 0451T-0463T are covered services listed in Chapter 4, Section 9.1.

3.9 Category III code 0474T is a covered service as listed in Chapter 4, Section 21.1.

3.10 Category III codes 0100T, 0472T, and 0473T are a covered service as listed in Chapter 4, Section 21.1 (in accordance with the humanitarian device policy, Chapter 8, Section 5.1).

3.11 Category III codes 0378T-0380T are a covered service as listed in Chapter 7, Section 6.1.

3.12 Category III codes 0515T-0522T are covered services as listed in Chapter 4, Section 9.1 (in accordance with FDA-approved IDE policy, Chapter 8, Section 5.1).

4.0 EXCLUSIONS

4.1 Unlisted codes for Category III codes. Effective January 1, 2002.

4.2 Ultrasound ablation (destruction of uterine fibroids) with Magnetic Resonance Imaging (MRI) guidance (CPT procedure code 0071T) in the treatment of uterine leiomyomata is unproven.

4.3 Computer-Aided Detection (CAD) with breast MRI (CPT procedure code 0159T) is unproven.

4.4 Ultrasound-guided facet joint injection (CPT procedure codes 0216T and 0217T) is unproven.

4.5 Magnetic Resonance Guided High-Intensity Focused Ultrasound Surgery (MRgFUS) (CPT procedure code 0398T) for the treatment of essential tremor is unproven.

4.6 High-Intensity Focused Ultrasound (HIFU) for the treatment of prostate cancer (HCPCS code C9747) is unproven.

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