Fee Setting: Category III Codes or Unlisted Procedures

Question:

We are looking at CPT code 0707T for reporting subchondroplasty in our practice. We have never billed a Category III code and do not know how to set the fee.

Answer:

Setting the fee for the Category III code will follow the same methodology as an unlisted procedure code. KZA recommends including the surgeon in the discussion to ensure the most appropriate CPT code is selected as the comparison code. Here are some considerations:

1. Choose a code similar to the Category III procedure (or unlisted procedure) you performed. This includes the approach and anatomic location, if possible. This will be your “base code” or “comparison” code.
2. List 2–3 things that make the Category III (or unlisted) procedure more or less difficult than the comparison CPT code.
3. Assess the RVUs of the similar code, making sure you feel it represents a fair value for the work involved. If it does not, continue looking.
4. Convert the greater or lesser degree of difficulty to a % increase or decrease in your fee for the comparison code. This becomes the fee for your Category III (or unlisted) code.
5. Report the appropriate Category III (or unlisted) code on the claim form linked to the appropriate diagnosis. Either in box 19 or on the same line, identify the comparison CPT code and the name of the procedure performed. This provides the payor information to hopefully process the claim the first time.
6. If the payor allows it, submit the operative note electronically with the claim.

We hope this helps you and your surgeon arrive at the most appropriate comparison code.