Reimbursement
The American Medical Association (AMA) issued two Category III CPT® codes effective July 1, 2022 that may be utilized when billing for services related to utilization of the Optellum® Lung Cancer Prediction (LCP) technology. Category III CPT codes are temporary codes used to describe emerging technologies, services or procedures. Submitting claims with Category III codes may require additional information be provided to the payer regarding the service to establish medical necessity and substantiate charges and payment for the service..
CPT 2023 Professional Edition, 2023 American Medical Association (AMA). CPT is a registered trademark of the AMA. All rights reserved.
For additional information, please contact our team via email at reimbursement@optellum.com.
Physician Coding & Medicare Payment
Category III CPT codes do not have any assigned relative value units (RVUs) and therefore there is no fee schedule payment rate established for physician payment under Medicare. Payment for physician services is at the discretion of the individual Medicare contractor.
Note:
Reimbursement from commercial payers will vary due to individual negotiated contractual agreements between the provider and the payer. Providers are encouraged to check with their individual payers regarding payment for specific services and procedures.
Hospital Outpatient Facility Coding & Medicare Payment
When the Optellum® technology is utilized in the hospital outpatient site of service, reimbursement is determined by the Hospital Outpatient Prospective Payment System (OPPS). Procedures are assigned to the applicable Ambulatory Payment Classification (APC) for the CPT code used to describe the service. Generally, Medicare assigns CPT codes into groups where the codes are similar in terms of clinical characteristics and resource costs. Alternatively, New Technology APCs, like that under which the Optellum® technology is reimbursed, are defined on the basis of cost. Under APCs, payment is determined by the services and procedures provided as reported by the CPT code.
2023 Medicare National Average Payment OPPS New Technology
The Medicare payment amounts listed do not reflect adjustments for deductible, co-payment, coinsurance, sequestration or any other reductions. All payment amounts listed are based on national averages and will vary by geographical locations. Facilities should review their contracts and negotiated rates for each of their Commercial insurers to determine what their appropriate reimbursement will be.
CPT codes assigned to a status indicator S are not subject to multiple procedure discounting and are
paid at 100% of the current OPPS payment rate.
Disclaimer:
Coding information is supplied for informational purposes only and represents no statement, promise, or guarantee by Optellum® Ltd that these codes will be appropriate or that reimbursement will be made. Information provided is not intended to increase or maximize reimbursement by any payer. Laws, regulations and payer policies concerning reimbursement are complex and subject to change. It is the responsibility of the providers to make appropriate decisions related to coding and reimbursement submissions.