Physicians’ Current Procedural Terminology (CPT), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures physicians and other medical professionals perform.

• The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, thereby serving as a means for standardized communication among physicians, patients and third parties.
• HCFA-1500 claims for physician services and UB-92 claims for hospital outpatient procedures must contain appropriate CPT codes. We understand physicians most often use CPT codes 0062T, 0063T and 64999 to report this service.

Modifiers indicate that a service was altered in some way from the stated CPT descriptor without changing the definition. The American Medical Association (AMA) CPT modifiers are 2-digit numeric codes listed after a procedure code and separated from the CPT code by a hyphen. The following CPT modifiers may be relevant to the IDET^◊ procedure:

Medicare policy specifies that payment for physician services is based on the lesser of the actual charge or a payment amount computed under the physician fee schedule.

• Payment amounts for specific services under the physician fee schedule are computed as the product of three factors:
  • Relative value unit (RVU) for the service
  • Geographic adjustment (GAF) for the fee schedule area
  • A nationally uniform dollar conversion factor (CF)
• The actual amount paid by Medicare to participating physicians is 80% of the fee schedule, or their actual charge, whichever is lower. Physicians are permitted to bill the Medicare beneficiary and/or secondary carrier for the remaining 20%.
• Non-participating physicians must collect their fee directly from the Medicare beneficiary. The physician may bill the beneficiary and/or secondary carrier up to a “limiting charge” of 115% of the non-participating fee schedule amount. Medicare will directly pay the Medicare beneficiary 80% of the fee schedule amount.

Additional coding information

For CT or MRI guidance and localization for needle placement and annuloplasty in conjunction with codes 0062T, 0063T, see 76360 and 76393.

All claim forms must use ICD-9-CM diagnosis codes to report the patient’s condition. These codes reflect the physician’s assessment of a particular patient’s condition. The following diagnosis codes may apply to patients undergoing the IDET^◊ procedure and should be used only if they describe a patient’s condition accurately:

Private insurers have varying payment guidelines, especially regarding new procedures. Typically they base payment on charges, discounted charges, fee schedules, or capitation.

• Payment amounts will vary based on contractual arrangements with the individual payors. Due to these arrangements, the insurer should be contacted for their specific payment guidelines regarding the IDET^◊ procedure.
• Cautionary Note: Many third-party payors require prior authorization before paying for a new procedure and will generally deny reimbursement if such approval is not received in advance.

For further help with insurance and reimbursement, use our Reimbursement Calculation Tools.