Payment Shifts: Expect reimbursement structure changes ahead, policy experts say

To make this work, emphasis is placed on the development of good evidence or studies on which to base the recommended new technology. “There is an emphasis on the development of good literature that is increasingly important for coverage by payors,” Dr. Dillon said. “Without this literature support, we may get a code and even a decent value, but we may not get paid. Development of literature, before a code is even proposed to CPT, is key.”

The information the AAO-HNS needs to evaluate a code inquiry and to start the process, including CPT requirements, includes a description of the service or procedure by the requesting party, the type of request (e.g., is it for a new, revised, or revalued CPT code or is it a coding inquiry for a new technology). The AAO-HNS also needs to know whether approval by the Food and Drug Administration (FDA) has been obtained, whether it is widely performed and how the service or procedure is currently reported. Also needed is whether there is support for a code for the service or procedure through the relevant subspecialty society and AAO-HNS subspecialty committees and whether members of other specialties will also perform the service or procedure.

One area in which this New Technology Pathway may be used is for new technologies that are categorized by insurance carriers as “investigational and experimental” and, therefore, not reimbursable. “I think this is one of the biggest challenges to reimbursement and one of the biggest issues moving forward,” Dr. Setzen said. ENT Today