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Reimbursement & Market Access

Name: Reimbursement & Market Access
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Coverage, coding, and payment fundamentals: CPT, HCPCS, ICD-10, CMS coverage decisions, TCET, prior authorization, and health economics.

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1
Reimbursement
Current Procedural Terminology Codes(CPT)
AMA-maintained codes used to report medical procedures and services for billing.
Why this term here: How a physician procedure gets described and paid; the AMA-owned foundation.
2
Reimbursement
CPT Codes(CPT)
AMA-maintained codes that describe medical procedures and services.
Why this term here: The three CPT categories (I / II / III) and when each applies.
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Reimbursement
HCPCS Codes(HCPCS)
CMS-maintained codes for products, supplies, and services not in CPT.
Why this term here: The CMS-owned code set that covers supplies, devices, and injectables CPT does not.
4
Reimbursement
ICD-10-CM / ICD-10-PCS
Diagnosis (CM) and inpatient procedure (PCS) coding systems used in U.S. claims.
Why this term here: Diagnosis codes that justify medical necessity for payer claims.
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Reimbursement
National and Local Coverage Determinations(NCD / LCD)
Medicare coverage policies issued nationally (NCD) or by individual MAC contractors (LCD).
Why this term here: National vs Local Coverage Determinations, the two CMS coverage vehicles.
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Reimbursement
LCD and NCD
Local and National Coverage Determinations from Medicare.
Why this term here: Same relationship viewed from the local (MAC) side.
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Reimbursement
Medicare Administrative Contractor(MAC)
Private contractors that process Medicare Part A/B and DME claims and issue Local Coverage Determinations within their jurisdictions.
Why this term here: Medicare Administrative Contractors: the actual entities that adjudicate claims.
8
Reimbursement
New Technology Add-On Payment(NTAP)
Supplemental Medicare payment for inpatient use of qualifying new technologies.
Why this term here: New Technology Add-on Payment: the inpatient reimbursement lift for novel devices.
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Reimbursement
Transitional Coverage for Emerging Technologies(TCET)
CMS pathway providing time-limited Medicare coverage for FDA-designated Breakthrough Devices.
Why this term here: Transitional Coverage for Emerging Technologies: the modern replacement for MCIT.
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Reimbursement
Prior Authorization
Payer requirement for approval before a service or device is covered.
Why this term here: The payer control that can silently kill utilization even after coverage exists.
11
Reimbursement
Health Technology Assessment(HTA)
Systematic evaluation of clinical and economic value of a health technology.
Why this term here: Health Technology Assessment: standard in EU, growing in the US.
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Reimbursement
Budget Impact Model(BIM)
Financial model that estimates the total cost consequences of adopting a new technology to a payer's budget over a defined horizon.
Why this term here: The financial narrative payers ask for alongside clinical evidence.
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Reimbursement
Value-Based Care(VBC)
Payment tied to outcomes and total cost of care, not volume of services.
Why this term here: Where reimbursement risk is shifted onto providers and manufacturers.
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Reimbursement
RWE for Reimbursement
Real-world evidence used to support coverage and payment decisions.
Why this term here: How RWE increasingly closes coverage decisions.

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Reimbursement & Market Access

Current Procedural Terminology Codes(CPT)

CPT Codes(CPT)

HCPCS Codes(HCPCS)

ICD-10-CM / ICD-10-PCS

National and Local Coverage Determinations(NCD / LCD)

LCD and NCD

Medicare Administrative Contractor(MAC)

New Technology Add-On Payment(NTAP)

Transitional Coverage for Emerging Technologies(TCET)

Prior Authorization

Health Technology Assessment(HTA)

Budget Impact Model(BIM)

Value-Based Care(VBC)

RWE for Reimbursement