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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.
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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.
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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.
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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.
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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