Custom CPT Code Analysis
Honest assessment of whether your product needs a new CPT code, and whether your current evidence will get one approved.
Overview
Pursuing a new CPT code is a multi-year, evidence-heavy commitment. Done well, it transforms a product's reimbursement story. Done early, it burns 18 months and produces a Category III placeholder that nobody bills.
We assess your product, your evidence base, and your timeline candidly. If a new code is the right path, we map the AMA process and the supporting evidence you will need. If it is not, we say so and recommend the better adjacent path.
Our Process
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1
Evidence inventory
Catalog your clinical studies, published literature, real-world data, and adoption metrics.
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2
AMA pathway analysis
Map the Category III → Category I transition and the milestone evidence required for each step.
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3
Realistic cost & timeline
Document the expected investment, calendar time, and probability of success.
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4
Go/no-go memo
Written recommendation with dissent, addressed to your exec team.
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5
Implementation plan (if go)
Evidence-generation plan, timeline, named owners, AMA submission roadmap.
Frequently Asked Questions
How long does a Category III → Category I transition take?
Typically 3-5 years with sustained evidence generation. Faster is rare; slower is common.
What is the success rate?
Public AMA data suggests roughly 50-60% of Category I applications succeed at the first attempt with adequate evidence.
Can you write the AMA application?
Yes, as a separate engagement once the go decision is made and the evidence base is in place.
What if we cannot get a code?
Adjacent strategies: pursue an established code with appropriate modifier, build payer-direct contracting, or focus on procedure-bundled value-based contracts.
Decide whether the CPT path is worth the years.
Send us your evidence base and your commercial timeline. We will return a candid go/no-go memo within four weeks.
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