Key Lesson:
In 2026, AMA CPT began assigning whole-slide-imaging digital pathology codes to Category III, rather than the PLA pathway used for earlier WSI codes. That matters because PLA lab codes can move onto the Clinical Laboratory Fee Schedule and be priced by crosswalk or gapfill, while Category III codes are usually not nationally priced by CMS.
If software-intensive WSI services instead fall into the Medicare RVU/practice-expense system, they face a known trap: CMS may count only technician time and tiny amortized equipment costs, while rejecting per-use software fees. CPT 92229, autonomous retinal imaging, is the warning case. In the past, CMS has elected to leave such codes "carrier priced" rather than underprice them by 80% - but this does nothing to fix the underlying problems for software-intensive services.
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In February 2026, and May 2026, AMA CPT began adding whole-slide-imaging digital pathology codes to the AMA CPT book, but in Category III ("emerging technologies") rather than the PLA category, where about ten WSI codes were previously assigned.
Those WSI codes assigned to the PLA category were quickly processed as clinical laboratory codes by CMS, added to the Clin Lab Fee Schedule, and priced by either crosswalk or gapfill. (A couple later got "ADLT" pricing.)
What About Category III?
Clinical laboratory codes have never, or almost never, been added to Category III, emerging technology codes. Codes in Category III are nearly-never priced nationally by CMS (though CMS reserves the right to do so, at its own election; see e.g. statements at 86 Fed Reg 65039, 2021, bottom col 3).
If software-intensive codes do get into the CMS Part B RVU practice expense process, the AMA RUC and CMS rules generally have made a mess, as is widely recognized. Here's a quick case study of what happens: 92229.
92229: The Canary in the Coal Mine and Why It's Choking
Code 92229 was one of the first software-intensive codes valued by CMS in RVUs, and it was a big mess. Here's the code text:
- 92229 Imaging of retina for detection or monitoring of disease; point-of-care autonomous analysis and report, unilateral or bilateral
The code went to the AMA RUC committee in October 2019. Find the minutes online at AMA CPT (email registration required.) The code was used (Part B) 429 times in 2021, 1426 times in 2022, 3631 times in 2023, 5115 times in 2024.
Here's the vignette describing the code:
- The technician is acquiring the images during this period. Aligning the pupil with the camera includes real-time adjustments to position, adjusted fixation, and management of involuntary blepharospasm with the camera flash. There are between two and five images taken typically per eye focusing both on the optic disc alone as well as the entire posterior pole with macula, vessels, and disc in focus. These photographs of each eye are separated by a repositioning for photography of the other eye.
Zero minutes of physician time are used.
I used the AMA RBRVS Data Manager [subscription] to look up the practice expense data. AMA RUC data allots 18 minutes of clinical staff time, for $9.72 nominal dollars. There are 0 supply costs (disposables).
Capital equipment is allotted 76 cents. CMS rates the equipment (ED061, camera, remote imaging, retinal) at $14,156 with a 5 year life and 13 minutes of use per case. Basically - in round numbers - CMS allows a 5 year life in which it is used about 1000 hours per year, or in other words, CMS divides the $14,156 cost by 5000 hours of use, or about $3 an hour. That's about 75 centers per quarter hour. That's how CMS capitalizes the equipment cost, and the RUC rules mirror this.
The PDF of the output of the October 2019 RUC meeting was used for CMS policymaking in 2020 for new codes of January 2021. See PDF page 1180 forward, esp. PDF page 1208 forward (aka Tab 9). Note that 92229 is autonomous diagnostic for retina; preceded codes use an expert (92227, 92228).
The AMA RUC considered per-click (per patient) reported software fees of $34 and $25, and recommended use of $25 as a cost of service in valuation. This would give a nominal value of about $9.72 clinical staff, 76 cents of capital equipment and $25 of software fee ($35.48).
However, in rulemaking for summer and fall 2020, CMS declined to accept a "per click" fee as a cost, and therefore, deleted this fee. (See here.) This left only about $10.50 (actually, it would deflate to about $6 or $7 for complex reasons in practice expense math; RVU entry point here).
Carrier Priced Limbo then 1.4 RVU
The code was left "carrier priced" for a while, rather than assign it a lethal value of $6.
Eventually, CMS gave up pricing via bottom-up RVU methods and simply assigned a terminal RVU value (by crosswalk to an unrelated service) of 1.40 RVU, which is currently $46.
- See a more detailed history of 92229, with links, here. For the specific crosswalk decision, see 86 Fed Reg 65037-9, 11/19/2021. (After which they propose a hospital outpatient based crosswalk for fractional flow reserve FFRCT; 65039-40
Implications for Category III Codes "Not on CLFS"
If Category III WSI codes ARE put on the CLFS, then they are priced by "crosswalk or gapfill" which are entirely outside the RVU process.
If Category III WSI codes are eventually put into the RVU system, there is a risk there will be valuation of only practice expense technician time to handle slides (a few dollars) and extremely attenuated capital equipment costs (as the 75 cents explained above.) This would be the result, if CMS continues to decline to accept software fees as part of the cost buildup in the RVU system.
