In the previous blog, I noted that CMS provides proposed OPPS/APC prices of Cat III codes that won't be effective for six months...and that don't even have public final code numbers. (The same blog shows a comment letter from Valar that includes both the placeholder codes and real codes side-by-side).
This is a Chat GPT explanation of how that particular bit of CMS magic works.
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CMS Prices New CPT Category III Codes
Before Their Final Code Numbers Are Public
Yes it does! And CMS explicitly discusses how it handles new CPT Category I and Category III codes that will take effect January 1, 2027 even though their final CPT numbers have not yet been released publicly.
The key discussion is in the CY 2027 OPPS Proposed Rule at 91 Fed. Reg. 41787–41788, Section III.A.4.b, “New CPT Codes Proposed Rule Comment Solicitation.”
CMS explains that it receives the upcoming January CPT codes from the AMA early enough to use them in the OPPS proposed rule:
“For the CY 2027 OPPS update, we received the CPT codes that will be effective January 1, 2027, from the AMA in time [by June 1?] to be included in this proposed rule [with proposed prices].”
However, because the permanent CPT numbers are not yet available for use in the proposed rule, CMS uses five-character AMA/CMS placeholder codes. Thus codes such as X568T, X569T, X614T, X623T, and X624T appear in the proposed OPPS files even though those are not the eventual CPT numbers.
CMS divides the information between two addenda.
Addendum B contains the placeholder code, a short descriptor, the proposed OPPS status indicator, APC assignment, and therefore the proposed payment.
Addendum O contains the placeholder code together with the full long CPT descriptor. CMS specifically explains:
“Therefore, we are including the 5-digit placeholder codes and the long descriptors for the new and revised CY 2027 CPT codes in Addendum O, specifically under the column labeled ‘CY 2027 OPPS/ASC Proposed Rule 5-Digit AMA/CMS Placeholder Code.’”
Nerd note: Appendix O has nearly 200 codes of different types (Cat III, also CPT Cat I, G-code, etc) that were in some state of partial definition as the rule went to press in June.
CMS then states that the final HCPCS/CPT code numbers will appear in the CY 2027 OPPS/ASC final rule. Thus CMS is able to propose an APC assignment—and an actual dollar payment—for a new Category III service before the public-facing permanent Category III number has appeared. 91 Fed. Reg. 41787–41788.
CMS's OPPS rule and addenda are available here:
The Regulations.gov docket for the CY 2027 OPPS proposed rule is:
https://www.regulations.gov/docket/CMS-2026-2344
There is also a parallel discussion for the ASC payment system at 91 Fed. Reg. 41935–41936. There CMS again explains that it has received the January 2027 CPT codes from AMA, uses five-character placeholder codes in the proposed rule, places their complete long descriptors in Addendum O, and will substitute the final CPT numbers in the final rule.
The Valar Codes Provide a Good Example
The Valar comment supplies the subsequent permanent numbers for several of these placeholders:
X568T → 1063T — Vesta Bladder Risk Stratify
X569T → 1064T — Vesta Bladder BCGPredict
X614T → 1097T — Vitara Pancreas ChemoPredict
X623T → 1106T — H&E AI analysis, breast cancer
X624T → 1107T — H&E AI analysis, prostate cancer
Valar also reproduces the full descriptors for its three own codes.
So the somewhat counterintuitive sequence is:
AMA creates and communicates the new CPT code to CMS → CMS publishes it under an Xxxxx placeholder and proposes an APC/payment → AMA's permanent CPT number becomes available → CMS substitutes that final number in the OPPS final rule.
The particularly interesting point for the SaMS discussion is that CMS isn't merely acknowledging these unreleased codes are in play. CMS staff are already making substantive payment-policy decisions about them—including whether an algorithm gets $350.50 or $750.50—while identifying the service publicly only through its temporary AMA/CMS placeholder code.
