Digital Health: CPT Codes for Specific Health Categories

Cameron Jacox is the founder of Rocket Digital Health, the foremost digital health scale consultancy. Go-to-market is hard in healthcare, and we believe that you don’t need to reinvent the wheel to bring your brilliant invention to market. Having helped scale 13 digital health startups, including for 4 years as Chief Growth Officer at Lark Health from Series A to Unicorn status, Cameron & his team work with select startups to bring growth strategy to bear to beat their growth goals and catch their stride.

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Reimbursement plays a pivotal role in the success of digital health startups. Securing reimbursement for products and services can be challenging, particularly as it varies across different health categories. In this article, we will discuss key points for digital health startups seeking reimbursement in a random selection of growing areas: nutrition, radiology, diabetes prevention, weight loss, asthma management, social determinants of health, and neurodevelopmental issues, along with relevant Current Procedural Terminology (CPT) codes for each category.

Digital Health Category Reimbursement Category: Radiology

1. Startups in the radiology space must ensure their products meet regulatory standards and offer advantages over existing imaging technologies. Key considerations include:

• Obtaining FDA approval and other relevant certifications

• Demonstrating improved accuracy, efficiency, or cost-effectiveness

• Ensuring seamless integration with existing healthcare systems

Relevant CPT codes:

• Radiology CPT codes vary depending on the imaging modality, such as:

• 70010-79999: Diagnostic Radiology

• 77001-77032: Radiologic Guidance

We’ll also cover Dermatologists in a future article, and how virtual care is helping people find dermatologists near them faster and easier..

Digital Health Category Reimbursement Category: Diabetes Prevention

1. Digital health startups focused on diabetes prevention should focus on evidence-based interventions that can effectively reduce the risk of developing the condition. Key considerations include:

• Demonstrating measurable improvements in risk factors, such as blood sugar levels and weight loss

• Offering personalized and user-friendly solutions

• Collaborating with healthcare providers to support patient engagement and adherence

Relevant CPT codes:

• 0403T: Continuous glucose monitoring, interpretation and report

• 98960-98962: Diabetes self-management training and education

Digital Health Category Reimbursement Category: Weight Loss

1. Weight loss products must be backed by clinical evidence and offer a sustainable approach to achieving long-term results. Key considerations include:

• Providing data on the safety and efficacy of the product

• Ensuring the product is adaptable to individual needs and preferences

• Highlighting cost savings for health plans, as obesity is often associated with high healthcare costs

Relevant CPT codes:

• 99401-99404: Preventive medicine counseling and risk factor reduction

• 97802, 97803: Medical nutrition therapy provided by a registered dietitian or nutrition professional

Digital Health Category Reimbursement Category: Asthma Management

1. Asthma management solutions should aim to improve patient outcomes and reduce the burden on healthcare systems. Key considerations include:

• Validating the product through clinical trials or real-world evidence

• Demonstrating improved patient adherence to treatment plans

• Ensuring compatibility with existing asthma management protocols and technologies

Relevant CPT codes:

• 94010-94799: Pulmonary diagnostic procedures and services

• 94664: Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device

Digital Health Category Reimbursement Category: Social Determinants of Health

1. Digital health startups addressing social determinants of health should focus on scalable solutions that can impact large populations. Key considerations include:

• Demonstrating the product's ability to address specific social determinants, such as access to care, housing, or education

• Collaborating with community organizations and healthcare providers to ensure effective implementation

• Providing data on the product's impact on health outcomes and healthcare costs

CPT codes:

• 99401-99404: Preventive medicine counseling and risk factor reduction

• 99420: Collection and interpretation of health risk assessment instrument data

Digital Health Category Reimbursement Category: Neurodevelopmental Issues

1. Digital health startups focusing on neurodevelopmental issues should aim to provide innovative, evidence-based solutions that improve patient outcomes and quality of life. Key considerations include:

• Validating the product through clinical trials or real-world evidence

• Demonstrating the product's ability to improve diagnostic accuracy, treatment efficacy, or patient engagement

• Ensuring compatibility with existing neurodevelopmental assessment tools and management strategies

Relevant CPT codes:

• 90785: Interactive complexity (add-on code for psychotherapy services)

• 96110, 96112, 96113: Developmental screening and testing

• 96116, 96121: Neurobehavioral status examination

• 96132, 96133: Neuropsychological testing evaluation services by a psychologist or physician

Digital Health Category Reimbursement Category: Nutrition

1. Digital health startups focusing on nutrition should emphasize the role of their products in preventing and managing chronic diseases, as well as promoting overall health. Key considerations include:

• Aligning with established nutritional guidelines and recommendations

• Demonstrating the efficacy of the product in improving health outcomes

• Partnering with healthcare professionals to validate and support the product

Relevant CPT codes:

• 97802, 97803: Medical nutrition therapy provided by a registered dietitian or nutrition professional

Digital Health Category Reimbursement Category: Body Composition Scans (DEXA)

1. Digital health startups focusing on body scans for bone health, osteoporosis, and body composition such as body fat, visceral fat, and lean/muscle mass tracking, have struggled to get reimbursement beyond the DEXA scan’s “fracture risk” medical use case. But, they’ve thrived with consumer self-pay models. Ultimately, the health insights from full body composition scans - especially for those with obesity or who are using weight loss drugs such as GLP-1s - should be considered by health plans and CMS for broader reimbursement given their proven value.

Takeaways?

Navigating reimbursement for digital health startups requires a deep understanding of the specific health category and the relevant CPT codes. By focusing on key considerations within each category, startups can maximize their chances of securing reimbursement and achieving success in the digital health market.