The transition is expected to reduce professional fees and potentially impact procedure volume.
Key takeaways:
- Inspire Medical Systems says the Inspire V billing to CPT code is 64582 with a -52 modifier.
- The company estimates a 10% to 50% reduction in professional fees, which may affect physician willingness to perform the procedure.
- Revenue outlook is revised to a range of $950 million to $1.0 billion to reflect coding uncertainty and reimbursement rates.
- Inspire is pursuing a long-term solution involving the creation of a separate CPT code.
As part of the release of its financial results for the quarter and year ended December 31, 2025, Inspire Medical Systems also clarified Current Procedural Terminology (CPT) coding for its Inspire V procedure following recent clarification on reimbursement policies. Healthcare centers and physicians are now advised that the procedure should likely transition to CPT code 64582, including the use of a -52 modifier.
“In the last week, we received clarification regarding the coding that should be used for the Inspire V procedure. Currently, healthcare centers and physicians should bill the most recent healthcare policies, be it a Medicare Administrative Contractor (MACs) or a commercial payor, and based on this clarification, we believe the code will transition to CPT code 64582 for the Inspire V procedure, including the use of a -52 modifier,” says Tim Herbert, chairman and CEO of Inspire Medical Systems, in a release.
The application of the -52 modifier is expected to impact professional fees. During a financial conference call, the company provided estimates on the potential financial variance.
“We estimate that the reduction to the professional fee associated with applying the -52 modifier could range from approximately 10% to 50% of the base rate,” Herbert said during the call. “The actual reduction may vary by MAC, and we will not know the precise impact until sufficient claims data have been submitted and processed across payers.”
Herbert noted that this reduction could have downstream effects on procedure volume. “In any case, we believe that a significant decrease in the professional fee resulting from use of the -52 modifier will likely influence physicians’ willingness to perform the Inspire V procedure and may limit the number of cases they choose to undertake,” he said.
In light of these developments, Inspire Medical Systems is revising its revenue outlook. The company now projects revenue in the range of $950 million to $1.0 billion, representing expected annual growth of 4% to 10%. This revised range reflects the estimated impact on the first quarter regarding coding uncertainty, as well as the range of outcomes associated with the move to CPT code 64582 with the –52 modifier.
Despite the shift, the company reports strong execution closing out 2025. “We are very excited with the strong finish to 2025. The team made excellent progress with the Inspire V launch, with clinical insights from the early phase of commercial adoption continuing to validate positive patient outcomes and improvements in therapy delivery,” says Herbert in a release.
Moving forward, the company intends to work with payers, MACs, government agencies, and physician societies to minimize the impact on physician fees.
“While we are disappointed with this result, this clarification provides direction for us going forward,” says Herbert in a release. “Additionally, we are seeking a long-term solution, namely the creation of a separate CPT code that would support appropriate reimbursement for the Inspire V procedure. We remain focused on our commitment to put the patient first and deliver strong patient outcomes.”
