Coding Change Application
Category I CPT Code(s)
Category III CPT Code(s) – Emerging Technology
American Medical Association, Current Procedural Terminology (CPT®)
Application Submission Requirements
All CPT Code Change applications are reviewed and evaluated by CPT staff, the CPT/HCPAC Advisory
Committee, and the CPT Editorial Panel. Strict conformance with the following is required for review of a
code change application:
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Submission of a complete application, including all necessary supporting documents;
Adherence to all posted deadlines;
Cooperation with requests from CPT staff and/or Editorial Panel members for clarification and
information; and
Compliance with CPT Lobbying Statement. (press “Ctrl” key and click link)
Application Review Links (Press “Ctrl” key and click link)
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Applicant’s Name
Question 1
Descriptor
Typical Patient Description
General Criteria for Category I and Category III Codes
All Category I or Category III code change applications must satisfy each of the following criteria:

The proposed descriptor is unique, well-defined, and describes a procedure or service which is clearly
identified and distinguished from existing procedures and services already in CPT;

The descriptor structure, guidelines and instructions are consistent with current Editorial Panel standards
for maintenance of the code set;

The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure
or service nor currently reportable as a complete service by one or more existing codes (with the
exclusion of unlisted codes). However, procedures and services frequently performed together may
require new or revised codes;

The structure and content of the proposed code descriptor accurately reflects the procedure or service as
typically performed. If always or frequently performed with one or more other procedures or services, the
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descriptor structure and content will reflect the typical combination or complete procedure or service;

The descriptor for the procedure or service is not proposed as a means to report extraordinary
circumstances related to the performance of a procedure or service already described in the CPT code
set; and

The procedure or service satisfies the category-specific criteria set forth below.
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Category Specific Requirements
A. Category I Criteria
A proposal for a new or revised Category I code must satisfy all of the following criteria:

All devices and drugs necessary for performance of the procedure or service have received FDA
clearance or approval when such is required for performance of the procedure or service;

The procedure or service is performed by many physicians or other qualified health care
professionals across the United States;

The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a
service for a common condition should have high volume, whereas a service commonly performed for
a rare condition may have low volume);

The procedure or service is consistent with current medical practice;

The clinical efficacy of the procedure or service is documented in literature that meets the
requirements set forth in the CPT code change application.
B. Category III Criteria
The following criteria are used by the CPT/HCPAC Advisory Committee and the CPT Editorial Panel for
evaluating Category III code applications:

The procedure or service is currently or recently performed in humans, AND
At least one of the following additional criteria has been met:

The application is supported by at least one CPT or HCPAC advisor representing practitioners who
would use this procedure or service; OR

The actual or potential clinical efficacy of the specific procedure or service is supported by peer
reviewed literature which is available in English for examination by the Editorial Panel; OR

There is a) at least one Institutional Review Board approved protocol of a study of the procedure or
service being performed, b) a description of a current and ongoing United States trial outlining the
efficacy of the procedure or service, or c) other evidence of evolving clinical utilization .
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Cover Sheet for CPT® Coding Change Application
It is recommended that applicants consult with national medical specialties and other qualified healthcare
professional organizations that will typically provide the proposed procedure(s)/service(s) requested in this
application to obtain comments on the type of work and potential for development of relative value units (RVUs)
by the AMA Specialty Society RVS Update Committee (RUC). With recognition of scheduling needs of the
specialty societies, when assistance from a specialty society will be sought, it is highly recommended that the
applicant plan for enough time for scheduling such discussions in advance of the application deadline to avoid
violation of the AMA Lobbying Policy. Interested national specialty organizations may have deadlines prior to the
CPT application submission deadline to allow for application review and comment.
Date:
Change Requested by:
Name(s):
Organization:
Address:
City:
State:
Zip Code:
Telephone:
Email:
Please include this cover sheet with your application.
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NOTICE: Individuals or organizations that believe they may be affected by a decision of the CPT Editorial Panel
on your code change application may request review of your application in advance of the CPT Editorial Panel
meeting. To ensure transparency in the CPT Editorial Panel process, the AMA will provide your code change
application and supporting documentation to such interested parties (provided they can demonstrate a valid
interest) so they can be prepared, if desired, to comment at the CPT Editorial Panel meeting from the floor
microphones or to submit written comments in advance of the meeting.
If the AMA receives a request from an interested party to review this code change application, you will be notified
of that request and given five business days to submit a redacted version of the application that deletes any
confidential and proprietary information. Failure to respond in that time will be deemed by the AMA as your
approval to release the full application. The CPT Editorial Panel and CPT/HCPAC Advisory Committee will be
provided the unredacted version of the application.
Yes. I approve of sharing this application in full to an interested party that requests to
review the application.
This form plays a vital role in maintaining and increasing the efficiency of the CPT process. It can be used to
submit a coding change application for either Category I or Category III CPT codes. For Pathology and Molecular
Pathology codes, please utilize the appropriate application form. As you fill out the form, please consider which
category of code change you are requesting. For more information and code criteria for the code categories,
please see the Code Change Application Instructions. For other forms, see the AMA CPT website.
(Press “Ctrl” key and click link)
When requesting a new code, the entire form should be completed. When submitting a request for multiple new
codes, a response should be provided for each new code. The applicant may need to create additional lines and
pages as needed. Refer to the Code Change Application Instructions if necessary. Once the application is
completed, submit the form electronically to the AMA. (See information on submitting applications on the last
page for instructions on uploading applications, literature supplements and other documents.)
You may withdraw your application up until the time that the CPT Editorial Panel takes up the agenda item
at a CPT Editorial Panel meeting. At that time, the discussion falls under the authority of the Editorial
Panel, and the application may not be withdrawn. If the CPT Editorial Panel determines that additional
information or evaluation is warranted, consideration of your application may be tabled until later during
that meeting or postponed until time certain (a specific future CPT meeting) or to time uncertain.
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Code Descriptor Formatting Instructions
When entering code information on this application, please use the formatting shown below., When ADDING
codes, this will require specifying the recommended terminology (code descriptor) for the proposed CPT code and
the placement of the proposed code in the current text of CPT (list section, subsection as illustrated below).
When requesting a code REVISION you should use strike-pouts for deletions and underlining for
additions/revisions (example: 33420 Valvotomy, mitral valve (commissurotomy); closed heart). You may copy and
paste the following symbols as appropriate:

This symbol precedes a new code (example:  1234X)
▲
This symbol precedes a revised code (example: ▲12345)

This symbol indicates moderate sedation is inherent in the procedure (example: 12345)

This symbol indicates an add-on code to be reported with another code (example: 12345)
Example:
Surgery
Digestive System
Stomach
Incision
D12345 Old procedure
(Code 12345 has been deleted. To report, see 1234X1-1234X2)
1234X1 New procedure first
1234X2
each additional (list separately in addition to primary procedure)
(Report code 1234X2 in conjunction with code 1234X1)
return
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1.
Does the procedure/service involve the use of a drug, vaccine product* or device that requires approval
from the Food and Drug Administration (FDA)?
Yes (go to 2a.)
No (skip to 3.)
* Applications requesting establishment of CPT codes for vaccine products will not be considered until
evidence substantiating completion of Phase III Clinical Trials and review of unblinded data is
submitted to AMA. However, coding applications may be considered prior to submission of the Biologic
License Application (BLA) to the FDA.
2a. If approval is necessary, have all devices and drugs necessary for performance of the procedure or
service received FDA clearance or approval when such is required for performance of the procedure or
service?
Yes FDA has approved all necessary aspects of the service.
No Some necessary element of the service has not received FDA approval (Provide details)
2b. Does the procedure/service utilize a humanitarian use device (HUD) as defined by FDA?
Yes (go to 2c.)
No (skip to 3.)
2c. Has FDA approval for humanitarian device exemption (HDE) been received authorizing the marketing
of the humanitarian use device?
Yes (Submit documentation of the FDA approval with the application)
No
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3.
Indicate the specific reasons why this code change is necessary (rationale). For example, “This is a
new procedure, not described in CPT”. Avoid non-rationales. Reasons like “no-code currently available”
or “need new code” do not describe the clinical reason for which you are requesting a coding revision.
4.
Following the Code Descriptor Formatting Instructions (press “Ctrl” key and click link) on the page 5 of this
application form, specify the proposed new, revised and/or deleted codes, descriptors, inclusionary and
exclusionary parentheticals and guidelines (as applicable) in the box below. List all current codes
related to your request, not just the individual code changes. (Refer to the code change application
instructions for more detailed information.)
5.
Has the clinical efficacy of the procedure/service for which you are requesting a code change been
documented in literature provided with this application?
Yes
No
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6.
For each NEW and/or REVISED code, indicate which CPT or HCPCS Level II code(s) is currently
being used for reporting and specify why each current code is inadequate to describe the new and /or
revised procedure/service.
7.
For each NEW and/or REVISED code, please estimate the percentage of times a current code(s) is
reported that would now be reported using the proposed new and/or revised code. Example: Current
code 12345 will now be reported by 123X1 30% of the time and 123X2 70% of the time.
8.
For each NEW and/or REVISED code, identify the major differences with other related codes already
in CPT.
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9.
Provide a list of CPT codes which are an integral (inherent) part of the proposed NEW and/or
REVISED code(s). This list should include all CPT codes that would represent unbundling if reported in
addition to the proposed new and/or revised codes.
10. Will the proposed NEW and/or REVISED code(s) typically (more than 50% of the time) be reported on
the same date with other CPT codes(s)? Or will any current CPT code(s) be reported typically (more
than 50% of the time) with the proposed NEW and/or REVISED code(s)?
No
Yes Please specify below why the procedure(s)/service(s) are reported using multiple codes
instead of just one code (Check all that apply.)
The code is an add-on code or a base code expected to be reported with an add-on code.
Different providers work together to accomplish the procedure/service; each provider reports
his/her part of the work using different codes.
Multiple codes allow flexibility to describe exactly what components of the procedure/service
have been performed.
Multiple codes are used to maintain consistency with similar codes.
Historical precedents.
Other. Please explain.
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11. CPT does not set a global period. However, to assist the CPT Editorial Panel in consideration of the
extent of total work involved in each proposed NEW code, select a recommended global period.
NOTE: Information provided on this application has no binding effect on the Centers for Medicare and
Medicaid Services and other payers in assignment of global periods.
000 (0 days of post procedure work included)
010 (10 days of post procedure work included)
090 (90 days of post procedure work included)
ZZZ (add-on code)
XXX (global period does not apply)
What is the rationale for this global period recommendation? (e.g., Is this the same global period as
similar codes? Will the proposed procedure(s)/service(s) require related post-service inpatient and or
outpatient follow-up visits?)
12. For each proposed NEW code that may have a global period of 000, 010 or 090, do you request the
code be modifier 51 exempt (i.e., added to Appendix E)?
Yes
No
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13. What is the typical site of service for each proposed NEW code(s)? (check all that apply)
Hospital inpatient
Skilled nursing facility
Hospital outpatient
Nursing facility
Ambulatory surgical center
Assisted living facility
Emergency department
Patient’s home
Office
Independent laboratory
Inpatient Psychiatric Facility
Other, specify below.
14. Indicate the diagnoses (ICD codes) or conditions that the service(s) or procedure(s) described by the
proposed NEW code(s) are designed to diagnose/treat.
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15. What is the prevalence of the disease(s) that the service(s) or procedure(s) described by the proposed
NEW code(s) is/are designed to diagnose/treat? Please quantify when possible (e.g., patients per
year; admissions per year).
16. For how many years has the service(s) or procedure(s) described by the proposed NEW or REVISED
code(s) been provided for patients? Indicate your source.
17. Please identify the specialties or subspecialties that might perform the service(s) or procedure(s)
described by the proposed NEW code(s).
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18. Are the service(s) or procedure(s) described by the proposed NEW code(s) performed widely across
the United States?
Yes. Please provide the source(s) for all volume, frequency and distribution statements
(e.g. published epidemiology, registries, sales statistics)
No. Only at limited centers/locations. Please explain below.
19. Do many physicians and/or other qualified health care professionals provide the service(s) or
procedure(s) described by the proposed NEW code(s)?
Yes. Please provide the source(s) for all volume, frequency and distribution statements (e.g.,
published epidemiology, registries, sales statistics)
No. Please explain below.
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20. How often do individual physicians and/or other qualified health care professionals personally perform
the service(s) or procedure(s) described by the proposed NEW code(s) in a 12 month period?
Commonly
Sometimes
Rarely
21. How often was the service(s) or procedure(s) for each proposed NEW code provided nationally in the
most recent one-year period?
22. Are you aware of any practice parameters/guidelines or policy statements about the service(s) or
procedure(s) described by the proposed NEW code(s)?
Yes. Please specify below.
No
Don’t Know
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23. For each proposed NEW and/or REVISED code(s), provide a clinical vignette that describes the typical
patient who would receive the procedure/service including diagnosis and relevant conditions. Please
refer to the sample format and examples of appropriate clinical vignettes included in the code change
application instructions. NOTE: This same vignette will be used during the development of work
relative value units (RVUs) by the AMA/Specialty Society RVS Update Committee (RUC), if the service
requires RUC review. It is important that the description of the typical patient make apparent the typical
degree of complexity of the patient receiving this procedure/service.
24. For each proposed NEW and/or REVISED code(s), provide a brief description of the procedure/service
performed by the physician or other qualified health care professional. Please refer to the sample
format and examples of appropriate descriptions of service included in the code change application
instructions. This should be a summary description and should not contain the details for pre, intra and
post service breakdowns that are required as part of the AMA/Specialty Society RVS Update
Committee (RUC). It is important that the description of the service make apparent the services that
are integral or separately reported.
If the description includes services that are reported separately, please clearly indicate this separate
reporting. If more than one physician or other qualified health care professional is involved in the
provision of the total service, please indicate who does what.
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25a. Please provide electronic (PDF or Word documents) copy(s) (and internet addresses, if available) of
literature to support your application, and cite the author, title, journal, year, volume and page(s) in the
“Publication Details and Attributes Grid” (press “Ctrl” key and click link) (PDA grid) that follows. Each item
of submitted literature shall be identified in the PDA grid according to each of the following
requirements:
1. Identify the Level of Evidence by selecting a level from the LOE table below;
2. Identify whether this is a U.S. based journal or a non-U.S. based journal, and identify whether the
population studied is U.S. or non-U.S. or both;
3. Identify the number of patient studies (total of all group(s) including controls) and indicate whether
study is a prospective study;
4. Provide a concise “relevance statement”.
5. Provide up to 5 references, of which at least 3 report the procedure/service in a U.S. patient
population. Of these, at least 2 articles must report different patient populations or have different
authors (no overlapping patient populations or no overlapping authors). Articles submitted with the
designation of “Confidential” will not be accepted nor included in the supporting literature reviewed
by the CPT Editorial Panel. Any “in press” manuscripts that are submitted will only be appropriate
for consideration by the Panel if accompanied by the letter from the editor/publisher of the
applicable journal informing the author that the manuscript has been accepted for publication in its
final form, subject only to final copy editing. It is the responsibility of the submitter to ensure that
such submission to CPT (despite its very limited use by the Editorial Panel) does not jeopardize
publication of the article being considered.
Literature Criteria Definitions:
New Technology:
Individuals or organizations putting forth Code Change Applications will be required to specifically
indicate the pathway for FDA approval or clearance.
Services or procedures requiring devices or other technology necessitating the following Food and
Drug Administration (FDA) pathways are defined for CPT literature requirements as those involving
“new” technology:
1. Premarket Approval (PMA) or Investigational Device Exemption (IDE)
2. Panel Track Submission
3. DeNovo 510(k)
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Existing or Non-Contributory Technology:
Services or procedures which are approved or cleared via other FDA requirements (e.g., traditional
510(k)) or those which do not involve technology are defined for CPT literature requirements as those
where technology is “existing or non-contributory.” Most CPT Code Change Applications currently fall
within this category.
Limited, Specialized or Humanitarian Utilization:
Only very few Code Change Applications are anticipated to be designated by this special status,
intended to maintain the integrity of CPT literature requirements, but also recognize that such
requirements may be impossible to meet for very unique service or procedures. To qualify for this
special status, individuals or organizations submitting Code Change Applications must provide
documentation of at least one of the following:
1. Evidence that the device or technology involved has been deemed by the FDA to have met
criteria for a “Humanitarian Device Exemption.”
2. Proof that the service or procedure is used primarily for humanitarian reasons or is reserved
for unique, small and/or underserved populations is the responsibility of requester. Using
this level of proof would make it impossible to conduct research to meet CPT literature
requirements for more typical or traditional services or procedures. Examples might include
surgical procedures to repair rare congenital heart defects or those required to address other
rare conditions. Individuals or organizations seeking this status as part of a Code Change
Application would be required to provide compelling evidence to the CPT Editorial Panel that
the service or procedure for which they seek a code or codes merits this special designation.
The burden of evidence for assignment of this status would fall entirely on the requesting
individual or organization, and the decision to assign this very unique status rests entirely on
the CPT Editorial Panel.
Please note that submittal of articles meeting the minimum literature requirements specified in this
application does not necessarily mean that clinical efficacy has been established as required by the
Category I criteria. Whether clinical efficacy has been established in the literature is a judgment
reserved for the CPT Editorial Panel.
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The following includes a listing of the utilization and technology types that best describe the procedure that
is being requested. General Guidelines for inclusion of the articles should be chosen from one of the four
types of procedures as listed in the following:
Limited,
Specialized or
Humanitarian
Existing or NonContributory
New
Existing or NonContributory
5
5
5
3-5
Minimum # with U.S.
Patient Populations:
3
3
2
1
Minimum # with Different
Patient Populations:
2
2
1
1
Minimum Level of
Evidence for at least One
Article
IIa
IIIa/IIIb
IIb
IV
Utilization
Limited,
Specialized or
Humanitarian
Typical
New
# of Peer-Reviewed
Publications:
Category I
Literature
Requirements
Technology
Typical
Make an “X” in the box for
the type of utilization and
technology that best fits
the procedure/literature
being requested.
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25b. For Category III codes, please reference studies or research performed by national organizations if
available.
The following is used as formalized criteria by the CPT Advisory Committee and the CPT Editorial
Panel for evaluating Category III code applications, and includes identification of the following elements
as guidelines for establishment of a Category III code:

The procedure or service is currently or recently performed in humans; AND
At least one of the following additional criteria has been met:

The application is supported by at least one CPT or HCPAC advisor representing practitioners
who would use this procedure or service; OR

The actual or potential clinical efficacy of the specific procedure or service is supported by peer
reviewed literature which is available in English for examination by the Editorial Panel; OR

There is a) at least one Institutional Review Board approved protocol of a study of the
procedure or service being performed. b) a description of a current and ongoing United States
trial outlining the efficacy of the procedure or service; or c) other evidence of evolving clinical
utilization.
Level of Evidence Table – LOE
Level
Short Description (based on Oxford Centre 2009)
Ia
Evidence obtained from systematic review of randomized controlled trials
Ib
Evidence obtained from an individual randomized controlled trial
IIa
Evidence obtained from systematic review of cohort studies
IIb
Evidence obtained from an individual cohort study
IIIa
Evidence obtained from systematic review of case control studies
IIIb
Evidence obtained from a case control study
IV
Evidence obtained from case series
V
Evidence obtained from expert opinion without explicit critical appraisal
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* For each article cited, please provide a description of why the specific literature reference is relevant to the
Code Change Application (e.g., “this is the hallmark double blinded controlled study establishing the value of
the procedure/service”, “this is a case report describing the procedure/service in detail”, or “this is an opinion
statement from a respected authority in the field”).
Publication Details and Attributes (PDA) Grid
Code #
Click here to enter text.
References
Study
Level of
Duration Evidence
Based on
LOE Table
Article #1
U.S. or
Organization Impact
Foreign
Sponsoring Factor
Peer
Journal
Reviewed
U.S.
Foreign
U.S. or
Prospective Total
Foreign
Study?
Patients
Population
Studied
Studied
U.S.
Yes
Foreign
No
Both
Provide brief description regarding relevance to Code Change Application*
References
Article #2
Study
Level of
Duration Evidence
Based on
LOE Table
U.S. or
Organization Impact
Foreign
Sponsoring Factor
Peer
Journal
Reviewed
U.S.
Foreign
U.S. or
Prospective Total
Foreign
Study?
Patients
Population
Studied
Studied
U.S.
Yes
Foreign
No
Both
Provide brief description regarding relevance to Code Change Application*
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References
Study
Level of
Duration Evidence
Based on
LOE Table
Article #3
U.S. or
Organization Impact
Foreign
Sponsoring Factor
Peer
Journal
Reviewed
U.S.
Foreign
U.S. or
Prospective Total
Foreign
Study?
Patients
Population
Studied
Studied
U.S.
Yes
Foreign
No
Both
Provide brief description regarding relevance to Code Change Application*
References
Study
Level of
Duration Evidence
Based on
LOE Table
Article #4
U.S. or
Organization Impact
Foreign
Sponsoring Factor
Peer
Journal
Reviewed
U.S.
Foreign
U.S. or
Prospective Total
Foreign
Study?
Patients
Population
Studied
Studied
U.S.
Yes
Foreign
No
Both
Provide brief description regarding relevance to Code Change Application*
References
Article #5
Study
Level of
Duration Evidence
Based on
LOE Table
U.S. or
Organization Impact
Foreign
Sponsoring Factor
Peer
Journal
Reviewed
U.S.
Foreign
U.S. or
Prospective Total
Foreign
Study?
Patients
Population
Studied
Studied
U.S.
Yes
Foreign
No
Both
Provide brief description regarding relevance to Code Change Application*
return
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26. Have you found any publications, in addition to those cited in the Code Change Application, which offer
conflicting data or different opinions, and that you feel are important for Editorial Panel consideration in
evaluating this code change application? If so, please provide the literature reference, level of
evidence and reason that you consider the publication(s) relevant, and why you excluded them from
the articles cited in 25a.
Reference (list Author,
Brief description regarding relevance and why you
excluded from articles in 25a.
Article #1
Level of
Evidence based
on LOE Table
Level #
Article #2
Level #
Describe:
Article #3
Level #
Describe:
Article #4
Level #
Describe:
Title, Journal, Year, Volume,
Pages)
27.
Describe:
Other Comments:
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Conflict of Interest Policy of Presenters
Every code change proposal applicant or his/her designee(s) making a presentation (“Presenter”) to the CPT®
Editorial Panel on a code change application shall disclose all individual and corporate disclosable interests as
defined below, but without regard to financial limit. Presenters who are applicants shall complete a written disclosure
at the time of the code change application. Presenters who are a designee(s) of the code change proposal applicant
shall complete a written disclosure in response to the “presenter letter” sent to applicants approximately two weeks
in advance of the meeting of the CPT Editorial Panel. All Presenters are also asked by the Chair of the CPT Editorial
Panel to make a verbal disclosure of individual and corporate interests at the time of presentation. Any disclosable
interest that is a material individual interest or a material corporate interest must be designated as such in the
disclosure.
CODE CHANGE APPLICATION APPLICANT OR DESIGNEE (“PRESENTER”)
DISCLOSURE OF INTEREST
I affirm that I have read and understand the Conflict of Interest Policy of the CPT Editorial Panel and Workgroup
Members, Advisors and Presenters, a copy of which is available on the AMA CPT website. (press “Ctrl” key and
click link) I have no individual or corporate disclosable interests at this time, except as set forth below. I
understand that I have a continuing obligation to comply with the Conflict of Interest Policy and will update this
form prior to any code change proposal application. Disclosure does not restrict or limit the ability of the presenter
to support the applicant’s code change proposal.
DISCLOSABLE INTERESTS
INDICATE IF MATERIAL INTEREST
Print Name
Signature
Date
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June 6, 2017
Key Elements of Conflict of Interest Policy
For convenience, key elements of the Conflict of Interest Policy applicable for Applicants/Presenters are
summarized below. The Conflict of Interest Policy in its entirety is controlling (please refer to the Conflict of
Interest Policy in its entirety on the AMA CPT website): (press “Ctrl” key and click link)

Presenters members must disclose all individual and corporate disclosable interests as defined in
the Policy held by the member or immediate family without regard to financial limit.

“Immediate family” means a spouse, domestic partner, parent, child, brother or sister of a
Presenter. Requirements for disclosure of interests of immediate family apply to the extent such
interests are known by the Presenter.

“Disclosable individual interest” means cash, goods or other value (e.g., consultancies, speaking
honoraria, salary or salary support, research or other grant support, stock ownership or options,
expert testimony, royalties or other intellectual property rights, service on a speakers bureau, gifts, or
paid travel and vacation) that, with respect to the Applicant/Presenter or the Applicant/Presenter’s
immediate family members, the individual may receive such interest as a result of the approval or
denial of the code change, the value of which exceeds $1.00 in the past two years.

“Disclosable corporate interest” means cash, goods or other value (e.g., increased sales,
decreased sales of competitors, increased value of intellectual property, increased grant support,
etc.) which in the aggregate exceeds $5,000 within the past two years or is reasonably expected to
exceed $5,000 in the next two years, only where the Presenter is a consultant, agent, or employee
and the Presenter should reasonably be aware that their client or employer may receive such
interest from the approval or denial of the code change proposal.

Individual and corporate disclosable interests do not include [i] any interest that is limited to
providing clinical services to patients (including the service for which a code change proposal has
been submitted), or [ii] providing professional educational services or interpretative advice on proper
coding.

“Material individual interest” means a disclosable individual interest the value of which exceeds
$10,000 in the aggregate within the past two years.

“Material corporate interest” means disclosable corporate interest the value of which in the
aggregate exceeds $10,000 within the past two years or is reasonably expected to exceed $10,000
in the next two years.
Presenters who are applicants shall complete a written disclosure at the time of the code change
application. Presenters who are a designee(s) of the code change proposal applicant shall complete a
written disclosure in response to the “presenter letter” sent to applicants approximately two weeks in
advance of the meeting of the CPT Editorial Panel. All Presenters are also asked by the Chair of the CPT
Editorial Panel to make a verbal disclosure of individual and corporate interests at the time of presentation.
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CPT is a registered trademark of the American Medical Association
Copyright 2017, American Medical Association, All rights reserved
June 6, 2017
Statement on Lobbying
Applicants and other interested parties must not engage in “lobbying” for or against code change
applications. “Lobbying” means unsolicited communications of any kind made at any time (including during
Editorial Panel meetings) for the purpose of attempting to influence either (1) the CPT Advisors’ evaluation
of or comments upon a code change application or (2) voting by members of the Editorial Panel on a code
change application. Lobbying is strictly prohibited. Violation of the prohibition on lobbying may
result in sanctions such as being barred from further participation in the CPT process. Information
that accompanies a code change application, presentations or commentary to the full Editorial Panel during
an open meeting and responses to inquiries from a Panel member or a CPT staff member do not constitute
“lobbying.”
In order for the CPT Editorial Panel to effectively review and act on proposed changes to the CPT code set,
code change applications must be reviewed by the CPT Advisors and the Editorial Panel based on the
information contained in the application and available clinical literature. CPT staff is responsible for
organizing and submitting information to the CPT Advisors and the Editorial Panel for consideration.
Information relating to a code change application must be submitted to CPT staff no later than thirty days
prior to the start of the Editorial Panel meeting at which the code change application will be considered. In
some cases, the Chair of the Editorial Panel may establish rules which allow for supplemental submissions
of information to workgroups or facilitation sessions established by the Chair or for postponed or appealed
agenda items.
(A facilitation session is an informal meeting requested by the Chair during a CPT Editorial Panel meeting to
allow interested parties to confer and attempt to reach a consensus recommendation for presentation at the
meeting.) During development of a code change application, an applicant may seek input or assistance from
staff or advisors of medical specialty societies but may not engage in “lobbying” as defined above. Medical
specialty societies may have their own policies governing interactions with applicants or other interested
parties regarding code change applications. The AMA encourages medical societies to work with applicants
from both industry and other medical specialty societies to assure that code change applications are
complete, coherent and consistent with current medical practice. Contacts with consulting medical societies
should be limited to that which is necessary to construct and submit the code change application. After the
date a code change application is posted for review and comment by the CPT Advisors and the Editorial
Panel, contact between an applicant and medical society representatives should be confined to
communications pertaining to feedback from the CPT staff or Advisors’ comments regarding the application.
If an applicant or other interested party wishes the CPT Advisors or the Editorial Panel to consider additional
information, that information must be submitted to AMA's CPT staff and not directly to the CPT Advisors or
the Editorial Panel.
Applicants and other interested parties are invited to participate in open CPT Editorial Panel meetings and
present their views on code change applications when recognized by the Chair during the course of the
meeting. The views of applicants and other interested parties may be sought during work group or
facilitation sessions established by the Chair and participation in a workgroup or a facilitation session is not
considered lobbying.
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CPT is a registered trademark of the American Medical Association
Copyright 2017, American Medical Association, All rights reserved
June 6, 2017
Attestations
By signing below, I hereby attest to each of the following:
1)
the information provided in this application is true, correct and complete, and, to the best of my
knowledge, accurately depicts current clinical and or surgical practice;
2)
I have read the CPT Statement on Lobbying, Criteria for Development and Evaluation of CPT
Category I and Category III codes, CPT Code Application Instructions, CPT Editorial Panel
Confidentiality Agreement, and CPT Application Process FAQs all referenced on the Applying for
CPT Codes (press “Ctrl” key and click link) page and on related pages; and
3)
I have authority to sign this application in both an individual and organizational capacity.
Copyright Assignment
In consideration of the American Medical Association’s review of this code change application, on behalf
of myself and the organization names below, I hereby assign to the AMA all rights including copyright, if
any, in the changes to the CPT code set contained in the application and any variation thereof approved
by the CPT Editorial Panel.
Signature
Print Name
Organization (if
applicable)
Date
American Medical Association
CPT Coding, Editorial and Regulatory Services
AMA Plaza
330 N. Wabash Avenue, Suite 39300
Chicago, IL 60611-5885
Phone (312) 464-5486
Fax (312) 224-6916
If you have any questions concerning the requirements on the Coding Change Application, please consult with
AMA staff prior to the submission of your application. An incomplete application may delay processing of your
request and may cause it to be returned.
AMA CPT Editorial Research and Development
Voice (312) 464-5486, fax (312) 224-6916
.
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CPT is a registered trademark of the American Medical Association
Copyright 2017, American Medical Association, All rights reserved
June 6, 2017
Instructions for Submitting your Code Change Application
Coding Change Application:
 Email the application and any signature pages to [email protected].
 Only the Coding Change Application and any signature pages should be emailed to
[email protected].
Supporting documents for your Code Change Application should be uploaded to the AMA CPT
Submissions page (https://connection.ama-assn.org/sites/CPT/Submit/default.aspx).
 You will be required to sign in to have access to this site.
 Any AMA website login account that you currently have (including your CPT Collaboration website
username and password) should allow access to this site.
 If you do not have an AMA login account, press the link that says Create an Account on the login
page in order to establish access to the AMA CPT Submissions site.
To use the drag and drop option for submissions of documents:
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The AMA CPT Submissions site is compatible with the following browsers: Internet Explorer,
Chrome and Firefox. We have found that using Mozilla Firefox provides optimum performance. This
browser can be obtained with a free download through the Mozilla website.
Open the AMA CPT Submissions site using the link shown above. (Click the AMA CPT
Submissions link or copy and paste the URL onto your browser address bar.)
On the login screen, enter your username and password.
Open the file on your computer that contains the documents to be uploaded.
To make things easier, decrease the size of the window that you just opened as well as the size of
the AMA CPT Submissions window. You may do this by clicking the icon that has the "2 overlapping
boxes" located in the upper right hand corner of each page.
Hold the Ctrl key down and highlight the files on your computer that you want to upload to the AMA
CPT Submissions site.
Place your curser in this group of highlighted files, hold down the left button on your mouse and drag
the documents from the source file directly to the AMA CPT Submissions site just below the heading
Drop Off Library.
When you see the notice Drop Here on the AMA CPT Submissions site, release the mouse button,
and the files will transfer over. You will see the titles to the documents that you just submitted.
If you decide to upload each document separately, press the “New Document” link. An “upload
dialog box” will open allowing you to submit an individual document. These documents will not
appear on the CPT Submission home page. They will be uploaded directly to the CPT staff site.
For security reasons, the files that you upload or drag and drop to the AMA CPT Submissions page will
not be visible by any person other than you. Within approximately one hour, these items will be
transferred to a different site that will allow the CPT Staff to review them.
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CPT is a registered trademark of the American Medical Association
Copyright 2017, American Medical Association, All rights reserved
June 6, 2017