Affects a large segment of health care community Tied to health outcomes Addresses clinical conditions of high prevalence, high costs, high risks

Transcription

1 Cding Change Applicatin Categry II CPT Cde(s) Perfrmance Measurement American Medical Assciatin, Current Prcedural Terminlgy (CPT ) Applicatin Submissin Requirements All CPT Cde Change applicatins are reviewed and evaluated by CPT staff, the CPT/HCPAC Advisry Cmmittee, and the CPT Editrial Panel. Strict cnfrmance with the fllwing is required fr review f a cde change applicatin: Submissin f a cmplete applicatin, including all necessary supprting dcuments; Adherence t all psted deadlines; Cperatin with requests frm CPT staff and/r Editrial Panel members fr clarificatin and infrmatin; and Cmpliance with CPT Lbbying Statement. (press Ctrl key and click link) Applicatin Review Links (Press Ctrl key and click link) Applicant s Name Questin 1 Descriptr Typical Patient Descriptin Categry II Specific Requirements Criteria fr Submitting CPT Categry II Cde Prpsals Definitin r purpse f the measure is cnsistent with its intended use (quality imprvement and accuntability, r slely quality imprvement) Aspect f care measured is substantially influenced by physician wrk (r wrk f ther practitiner r entity fr which the cde may be relevant) Reduces data cllectin burden n physicians (r ther health practitiner r entity), reflects the wrk they perfrm, and is useful in physicians practice Significant Evidence-based Affects a large segment f health care cmmunity Tied t health utcmes Addresses clinical cnditins f high prevalence, high csts, high risks Agreed upn Definable Measurable Risk adjustment specificatins and instructins fr all utcme measures submitted r cmpelling evidence as t why risk adjustment is nt relevant Cpyright American Medical Assciatin All rights reserved 1

2 Sufficiently detailed t make it useful fr multiple purpses Facilitates reprting f perfrmance measure(s) Inclusin f select patient histry, testing (eg, glychemglbin), ther prcess measures, cgnitive r prcedure services within CPT, r physilgic measures (eg, bld pressure) t supprt perfrmance measurements Perfrmance measure develpment prcess includes Definitins Natinally recgnized expert panel Multidisciplinary Vetting prcess Evidence-based practice is the integratin f best research evidence with clinical expertise and patient values. Best research evidence refers t clinically relevant research, ften frm the basic health and medical sciences, but especially frm patient-centered clinical research int the accuracy and precisin f diagnstic tests (including the clinical examinatin); the pwer f prgnstic markers; and the efficacy and safety f therapeutic rehabilitative and preventive regimens. Clinical expertise means the ability t use clinical skills and past experience t rapidly identify each patient s unique health state and diagnsis, individual risks and benefits f ptential interventins, and persnal values and expectatins. Patient values refers t the unique preferences, cncerns and expectatins that each patient brings t a clinical encunter and that must be integrated int clinical decisins if they are t serve the patient. American Medical Assciatin Department f CPT Editrial Research and Develpment 330 N. Wabash Ave., Suite Chicag, Illinis r ccpsubmit@ama-assn.rg Cpyright American Medical Assciatin All rights reserved 2

3 Cver Sheet fr CPT Cding Change Applicatin It is recmmended that applicants cnsult with natinal medical specialties and ther qualified healthcare prfessinal rganizatins that will typically prvide the prpsed prcedure(s)/service(s) requested in this applicatin t btain cmments n the type f wrk. With recgnitin f scheduling needs f the specialty scieties, when assistance frm a specialty sciety will be sught, it is highly recmmended that the applicant plan fr enugh time fr scheduling such discussins in advance f the applicatin deadline t avid vilatin f the AMA Lbbying Plicy. Interested natinal specialty rganizatins may have deadlines prir t the CPT applicatin submissin deadline t allw fr applicatin review and cmment. Date: Change Requested by: Name(s): Organizatin: Address: City: State: Zip Cde: Telephne: Please include this cver sheet with yur applicatin. Tp Cpyright American Medical Assciatin All rights reserved 3

4 NOTICE: Individuals r rganizatins that believe they may be affected by a decisin f the CPT Editrial Panel n yur cde change applicatin may request review f yur applicatin in advance f the CPT Editrial Panel meeting. T ensure transparency in the CPT Editrial Panel prcess, the AMA will prvide yur cde change applicatin and supprting dcumentatin t such interested parties (prvided they can demnstrate a valid interest) s they can be prepared, if desired, t cmment at the CPT Editrial Panel meeting frm the flr micrphnes r t submit written cmments in advance f the meeting. If the AMA receives a request frm an interested party t review this cde change applicatin, yu will be ntified f that request and given five business days t submit a redacted versin f the applicatin that deletes any cnfidential and prprietary infrmatin. Failure t respnd in that time will be deemed by the AMA as yur apprval t release the full applicatin. The CPT Editrial Panel and CPT/HCPAC Advisry Cmmittee will be prvided the unredacted versin f the applicatin. Yes. I apprve f sharing this applicatin in full t an interested party that requests t review the applicatin. This frm plays a vital rle in maintaining and increasing the efficiency f the CPT prcess. It can be used t submit a cding change applicatin fr Categry II CPT cdes. Fr Categry I, III, r Pathlgy and Mlecular Pathlgy cdes, please utilize the apprpriate applicatin frm. As yu fill ut the frm, please cnsider which categry f cde change yu are requesting. Fr mre infrmatin and cde criteria fr the cde categries, please see the Cde Change Applicatin Instructins. Fr ther frms, see the AMA CPT website. (Press Ctrl key and click link) When requesting a new cde, the entire frm shuld be cmpleted. When submitting a request fr multiple new cdes, a respnse shuld be prvided fr each new cde. The applicant may need t create additinal lines and pages as needed. Refer t the Cde Change Applicatin Instructins if necessary. Once the applicatin is cmpleted, submit the frm electrnically t the AMA. (See infrmatin n submitting applicatins n the last page fr instructins n uplading applicatins, literature supplements and ther dcuments.) Yu may withdraw yur applicatin up until the time that the CPT Editrial Panel takes up the agenda item at a CPT Editrial Panel meeting. At that time, the discussin falls under the authrity f the Editrial Panel, and the applicatin may nt be withdrawn. If the CPT Editrial Panel determines that additinal infrmatin r evaluatin is warranted, cnsideratin f yur applicatin may be tabled until later during that meeting r pstpned until time certain (a specific future CPT meeting) r t time uncertain. return Cpyright American Medical Assciatin All rights reserved 4

5 Specific Criteria Regarding the Measure The fllwing infrmatin is intended t help identify the imprtant factrs regarding the develpment prcess fr measure fr which the cde(s) is(are) being develped. Nte: Fr specific infrmatin regarding develping the cde descriptr, cde lcatin within the Categry II cde sectin, and the Alphabetical Clinical Tpics Listing fr the measure snapsht and cde listing(s) (including the title f the Clinical Tpic [r listing f the measure-cde within an existing clinical tpic], and the listing f the specific measure title), see the Specific Infrmatin fr Develpment f the Categry II cde sectin. In develping new and revised perfrmance measurement cdes, requests fr Categry II cdes are cnsidered frm: Measurements that were develped and tested by a natinal rganizatin; Evidenced-based measurements with established ties t health utcmes; Measurements that address clinical cnditins f high prevalence, high risk r high cst; Well established measurements that are currently being used by large segments f the health care industry acrss the cuntry; In additin, the fllwing criteria apply: Definitin r purpse f the measure is cnsistent with its intended use (quality imprvement and accuntability, r slely quality imprvement) Aspect f care measured is substantially influenced by physician wrk (r wrk f ther practitiner r entity fr which the cde may be relevant) Reduces data cllectin burden n physicians (r ther health practitiner r entity), reflects the wrk they perfrm, and is useful in physicians practice Significant Evidence-based Affects a large segment f health care cmmunity Tied t health utcmes Addresses clinical cnditins f high prevalence, high csts, high risks Agreed upn Definable Measurable Risk adjustment specificatins and instructins fr all utcme measures submitted r cmpelling evidence as t why risk adjustment is nt relevant Sufficiently detailed t make it useful fr multiple purpses Facilitates reprting f perfrmance measure(s) Inclusin f select patient histry, testing (e.g., glychemglbin), ther prcess measures, cgnitive r prcedure services within CPT, r physilgic measures (eg, bld pressure) t supprt perfrmance measurements Cpyright American Medical Assciatin All rights reserved 5

6 Perfrmance measure develpment prcess includes Natinally recgnized expert panel Multidisciplinary Vetting prcess Nte: These cdes are nt referred t the RUC fr valuatin because n RVUs are assigned t them. Since sme f the Categry II cdes are services embedded within E/M cdes, the aggregate service is already valued. The measure frm which the changes (ie, cdes, Alphabetical Clinical Tpics Listing, and Categry II Cdes Sectin) are being made SHOULD BE PROVIDED AS PART OF THE APPLICATION. The applicatin is cnsidered incmplete withut submissin f the measures frm which the changes are t be derived. Develpment f the Alphabetical Clinical Tpics Listing (fund n the AMA website at This is an alphabetical listing f clinical cnditins and tpics with which the measures and cdes are assciated. It prvides an verview f the perfrmance measures, a listing f CPT Categry II cdes that may be used with each measure, as well as any applicable reprting instructins. T view the entire Alphabetical Clinical Tpics Listing (Alphabetical Listing), see the AMA website. (CPT Categry II Cdes Alphabetical Clinical Tpics Listing (PDF) The fllwing questins are intended t assist in identifying the cmpnents that will be used t develp the listing that will be included in the Alphabetical Clinical Tpics Listing. A. The definitin r purpse f the measure is cnsistent with its intended use. A-1. Identify the type f measure that is being used t develp each cde(s). Chse frm the fllwing (select ne categry t define the purpse f yur measure [eg, PCPI Measure Designatin: Type f measure.]). If this applicatin requests cdes fr multiple measure types, cmplete a separate applicatin fr each measure type: Cmpsite Cdes Cmpsite cdes cmbine several measures gruped within a single cde descriptr t facilitate reprting fr a clinical cnditin when all cmpnents are met. If nly sme f the cmpnents are met r if services are prvided in additin t thse included in the cmpsite cde, they may be reprted individually using the crrespnding CPT Categry II cdes fr thse services. Patient Management Patient management cdes describe utilizatin measures r measures f patient care prvided fr specific clinical purpses (eg, prenatal care, pre- and pst-surgical care). Patient Histry Patient histry cdes describe measures fr select aspects f patient histry r review f systems. Cpyright American Medical Assciatin All rights reserved 6

7 A. The definitin r purpse f the measure is cnsistent with its intended use. Physical Examinatin Physical examinatin cdes describe aspects f physical examinatin r clinical assessment. Diagnstic/Screening Prcesses r Results Diagnstic/screening prcesses r results cdes describe results f tests rdered (clinical labratry tests, radilgical r ther prcedural examinatins, and cnclusins f medical decisin-making). Therapeutic, Preventive, r Other Interventins Therapeutic, preventive, r ther interventins cdes describe pharmaclgic, prcedural, r behaviral therapies, including preventive services such as patient educatin and cunseling. Fllw-up r Other Outcmes Fllw-up r ther utcmes cdes describe review and cmmunicatin f test results t patients, patient satisfactin r experience with care, patient functinal status, and patient mrbidity and mrtality. Patient Safety Patient safety cdes that describe patient safety practices. Structural Measures Structural measures cdes are used t identify measures that address the setting r system f the delivered care. These cdes als address aspects f the capabilities f the rganizatin r health care prfessinal prviding the care. A-2. Prvide the measure: List infrmatin fr the measure here. A. Enter Clinical cnditin here (Clinical Tpic Use the tpic listing identified in A-8) B. Enter the measure title here C. Enter a brief descriptin f the measure D. Enter numeratr statement frm measure E. Enter denminatr statement frm measure F. Enter any relevant exclusins fr this measure (medical, patient, r system) Cpyright American Medical Assciatin All rights reserved 7

8 A. The definitin r purpse f the measure is cnsistent with its intended use. G. Enter any reprting instructins needed fr prviding the service The fllwing includes an example language frm an Alphabetical Clinical Tpics Listing: Atrial Fibrillatin and Atrial Flutter (AFIB) Chrnic Anticagulatin Therapy 1 Whether r nt the patient aged 18 years and lder with a diagnsis f nnvalvular atrial fibrillatin r atrial flutter at high risk fr thrmbemblism was prescribed warfarin during the 12 mnth reprting perid Numeratr: Patients wh were prescribed warfarin during the 12 mnth reprting perid Denminatr: All patients aged 18 years and lder with a diagnsis f nnvalvular atrial fibrillatin r atrial flutter at high risk fr thrmbemblism Definitins f Risk Patients are identified by ACC/AHA/ESC 2006 guidelines at lw risk fr thrmbemblism if there are nne f the fllwing factrs: prir strke r TIA, age 75 years, hypertensin, diabetes mellitus, and heart failure r impaired left ventricular systlic functin. Patients are identified by ACC/AHA/ESC 2006 guidelines at intermediate risk fr thrmbemblism if there is ne f the fllwing factrs: age 75 years, hypertensin, diabetes mellitus, and heart failure r impaired left ventricular systlic functin. Patients are identified by ACC/AHA/ESC 2006 guidelines at high risk fr thrmbemblism if there is a prir strke r TIA OR tw r mre f the fllwing factrs: age 75 years, hypertensin, diabetes mellitus, and heart failure r impaired left ventricular systlic functin. Cpyright American Medical Assciatin All rights reserved 8

9 A. The definitin r purpse f the measure is cnsistent with its intended use. Exclusin(s): Dcumentatin f medical reasns (eg, patients with transient r reversible causes f atrial fibrillatin [eg, pneumnia r hyperthyridism], pstperative patients, patients wh are pregnant, allergy t warfarin, risk f bleeding) OR patient reasn(s) (eg, ecnmic, scial, and/r religius impediments, nncmpliance r ther reasn fr refusal t take warfarin) fr nt prescribing warfarin Percentage f patients aged 18 years and lder with a diagnsis f nnvalvular atrial fibrillatin r atrial flutter at high risk fr thrmbemblism wh were prescribed warfarin during the 12 mnth reprting perid Reprting Instructins: Reprt 3550F r 3551F r 3552F fr each patient aged 18 years and lder with a diagnsis f nnvalvular atrial fibrillatin r atrial flutter. If the patient is classified as high risk fr thrmbemblism and warfarin therapy is prescribed, als reprt 4012F. Fr the patient with apprpriate exclusin criteria, reprt 4012F with mdifier 1P r 2P. 4012F Denminatr Cdes 3550F 3551F 3552F Warfarin therapy prescribed Lw risk fr thrmbemblism Intermediate risk fr thrmbemblism High risk fr thrmbemblism A-3. Ratinale fr develpment f a cde frm the measure: Prvide a ratinale t describe hw this measure will imprve quality, accuntability, better patient utcmes, etc. Cpyright American Medical Assciatin All rights reserved 9

10 A. The definitin r purpse f the measure is cnsistent with its intended use. A-4. If the measure cntains data elements useful fr multiple purpses, describe the data elements. Cpyright American Medical Assciatin All rights reserved 10

11 Instructins fr develpment f cde descriptr and selectin f cde placement within the Categry II Cde Sectin A-5. Using the language that identifies the measure descriptin, specify the new cde(s) descriptr(s): Instructin fr Requesting a new Categry II Cde (additin f a cde): Categry II cdes are listed within a particular subsectin that mst accurately represent the tracking f the clinician interactin with the patient (eg, Patient Histry, Patient Management, and Physical Examinatin). Use the infrmatin prvided in respnse t A-1 t identify the sectin that the cde will be listed within. Include the cde and descriptr using language that identifies the measure descriptin. Example: Categry II Physical Examinatin 2010F 200XF Vital signs (temperature, pulse, respiratry rate, and bld pressure) dcumented and reviewed (CAP) 1 (EM) 5 New cde language New ftnte# (New Acrnym) Categry II [Enter Existing Sub-Sectin Title here] [Enter existing cde(s) fr placement] [Enter new cde number and descriptr listing] Cpyright American Medical Assciatin All rights reserved 11

12 A-6 Using the language that identifies the measure descriptin, specify the deleted cde(s) descriptr(s): Instructin fr Requesting a Categry II Cde deletin: Display the cde selected fr deletin and specify the recmmended crss-reference (ie, hw is the deleted service nw t be cded?) Include the cnventinal technique f strike-uts fr deletins. An example is listed fr additinal guidance. Example: Categry II Physical Examinatin 2002F Clinical signs f vlume verlad (excess) assessed 1 (HF) 2003F Auscultatin f the heart perfrmed 1 (Cde 2003F has been deleted. Fr perfrmance measurement cding infrmatin regarding Heart Failure, see the Heart Failure Clinical Tpic listing in Appendix Hthe Alphabetical Clinical Tpics Listing) Categry II [Enter Existing Sub-Sectin Title here (Respnse t questin A-1)] [Enter existing cde(s) t shw placement] [Enter existing cde listing with strike-thrugh ver the cde and descriptr language t shw the deletin] Cpyright American Medical Assciatin All rights reserved 12

13 A-7. Using the language that identifies the measure descriptin, specify the revised, cde(s) descriptr(s): Fr each cde requested, describe any specific cde(s) that with mdificatin might serve as a tracking cde. Instructin fr Requesting a Revised Categry II Cde: Specify the recmmended terminlgy (cde descriptr) fr the prpsed revised cde. Use the cnventinal techniques f strike-uts fr deletins and underlining fr additins/revisins. Als, indicate the revisin(s) in cntext with the current cde descriptr (list the cmplete family f cdes related t yur request). EXAMPLE: Therapeutic, Preventive r Other Interventins 4006F 4009F Beta-blcker therapy, prescribed 1 (HF, CAD) Angitensin cnverting enzyme (ACE) inhibitr r Angitensin Receptr Blcker (ARB) therapy, recmmended prescribed 1 (HF, CAD) Categry II [Enter Existing Sub-Sectin Title here] [Enter existing cde(s) fr placement] [Enter existing cde number and descriptr listing with revisins here (use strike-thrugh fr desired deleted text and underline desired additinal text] Cpyright American Medical Assciatin All rights reserved 13

14 A-8. Prvide the Clinical Tpic/cnditin/disease that this service is intended t address. This will be used t identify the Alphabetical Clinical Tpics Listing that will be included fr measure (this shuld be cmpleted fr each measure unless the measure may be included within a single tpic). Chse a tpic in which the measure listing and cde will be placed within the Alphabetical Listing. Acute Brnchitis (A-BRONCH) Acute Otitis Externa/Otitis Media with Effusin (AOE/OME) Amytrphic Lateral Sclersis (ALS) Anesthesilgy/Critical Care (CRIT) Annual mnitring (AM) Asthma Atrial Fibrillatin and Atrial Flutter (AFIB) Back Pain (BkP) Care fr Older Adults (COA) Chrnic Kidney Disease (CKD) Chrnic Obstructive Pulmnary Disease (COPD) Chrnic Stable Crnary Artery Disease (CAD) Chrnic Wund Care (CWC) Cmmunity-Acquired Bacterial Pneumnia (CAP) Crnary Artery Bypass Graft (CAGB) Dementia (DEM) Diabetes (DM) Distal Symmetric Plyneurpathy (DSP) Emergency Medicine (EM) End Stage Renal Disease (ESRD) Endscpy and Plyp Surveillance (End/Plyp) Epilepsy (EPI) Eye Care (EC) Gastresphageal Reflux Disease (GERD) Geriatrics (GER) Heart Failure (HF) Hematlgy (HEM) Hepatitis C (HEP C) HIV/AIDS (HIV) Hypertensin Inflammatry Bwel Disease (IBD) Lung Cancer/Esphageal Cancer (Lung/Esp Cx) Majr Depressive Disrder (MDD) Majr Depressive Disrder-Child and Adlescent (MDD ADOL) Melanma (ML) Nuclear Medicine (NUC_MED) Onclgy (ONC) Ostearthritis (Adult) (OA) Osteprsis (OP) Palliative/Endf Life Care (Pall Cr) Parkinsn s Disease (Prkns) Pathlgy (PATH) Pediatric Acute Gastrenteritis (PAG) Pediatric End Stage Renal Disease (P-ESRD) Pediatric Pharyngitis (PHAR) Cpyright American Medical Assciatin All rights reserved 14

15 Periperative Care 2 (PERI 2) Prenatal Care (Pre-Cr) Prenatal-Pstpartum Care (Prenatal) Preventive Care & Screening (PV) Prstate Cancer (PRCA) Radilgy (RAD) Rheumatid Arthritis (RA) Screening Clnscpy Adenma Detectin Rate (SCADR) Strke and Strke Rehabilitatin (STR) Substance Use Disrders (SUD) Upper Respiratry Infectin in Children (URI) Nn-Measure Claims Based Reprting: - Abdminal Artic Aneurysm Repair - Cartid Interventin A-9. List the clinical tpic/disease/cnditin and the cde that shuld be included within it. If a new tpic shuld be designated, include the name f the new tpic and the acrnym that will be used here. Existing Tpic name: Cdes t be included: New Tpic name: Cdes t be included: Cpyright American Medical Assciatin All rights reserved 15

16 B. The perfrmance measure develpment prcess includes a natinally recgnized expert panel with multidisciplinary representatin and apprpriate vetting. B-1. Identify belw the natinally recgnized expert panel that develped the measure. Ftntes 1 Physician Cnsrtium fr Perfrmance Imprvement, 2 Natinal Cmmittee n Quality Assurance (NCQA), Health Emplyer Data Infrmatin Set (HEDIS ), 3 The Jint Cmmissin (TJC), ORYX Initiative Perfrmance Measures, 4 Natinal Diabetes Quality Imprvement Alliance (NDQIA), 5 Jint measure frm The Physician Cnsrtium fr Perfrmance Imprvement, and Natinal Cmmittee n Quality Assurance (NCQA), 6 The Sciety f Thracic Surgens, Natinal Quality Frum, 7 Ingenix, 8 American Academy f Neurlgy, Or quality@aan.cm 9 Cllege f American Pathlgists (CAP), 10 American Gastrenterlgical Assciatin (AGA), 11 American Sciety f Anesthesilgists, 12 American Cllege f Gastrenterlgy (ACG), American Gastrenterlgical Assciatin (AGA), and American Sciety fr Gastrintestinal Endscpy (ASGE), If nt represented abve, prvide name and any relevant infrmatin regarding the surce f their authrity fr measure develpment (i.e., web site lcatin where the measure may be fund) 13 [Enter new sciety r name f measure develper here] B-2. Describe the multidisciplinary review prcess used t achieve cnsensus n the measure amng all cnstituents f the respective rganizatins, including internal and public cmment prcesses. Cpyright American Medical Assciatin All rights reserved 16

17 C. The perfrmance measure fr which a tracking cde is sught is nt currently cded using existing cde sets designated under HIPAA (eg, CPT Categry I, ICD-9-CM, r HCPCS cdes). Describe hw the testing fr validity and feasibility fr the measure was accmplished. D. The perfrmance measure develpment prcess includes a natinally recgnized expert panel with multidisciplinary representatin and apprpriate vetting. D. Describe any specific cde(s) that with mdificatin might serve as a tracking cde. See A-8 E. The aspect f care measured is substantially influenced by physician wrk (r wrk f ther practitiner r entity fr which the cde may be relevant E-1. Identify the clinician (eg, specialty/subspecialty r qualified health care prfessinal described by the new cdes) fr whm the cde is relevant and why. Cpyright American Medical Assciatin All rights reserved 17

18 E. The aspect f care measured is substantially influenced by physician wrk (r wrk f ther practitiner r entity fr which the cde may be relevant E-2. Describe the services f the physician r QHP required t cmplete/affect the perfrmance f the measure. Use the service(s) described in the measures Supprting Guideline[s]). F. The measure upn which this cde is based is significant F-1. Describe the relatinship f the measure t the desired utcme (eg, PCPI: Measure Imprtance Relatinship t desired utcme) F-2. Describe hw the measure addresses clinical cnditins f high prevalence, high csts, high risks? Cpyright American Medical Assciatin All rights reserved 18

19 G. The measure is evidence-based. G-1. Describe the evidence-base frm which this measure was derived. G-2. Describe the evidence-based prcess used fr develpment f the measure. Cpyright American Medical Assciatin All rights reserved 19

20 H. Risk adjustment instructins and specificatins fr utcme measures/ evidence f irrelevancy f risk adjustment. H. Identify the patient fr whm the measure wuld rdinarily apply but due t apprpriate reasns (i.e., medical, patient, r system reasns) shuld be EXCLUDED frm measurement (i.e., exclusins 1P, 2P, 3P). Cpyright American Medical Assciatin All rights reserved 20

21 Cnflict f Interest Plicy f Presenters Every cde change prpsal applicant r his/her designee(s) making a presentatin ( Presenter ) t the CPT Editrial Panel n a cde change applicatin shall disclse all individual and crprate disclsable interests as defined belw, but withut regard t financial limit. Presenters wh are applicants shall cmplete a written disclsure at the time f the cde change applicatin. Presenters wh are a designee(s) f the cde change prpsal applicant shall cmplete a written disclsure in respnse t the presenter letter sent t applicants apprximately tw weeks in advance f the meeting f the CPT Editrial Panel. All Presenters are als asked by the Chair f the CPT Editrial Panel t make a verbal disclsure f individual and crprate interests at the time f presentatin. Any disclsable interest that is a material individual interest r a material crprate interest must be designated as such in the disclsure. CODE CHANGE APPLICATION APPLICANT OR DESIGNEE ( PRESENTER ) DISCLOSURE OF INTEREST I affirm that I have read and understand the Cnflict f Interest Plicy f the CPT Editrial Panel and Wrkgrup Members, Advisrs and Presenters, a cpy f which is available n the AMA CPT website. (press Ctrl key and click link) I have n individual r crprate disclsable interests at this time, except as set frth belw. I understand that I have a cntinuing bligatin t cmply with the Cnflict f Interest Plicy and will update this frm prir t any cde change prpsal applicatin. Disclsure des nt restrict r limit the ability f the presenter t supprt the applicant s cde change prpsal. DISCLOSABLE INTERESTS INDICATE IF MATERIAL INTEREST Print Name Signature Date Key Elements f Cnflict f Interest Plicy Fr cnvenience, key elements f the Cnflict f Interest Plicy applicable fr Applicants/Presenters are summarized belw. The Cnflict f Interest Plicy in its entirety is cntrlling (please refer t the Cpyright American Medical Assciatin All rights reserved 21

22 Cnflict f Interest Plicy in its entirety n the AMA CPT website): (press Ctrl key and click link) Presenters members must disclse all individual and crprate disclsable interests as defined in the Plicy held by the member r immediate family withut regard t financial limit. Immediate family means a spuse, dmestic partner, parent, child, brther r sister f a Presenter. Requirements fr disclsure f interests f immediate family apply t the extent such interests are knwn by the Presenter. Disclsable individual interest means cash, gds r ther value (e.g., cnsultancies, speaking hnraria, salary r salary supprt, research r ther grant supprt, stck wnership r ptins, expert testimny, ryalties r ther intellectual prperty rights, service n a speakers bureau, gifts, r paid travel and vacatin) that, with respect t the Applicant/Presenter r the Applicant/Presenter s immediate family members, the individual may receive such interest as a result f the apprval r denial f the cde change, the value f which exceeds $1.00 in the past tw years. Disclsable crprate interest means cash, gds r ther value (e.g., increased sales, decreased sales f cmpetitrs, increased value f intellectual prperty, increased grant supprt, etc.) which in the aggregate exceeds $5,000 within the past tw years r is reasnably expected t exceed $5,000 in the next tw years, nly where the Presenter is a cnsultant, agent, r emplyee and the Presenter shuld reasnably be aware that their client r emplyer may receive such interest frm the apprval r denial f the cde change prpsal. Individual and crprate disclsable interests d nt include [i] any interest that is limited t prviding clinical services t patients (including the service fr which a cde change prpsal has been submitted), r [ii] prviding prfessinal educatinal services r interpretative advice n prper cding. Material individual interest means a disclsable individual interest the value f which exceeds $10,000 in the aggregate within the past tw years. Material crprate interest means disclsable crprate interest the value f which in the aggregate exceeds $10,000 within the past tw years r is reasnably expected t exceed $10,000 in the next tw years. Presenters wh are applicants shall cmplete a written disclsure at the time f the cde change applicatin. Presenters wh are a designee(s) f the cde change prpsal applicant shall cmplete a written disclsure in respnse t the presenter letter sent t applicants apprximately tw weeks in advance f the meeting f the CPT Editrial Panel. All Presenters are als asked by the Chair f the CPT Editrial Panel t make a verbal disclsure f individual and crprate interests at the time f presentatin. Cpyright American Medical Assciatin All rights reserved 22

23 Statement n Lbbying Applicants and ther interested parties must nt engage in lbbying fr r against cde change applicatins. Lbbying means unslicited cmmunicatins f any kind made at any time (including during Editrial Panel meetings) fr the purpse f attempting t influence either (1) the CPT Advisrs evaluatin f r cmments upn a cde change applicatin r (2) vting by members f the Editrial Panel n a cde change applicatin. Lbbying is strictly prhibited. Vilatin f the prhibitin n lbbying may result in sanctins such as being barred frm further participatin in the CPT prcess. Infrmatin that accmpanies a cde change applicatin, presentatins r cmmentary t the full Editrial Panel during an pen meeting and respnses t inquiries frm a Panel member r a CPT staff member d nt cnstitute lbbying. In rder fr the CPT Editrial Panel t effectively review and act n prpsed changes t the CPT cde set, cde change applicatins must be reviewed by the CPT Advisrs and the Editrial Panel based n the infrmatin cntained in the applicatin and available clinical literature. CPT staff is respnsible fr rganizing and submitting infrmatin t the CPT Advisrs and the Editrial Panel fr cnsideratin. Infrmatin relating t a cde change applicatin must be submitted t CPT staff n later than thirty days prir t the start f the Editrial Panel meeting at which the cde change applicatin will be cnsidered. In sme cases, the Chair f the Editrial Panel may establish rules which allw fr supplemental submissins f infrmatin t wrkgrups r facilitatin sessins established by the Chair r fr pstpned r appealed agenda items. (A facilitatin sessin is an infrmal meeting requested by the Chair during a CPT Editrial Panel meeting t allw interested parties t cnfer and attempt t reach a cnsensus recmmendatin fr presentatin at the meeting.) During develpment f a cde change applicatin, an applicant may seek input r assistance frm staff r advisrs f medical specialty scieties but may nt engage in lbbying as defined abve. Medical specialty scieties may have their wn plicies gverning interactins with applicants r ther interested parties regarding cde change applicatins. The AMA encurages medical scieties t wrk with applicants frm bth industry and ther medical specialty scieties t assure that cde change applicatins are cmplete, cherent and cnsistent with current medical practice. Cntacts with cnsulting medical scieties shuld be limited t that which is necessary t cnstruct and submit the cde change applicatin. After the date a cde change applicatin is psted fr review and cmment by the CPT Advisrs and the Editrial Panel, cntact between an applicant and medical sciety representatives shuld be cnfined t cmmunicatins pertaining t feedback frm the CPT staff r Advisrs cmments regarding the applicatin. If an applicant r ther interested party wishes the CPT Advisrs r the Editrial Panel t cnsider additinal infrmatin, that infrmatin must be submitted t AMA's CPT staff and nt directly t the CPT Advisrs r the Editrial Panel. Applicants and ther interested parties are invited t participate in pen CPT Editrial Panel meetings and present their views n cde change applicatins when recgnized by the Chair during the curse f the meeting. The views f applicants and ther interested parties may be sught during wrk grup r facilitatin sessins established by the Chair and participatin in a wrkgrup r a facilitatin sessin is nt cnsidered lbbying. return Cpyright American Medical Assciatin All rights reserved 23

24 Attestatins By signing belw, I hereby attest t each f the fllwing: 1) The infrmatin prvided in this applicatin is true, crrect and cmplete, and, t the best f my knwledge, accurately depicts current clinical and r surgical practice; 2) I have read the CPT Statement n Lbbying, Criteria fr Develpment and Evaluatin f CPT Categry I and Categry III cdes, CPT Cde Applicatin Instructins, CPT Editrial Panel Cnfidentiality Agreement, and CPT Applicatin Prcess FAQs all referenced n the Applying fr CPT Cdes (press Ctrl key and click link) page and n related pages; and 3) I have authrity t sign this applicatin in bth an individual and rganizatinal capacity. Cpyright Assignment In cnsideratin f the American Medical Assciatin s review f this cde change applicatin, n behalf f myself and the rganizatin names belw, I hereby assign t the AMA all rights including cpyright, if any, in the changes t the CPT cde set cntained in the applicatin and any variatin theref apprved by the CPT Editrial Panel. Signature Print Name Organizatin (if applicable) Date American Medical Assciatin CPT Cding, Editrial and Regulatry Services AMA Plaza 330 N. Wabash Avenue, Suite Chicag, IL Phne (312) Fax (312) If yu have any questins cncerning the requirements n the Cding Change Applicatin, please cnsult with AMA staff prir t the submissin f yur applicatin. An incmplete applicatin may delay prcessing f yur request and may cause it t be returned. AMA CPT Editrial Research and Develpment Vice (312) , fax (312) Instructins fr Submitting yur Cde Change Applicatin Cding Change Applicatin: the applicatin and any signature pages t ccpsubmit@ama-assn.rg. Cpyright American Medical Assciatin All rights reserved 24

25 Only the Cding Change Applicatin and any signature pages shuld be ed t ccpsubmit@ama-assn.rg. Supprting dcuments fr yur Cde Change Applicatin shuld be upladed t the AMA CPT Submissins page ( Yu will be required t sign in t have access t this site. Any AMA website lgin accunt that yu currently have (including yur CPT Cllabratin website username and passwrd) shuld allw access t this site. If yu d nt have an AMA lgin accunt, press the link that says Create an Accunt n the lgin page in rder t establish access t the AMA CPT Submissins site. T use the drag and drp ptin fr submissins f dcuments: The AMA CPT Submissins site is cmpatible with the fllwing brwsers: Internet Explrer, Chrme and Firefx. We have fund that using Mzilla Firefx prvides ptimum perfrmance. This brwser can be btained with a free dwnlad thrugh the Mzilla website. Open the AMA CPT Submissins site using the link shwn abve. (Click the AMA CPT Submissins link r cpy and paste the URL nt yur brwser address bar.) On the lgin screen, enter yur username and passwrd. Open the file n yur cmputer that cntains the dcuments t be upladed. T make things easier, decrease the size f the windw that yu just pened as well as the size f the AMA CPT Submissins windw. Yu may d this by clicking the icn that has the "2 verlapping bxes" lcated in the upper right hand crner f each page. Hld the Ctrl key dwn and highlight the files n yur cmputer that yu want t uplad t the AMA CPT Submissins site. Place yur curser in this grup f highlighted files, hld dwn the left buttn n yur muse and drag the dcuments frm the surce file directly t the AMA CPT Submissins site just belw the heading Drp Off Library. When yu see the ntice Drp Here n the AMA CPT Submissins site, release the muse buttn, and the files will transfer ver. Yu will see the titles t the dcuments that yu just submitted. If yu decide t uplad each dcument separately, press the New Dcument link. An uplad dialg bx will pen allwing yu t submit an individual dcument. These dcuments will nt appear n the CPT Submissin hme page. They will be upladed directly t the CPT staff site. Fr security reasns, the files that yu uplad r drag and drp t the AMA CPT Submissins page will nt be visible by any persn ther than yu. Within apprximately ne hur, these items will be transferred t a different site that will allw the CPT Staff t review them. Cpyright American Medical Assciatin All rights reserved 25