Form Cms-20017 - Advisory Panel On Hospital Outpatient Payment Page 2

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Part II – Presentation Required Checklist
In order to meet the presentation requirements, all information stated below must be on page 1 of your
presentation in a clear, logical format.
To ensure that all information has been supplied—which is required for each presentation at the
APC Panel meeting—please provide the following:
1. List the financial relationship of presenter(s),
if any, with any company whose product,
services, or procedures are under
consideration
2. Physicians’ Current Procedural Terminology
(CPT) code(s) and Health Care Common
Procedures Codes (HCPS) involved
3. APC(s) affected
4. Description of the issue(s)
5. Clinical description of the service under
discussion (with comparison to other services
within the APC)
6. Recommendations and rationale for change
7. Recommendations and rationale for change
8. Potential consequences of not making the
change
Form CMS-20017 (04/17)
2

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