Fillable ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT Presenter/Presentation Information (Medicare & Medicaid)

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ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT Presenter/Presentation Information (Medicare & Medicaid)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
1 Form CMS-20017 (04/17)
ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT
Presenter/Presentation Information Checklist
Instructions: Submit this checklist (Parts I and II) with your presentation to
APCPanel@cms.hhs.gov by 5 p.m. on the date specified in the Federal Register notice. Or, if unable
to submit by email, a hard copy sent to:
Designated Federal Official, HOP Panel
CMS/CM/HAPG/DOC
7500 Security Blvd., C4-01-26
Baltimore, Maryland 21244-1850
Part I: Personal Information for Presenter(s) (If you have more than three presenters, photocopy
the form, or go to https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20017.pdf
to print another copy.
Presenter’s Name Title Organizational Affiliation, Name,
Address, City, and State
Subject of Presentation E-mail Address Telephone Number
Clearly describe the action(s) that you are requesting CMS to take.
Presenter’s Name Title Organizational Affiliation, Name,
Address, City, and State
Subject of Presentation E-mail Address Telephone Number
Clearly describe the action(s) that you are requesting CMS to take.
2 Form CMS-20017 (04/17)
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
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ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT PresenterPresentation Information (Medicare & Medicaid)

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Completed 1 February 2021

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