To provide details on the 2016 CPT® changes, web2pro (BPS) has prepared this summary of new, deleted and revised codes for all specialties excluding Pathology/Laboratory, Radiology, Emergency Medicine, and Anesthesia issued by the American Medical Association (AMA).

All individuals should understand the various code symbols that AMA uses to denote new codes, revised codes, deleted codes, resequenced codes, etc. You should look under the Code Symbols section of the introduction in the code book for definitions and explanations of the various symbols.

Each year, the AMA publishes its new, revised and deleted CPT® codes for that calendar year. This document is to provide a summary of the changes on the following specialties: Evaluation and Management, Surgery, Medicine, Category II, and Category III codes. 

Summary review

















Category II




Category III




Evaluation and Management

In the Evaluation and Management (E/M) Services section, changes include the addition of a new subsection, guidelines, and two new codes (99415, 99416) to describe prolonged office observation care services provided by clinical staff in conjunction with physician or other qualified health care professional E/M services and psychotherapy services. The guidelines for the Prolonged Services subsection have been revised to reference the use of the new prolonged clinical staff services codes, as well as to provide instructions regarding how to report psychotherapy services. In addition, editorial revisions to the guidelines for Preventive Medicine Services and Counseling Risk Factor Reduction and Behavior Change Intervention have been made to clarify the use of behavior change intervention codes 99406-99409 and the use of modifier 25.


In the Surgery section, numerous changes have been made, starting with expansion of the guidelines to include instructions for the use of “imaging guidance.” In the Integumentary System subsection, two new codes (10035,10036) for soft tissue marker placement with imaging were added, and one code was deleted in the Musculoskeletal System subsection.

The Respiratory System subsection contains new guidelines, parenthetical notes, and three new codes (31652, 31653, 31654) for reporting bronchoscopy utilizing transendoscopic endobronchial ultrasound. The Cardiovascular System subsection also contains new guidelines for the Pacemaker or Implantable Defibrillator subsection and includes refinements and new instructions pertaining to the use of new Category III codes and new code 33477 for reporting transcatheter pulmonary valve implantation. A new diagram to describe reporting of ECMO/ECLS procedures has also been added.

In the Intravascular Ultrasound Services subsection, guidelines have been expanded to clarify that intravascular ultrasound is included in codes 37191, 37192, 37193, and 37197. Codes 37250 and 37251 have been deleted and replaced by new codes 37252 and 37253.

Mediastinoscopy code 39400 has been deleted and converted into two codes (39401, 39402) to reflect the current use of these procedures, including lymph node biopsy for cancer staging. In the Digestive System subsection, multiple Category I and Category III codes have been either added or deleted, including the addition of 14 new codes (47531-47544) and the addition of extensive guidelines and numerous parenthetical notes pertaining to transhepatic and transcholecystic biliary procedures. In addition, a new table has been added to direct users to the appropriate use of these new codes in association with catheters and stent procedures.

A large number of changes have been made to the Urinary System subsection, including some revisions that are editorial in nature pertaining to anatomy and the assignment of primary and secondary procedures. Other revisions include the deletion of codes 50392, 50393, 50394, and 50398, and the addition of new codes (50430, 50431, 50432, 50433, 50434, 50435), headings, and guidelines for reporting genitourinary catheter procedures and associated nephrostogram, nephrostomy, and nephroureteral services. Some of the new codes added describe biopsy and dilation of the ureter, nonendoscopic endoluminal biopsy of the ureter and/or renal pelvis, and the percutaneous placement of ureteral stent and embolization and balloon dilation of the ureter using nonendoscopic imaging guidance. In addition, the Male Genital System subsection contains two new codes (54437, 54438) to report traumatic penile injury repairs.

New codes and numerous instructional parenthetical notes pertaining to three new codes (61645, 61650, 61651) describing cerebral endovascular therapeutic interventions in intracranial arteries have been added in the Nervous System subsection. Rarely performed procedure code 64412 was deleted. Three codes (64461, 64462, 64463) to identify thoracic paravertebral blocks and continuous infusions has also been added, and changes have been made to the guidelines pertaining to the 64633-64636 series of codes.

Category III code 0099T has been converted to a Category I code (65785) in the Eye and Ocular Adnexa subsection, and codes 65855, 67227, and 67228 have been revised to omit the phrase “1 or more sessions.” In addition, a number of other editorial revisions to retinal detachment repair codes have been made to utilize standardized terminology throughout the code set.

In the Auditory System subsection, one new code (69209) has been added to report the removal of impacted cerumen using irrigation/lavage.


In the Medicine section, nearly all of the vaccine codes (90476-90749) have been updated to include Advisory Committee on Immunization Practices (ACIP) abbreviations, and numerous codes representing obsolete vaccine products have been deleted. Two new codes (90620, 90621) have been added to report the administration of serogroup B meningococcal (MenB) vaccines, and a new code (90625) to report the administration of a live oral cholera vaccine has been added. In addition, code 91040, included in the Gastroenterology subsection, has been revised to omit the provocation requirement and to specify the study as diagnostic.

The Ophthalmology subsection contains minor revisions pertaining to the trabeculoplasty and retinal detachment repair procedural codes, including editorial revisions and one code deletion. New codes for bithermal and monothermal caloric vestibular testing (92537, 92538) have been added under the Special Otorhinolaryngologic Services subsection. A single code (93050) has been added to the Cardiovascular subsection to report arterial pressure waveform analysis for the assessment of central arterial pressures.

A detailed set of instructions has been added to instruct users on the proper reporting of codes 95970-95979 within the Neurostimulators, Analysis-Programming subsection.

In the Special Dermatological Procedures subsection, six new codes (96931, 96932, 96933, 96934, 96935, 96936) have been added to report reflectance confocal microscopy for cellular and sub-cellular imaging of the skin.

Lastly, ocular screening code 99174 has been revised, and a new code (99177) has been added to differentiate between remote and on-site analysis.

Category II

In the Category II Codes section, code 6030F has been updated to comply with the revision of the Prevention of Catheter-Related Bloodstream Infections (CRBSI)—Central Venous Catheter Insertion Protocol performance measure for which this code is reported. Updates were made to match the language included within the revised measure to ensure the elements needed for compliance with the measure are stated in the code descriptor. In addition, the information listed for code 6030F within the Alphabetical Clinical Topics Listing has been revised.

Category III

In the Category III Codes section, the introductory guidelines have been revised to include reference to payer coverage, and an extensive number of Category III codes have been added to cover emerging technology. Also, some Category III codes have been converted to Category I codes, while others have been scheduled to sunset or be archived.

Some of the emerging technologies reflected in the new Category III codes include procedures to diagnose nocturnal epilepsy seizure events; procedures to laparoscopically place and remove esophageal sphincter augmentation devices; advancements in interstitial or intracavitary brachytherapy services; and procedures to treat uterine fibroids, and medical refractory movement disorders (utilizing magnetic resonance image–guided focused ultrasound). Other Category III codes have been added to describe procedures that detect implant stability during knee replacement arthroplasty and diagnose and manage ischemic heart disease by myocardial strain imaging.

A new section of Category III codes has been added for the insertion, removal, and evaluation and programming of leadless and pocketless cardiac pacemaker systems, and a new Category III code has been added for endoscopic retrograde cholangiopancreatography with optical endomicroscopy.

In addition, two new Category III codes have been added to report multi-spectral digital skin lesion analysis to analyze melanoma. Time-based Category III codes have been added to describe daily diabetes preventive behavior change intervention services and oversight of the care of extracorporeal liver assist system patients. The last two Category III codes added describe endoscopic drug eluting implants into the ethmoid sinus.

View the complete  (PDF, 478 KB) for academic, office-based and multi-specialty practices.

Author - Female

About the author

Stephanie Johnson, CHC, RHIT, CPC, CPEDS is Compliance Manager – Academic, Office-based and Multi-specialty Physicians of web2pro Business Performance Services.