Current Procedural Terminology (CPT®) 2016 contains new and revised codes for a variety of services and procedures related to emergency medicine services. web2pro Business Performance Services (web2pro) has prepared this summary to provide you with details on CPT code additions, deletions and modifications issued by the American Medical Association (AMA).

Procedural Code Changes

In CPT 2016, there are more than 300 code updates. This document discusses codes specific to the emergency medicine division.

Evaluation and Management

“Prolonged service codes 99354 and 99355 are used when a physician or other qualified health care professional provides prolonged service(s) beyond the usual service in either the inpatient or outpatient setting. Psychotherapy code 90837 was added to the prolonged service(s) description in the CPT manual. Time spent performing separately reported services other than E/M or psychotherapy service is not counted toward the prolonged service time. This service is reported in addition to the E/M at any level or code 90837 psychotherapy and 60 minutes with patient and/or family member. Prolonged clinical staff services with physician or other qualified healthcare professional supervision codes 99415 and 99416 are new to CPT that involves clinical staff face to face time beyond the typical time of the E/M service.”1


“The Surgery section had numerous changes starting with the expansion of the guidelines to include instructions for the use of “imaging guidance.” However, most of the new and revised procedures to CPT 2016 are not procedures typically performed in the emergency department. One new code from the Auditory System section of Surgery, 69209, was developed and added to the External Ear subsection to report the removal of impacted cerumen by irrigation and/or lavage. This new code was developed to differentiate between the approaches to remove the impacted cerumen. Code 69210 is the direct method of cerumen removal by using curettes, hooks, forceps, and suction.”2

Do not report 69209 with 69210 when performed on same ear. For bilateral procedure, you can report 69209 with modifier 50. When the cerumen is impacted and instruments are required, as mentioned above, use code 69210.


The Radiology section changes are also numerous in numbers and include revisions to guidelines, code descriptors and parenthetical notes to replace the term “film(s)” with “image(s)” to conform to the current practice for imaging procedures. The definition of “written report” has also been revised for 2016. “A written report (i.e., handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiological procedure or interpretation. With regards to CPT descriptors for radiological services, “images” refer to those acquired in either an analog (i.e., film) or digital (i.e., electronic) manner.”3


The Medicine section shows that ALL of the vaccine codes (90476 – 90749) have been updated to include Advisory Committee on Immunization Practices (ACIP) abbreviations. Codes that represent obsolete vaccine products have been deleted and 2 new codes were added to report the administration of serogroup B Meningococcal (MenB) vaccines and a new code for the administration of a live oral cholera vaccine.

Category II Codes

The Category II codes section, which are used for performance measurement, updated code 6030F to comply with the revision of the Prevention of Catheter-Related Bloodstream Infections (CRBSI) – this codes is used for the PQRS Measure # 76 on Central Venous Catheter Insertion Protocol.

Category III Codes

The Category III codes section contains a temporary set of codes for emerging technology, services, and procedures. If a category III code is available, this code must be used and reported instead of a category I unlisted code

 (PDF, 83 KB).

1 2016 CPT® Professional Edition, AMA, Page 32.
2 Ibid at Page 418.
3 Ibid at Page 427.

Author - Male

About the author

Robert Bunting, CPC, CPC-H, CHC, CEDC, CEMC, CAC is Compliance Director – Emergency Medicine, web2pro Business Performance Services.