			REFERENCE CODE			
*Please note: If a supply has a purchase price of $100 or more please bold the item name and CMS code.
**Please note: If you are including clinical labor tasks that are not listed on this spreadsheet please list them as subcategories of established clinical labor tasks whenever possible. Please see the PE Spreadsheet Instructions document for an example.   
			CPT Code #		CPT Code #	
Meeting Date: January 2014
Tab: 7
Specialty:  AAO-HNS, STS	CMS Code	Staff Type	43130  Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach		43180     Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker?s diverticulum)	
LOCATION			Non Fac	Facility	Non Fac	Facility
GLOBAL PERIOD			90	90	90	90
TOTAL CLINICAL LABOR TIME	L037D	RN/LPN/MTA	0	180	0	108
TOTAL  PRE-SERV CLINICAL LABOR TIME	L037D	RN/LPN/MTA	0	60	0	60
TOTAL SERVICE PERIOD CLINICAL LABOR TIME	L037D	RN/LPN/MTA	0	12	0	12
TOTAL POST-SERV CLINICAL LABOR TIME	L037D	RN/LPN/MTA	0	108	0	36
PRE-SERVICE						
Start:  Following visit when decision for surgery or procedure made						
Complete pre-service diagnostic & referral forms	L037D	RN/LPN/MTA	0	5	0	5
Coordinate pre-surgery services	L037D	RN/LPN/MTA	0	20	0	20
Schedule space and equipment in facility	L037D	RN/LPN/MTA	0	8	0	8
Provide pre-service education/obtain consent 	L037D	RN/LPN/MTA	0	20	0	20
Follow-up phone calls & prescriptions	L037D	RN/LPN/MTA	0	7	0	7
*Other Clinical Activity - specify:	L037D	RN/LPN/MTA	0	0	0	0
End: When patient enters office/facility for surgery/procedure						
SERVICE PERIOD						
Start: When patient enters office/facility for surgery/procedure: 						
Greet patient, provide gowning, ensure appropriate medical records are available					0	0
Obtain vital signs					0	0
Provide pre-service education/obtain consent					0	0
Prepare room, equipment, supplies					0	0
Setup scope (non facility setting only)					0	0
Prepare and position patient/ monitor patient/ set up IV					0	0
Sedate/apply anesthesia					0	0
*Other Clinical Activity - specify:					0	0
Intra-service						
Assist physician in performing procedure			0	0	0	0
Post-Service						
Monitor pt. following service/check tubes, monitors, drains					0	0
Clean room/equipment by physician staff					0	0
Clean Scope					0	0
Clean Surgical Instrument Package					0	0
Complete diagnostic forms, lab & X-ray requisitions					0	0
Review/read X-ray, lab, and pathology reports					0	0
Check dressings & wound/ home care instructions /coordinate office visits /prescriptions					0	0
*Other Clinical Activity - specify:					0	0
Dischrg mgmt same day (0.5 x 99238) (enter 6 min)			n/a		n/a	
Dischrg mgmt (1.0 x 99238) (enter 12 min)	L037D	RN/LPN/MTA	n/a	12	n/a	12
Dischrg mgmt (1.0 x 99239) (enter 15 min)			n/a		n/a	
End: Patient leaves office						
POST-SERVICE Period						
Start: Patient leaves office/facility						
Conduct phone calls/call in prescriptions	L037D	RN/LPN/MTA	0	0	0	0
Office visits: List Number and Level of Office Visits			# visits	# visits	# visits	# visits
99211    16 minutes		16				
99212    27  minutes		27		4		
99213    36  minutes		36				1
99214    53  minutes		53				
99215    63  minutes		63				
Total Office Visit Time	L037D	RN/LPN/MTA	0	108	0	36
*Other Clinical Activity - specify:						
End: with last office visit before end of global period						
MEDICAL SUPPLIES**	CODE	UNIT				
pack, minimum multi-specialty visit	SA048	pack	0	4	0	1
pack, post-op incision care (suture & staple)	SA053	pack	0	1	0	0
						
						
						
						
EQUIPMENT	CODE					
light, exam	EQ168		0	1	0	36
table, exam	EF023		0	1	0	36
