	Sample Practice Expense Spreadsheet				REFERENCE CODE			
					43130		43180	
					"Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach"		"Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed"	
Clinical Activity Code		Standards/Guidelines	Clinical Staff Type Code 	"Clinical 
Staff Type"				
	LOCATION				Non Fac	Facility	Non Fac	Facility
	GLOBAL PERIOD				090	090	090	090
	TOTAL CLINICAL STAFF TIME		L037D	RN/LPN/MTA	0	180	0	108
	TOTAL  PRE-SERVICE CLINICAL STAFF TIME		L037D	RN/LPN/MTA	0	60	0	60
	TOTAL SERVICE PERIOD CLINICAL STAFF TIME		L037D	RN/LPN/MTA	0	12	0	12
	TOTAL POST-SERVICE CLINICAL STAFF TIME		L037D	RN/LPN/MTA	0	108	0	36
	PRE-SERVICE PERIOD							
	Start:  Following visit when decision for surgery or procedure made							
CA001	Complete pre-service diagnostic and referral forms	"90 DAY:  NF5, F5, 000/10 DAY:  NF0, F0* 
*See Instructions for extensive/minimal use guidelines"	L037D	RN/LPN/MTA		5		5
CA002	Coordinate pre-surgery services (including test results)	"90 DAY:  NF10, F20, 000/10 DAY:  NF0, F0* 
*See Instructions for extensive/minimal use guidelines"	L037D	RN/LPN/MTA		20		20
CA003	Schedule space and equipment in facility	"90 DAY:  NF0, F8, 000/10 DAY:  NF0, F0* 
*See Instructions for extensive/minimal use guidelines"	L037D	RN/LPN/MTA		8		8
CA004	Provide pre-service education/obtain consent	"90 DAY:  NF10, F20, 000/10 DAY:  NF0, F0* 
*See Instructions for extensive/minimal use guidelines"	L037D	RN/LPN/MTA		20		20
CA005	Complete pre-procedure phone calls and prescription 	"90 DAY:  NF10, F7, 000/10 DAY:  NF0, F0* 
*See Instructions for extensive/minimal use guidelines"	L037D	RN/LPN/MTA		7		7
CA006	Confirm availability of prior images/studies	"Standard time for this activity is 2 minutes. 
For use in imaging services."	L037D	RN/LPN/MTA				
CA007	Review patient clinical extant information and questionnaire	"Standard time for this activity is 1 minute. 
For use in imaging services."	L037D	RN/LPN/MTA				
CA008	Perform regulatory mandated quality assurance activity (pre-service) 	"This is NOT standard. 
Rationale must be included on PE SOR."	L037D	RN/LPN/MTA				
			L037D	RN/LPN/MTA				
	Other activity: please include short clinical description here and type new in column A		L037D	RN/LPN/MTA				
	End: When patient enters office/facility for surgery/procedure							
	SERVICE PERIOD							
	Start: When patient enters office/facility for surgery/procedure: 							
	Pre-Service (of service period)							
CA009	"Greet patient, provide gowning, ensure appropriate medical records are available"	Standard time for this activity is 3 minutes.	L037D	RN/LPN/MTA				
CA010	Obtain vital signs	"Vital Sign Standards
Level 0 (no vital signs taken) = 0 minutes
Level 1 (1-3 vitals) = 3 minutes
Level 2 (4-6 vitals) = 5 minutes"	L037D	RN/LPN/MTA				
CA011	Provide education/obtain consent	Include only the additional education/consent activities not included in the pre-service period.	L037D	RN/LPN/MTA				
CA012	"Review requisition, assess for special needs "	"This is NOT standard. 
Rationale must be included on PE SOR."	L037D	RN/LPN/MTA				
CA013	"Prepare room, equipment and supplies "	2 minute standard	L037D	RN/LPN/MTA				
CA014	"Confirm order, protocol exam"	"Standard time for this activity is 1 minute. 
For use in imaging services."	L037D	RN/LPN/MTA				
CA015	Setup scope (nonfacility setting only)	5 minutes standard for scope set up in the non facility setting only. 	L037D	RN/LPN/MTA				
CA016	"Prepare, set-up and start IV, initial positioning and monitoring of patient"	2 minute standard	L037D	RN/LPN/MTA				
CA017	Sedate/apply anesthesia	2 minute standard RN/LPN/MA	L037D	RN/LPN/MTA				
			L037D	RN/LPN/MTA				
	Other activity: please include short clinical description here and type new in column A		L037D	RN/LPN/MTA				
	Intra-service (of service period)							
CA018	Assist physician or other qualified healthcare professional---directly related to physician work time (100% of physician intra-service time)	This is NOT standard	L037D	RN/LPN/MTA				
CA019	Assist physician or other qualified healthcare professional---directly related to physician work time (67% of physician intra-service time)	This is NOT standard	L037D	RN/LPN/MTA				
CA020	Assist physician or other qualified healthcare professional---directly related to physician work time (other% of physician intra-service time)	"This is NOT standard
Percentage must be included on PE SOR"	L037D	RN/LPN/MTA				
CA021	Perform procedure/service---NOT directly related to physician work time	This is NOT standard	L037D	RN/LPN/MTA				
			L037D	RN/LPN/MTA				
	Other activity: please include short clinical description here and type new in column A		L037D	RN/LPN/MTA				
	Post-Service (of service period)							
CA022	"Monitor patient following procedure/service, multitasking 1:4"	"For monitoring following procedure, the standard is 15 minutes of RN/LPN/MTA time per 1 hour of monitoring."	L037D	RN/LPN/MTA				
CA023	"Monitor patient following procedure/service, no multitasking"	This is NOT standard. Rationale must be included on PE SOR.	L037D	RN/LPN/MTA				
CA024	Clean room/equipment by clinical staff	3 minute standard	L037D	RN/LPN/MTA				
CA025	Clean scope	"Standards For Scope Cleaning
--5 minutes for a disposable scope, 
--10 minutes for a rigid scope, and 
--30 minutes for a flexible scope "	L037D	RN/LPN/MTA				
CA026	Clean surgical instrument package	"Standard for cleaning instruments 
*Must have instrument package included in equipment (based on guidelines)
Basic Surgical Instrument Package--10 minutes
Medium Surgical Instrument Package--15 minutes"	L037D	RN/LPN/MTA				
CA027	"Complete post-procedure diagnostic forms, lab and x-ray requisitions"	This is NOT standard. Rationale must be included on PE SOR.	L037D	RN/LPN/MTA				
CA028	"Review/read post-procedure x-ray, lab and pathology reports"	This is NOT standard. Rationale must be included on PE SOR.	L037D	RN/LPN/MTA				
CA029	"Check dressings, catheters, wounds"	Standard time for this activity is 1 minute.	L037D	RN/LPN/MTA				
CA030	"Technologist QC's images in PACS, checking for all images, reformats, and dose page"	This is NOT standard. Baseline time for this activity is 2 minute. For use in imaging services.	L037D	RN/LPN/MTA				
CA031	Review examination with interpreting MD/DO	Standard time for this activity is 2 minute. For use in imaging services.	L037D	RN/LPN/MTA				
CA032	Scan exam documents into PACS. Complete exam in RIS system to populate images into work queue.	Standard time for this activity is 1 minute. For use in imaging services.	L037D	RN/LPN/MTA				
CA033	Perform regulatory mandated quality assurance activity (service period) 	This is NOT standard.  Rationale must be included on PE SOR.	L037D	RN/LPN/MTA				
CA034	"Document procedure (nonPACS) (e.g. mandated reporting, registry logs, EEG file, etc.)"	This is NOT standard.  Rationale must be included on PE SOR.	L037D	RN/LPN/MTA				
CA035	"Review home care instructions, coordinate visits/prescriptions    "	"Standard time for this activity is 2 minutes. 
For non-facility (office) setting use this activity instead of discharge day management activities."	L037D	RN/LPN/MTA				
CA036	Discharge day management	"Dischrg mgmt same day (0.5 x 99238) (enter 6 min)
Dischrg mgmt (1.0 x 99238) (enter 12 min)
Dischrg mgmt (1.0 x 99239) (enter 15 min)"	L037D	RN/LPN/MTA	n/a	12	n/a	12
			L037D	RN/LPN/MTA				
	Other activity: please include short clinical description here and type new in column A		L037D	RN/LPN/MTA				
	End: Patient leaves office							
	POST-SERVICE PERIOD							
	Start: Patient leaves office/facility							
CA037	Conduct patient communications	"Phone calls/emails/texts are in 3 minute increments
Phone calls/emails/texts need to be fully justified, as the post op e/m codes already contain time for phone calls/emails/texts and adding any additional phone calls/emails/texts would be duplicative."	L037D	RN/LPN/MTA				
CA038	Coordinate post-procedure services	This is NOT standard. Rationale must be included on PE SOR.	L037D	RN/LPN/MTA				
	Office visits: List Number and Level of Office Visits		MINUTES		# 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					
CA039	Post-operative visits (total time)		L037D	RN/LPN/MTA	0.0	108.0	0.0	36.0
			L037D	RN/LPN/MTA				
	Other activity: please include short clinical description here and type new in column A		L037D	RN/LPN/MTA				
	End: with last office visit before end of global period							
Medical Supply Code	MEDICAL SUPPLIES		PRICE	UNIT				
SA048	"pack, minimum multi-specialty visit"		1.143	pack		4		1
SA053	"pack, post-op incision care (suture & staple)"		6.11	pack		1		
								
								
	Other supply item: please include the name of the item consistent with the paid invoice here and type new in column A							
Equipment Code	EQUIPMENT	"Please select the equipment formula you intend to use for each equipment item from the dropdown list in column E under equipment. If you select ""Other formula"" please explain in PE SoR. You must also include an excel formula adding the equipment minutes used in columns J and K (this will not be automatic). Please see key in equipment tab for clinical activities included in each equipment formula."	PRICE	EQUIPMENT FORMULA				
EF023	"table, exam"		1338.17	Non-highly Technical Equipment Formula		108.0		36.0
EQ168	"light, exam"		1630.12	Non-highly Technical Equipment Formula		108.0		36.0
								
								
								
								
	Other equipment item: please include the name of the item consistent with the paid invoice here and type new in column A							
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
								
