Submit A Code Request

✓ Code Request Saved

Request Number

Request Status

Date of Submission of Request

Schedule

procedural

diagnostic

Member submitting request

Type of Request

New Code

Suggested narrative for new procedure

Suggested code for new procedure

Schedule Chapter

Reason for the new code

Other (please specify)

Detailed description of the procedure (including approach options, LoS, anticipated theatre time) - Please include any relevant links and references below

Does the procedure have NICE approval?

If not NICE applicable/Approved with conditions please explain why

List specialist equipment used specifically for this procedure

List total consumables used in list price to nearest £50

Is this an alternative approach to an existing procedure (if yes please provide code and narrative of existing procedure)?

Yes

Code and narrative of existing procedure

Is there a similar code currently in use in the schedule? (if yes, please provide code and narrative of existing procedure)

Yes

Code and narrative of existing procedure

What are the current and anticipated volumes?

Is the intervention described performed in the NHS?

Yes

PDF Attachment

Narrative Change

Existing code/narrative

Proposed new narrative

Reason for narrative change

Other (please specify)

Other codes impacted by change

Reinstatement

Inactivated code/narrative

Do you want to change this narrative?

Yes

Proposed new narrative reinstatement

Reason for reinstatement

Other (please specify)

When/why was this code inactivated?

Inactivate

Existing code/narrative

Reason for inactivation

Other (please specify)

Any other codes impacted?

Signposting for future