Submit A Code Request

Request Number

Request Status

Date of Submission of Request

Schedule

procedural

diagnostic

Member submitting request

Type of Request

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)

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