Department__________________

Dept/Resp Center__________/__________

Earnings Class__________

Change Request
q Add Charge, (complete box 1, 2, & 3)		q Update Charge (complete box 1 & 2)					q Delete Charge, (complete box 1)
FDA Approved? Yes___ No___		Procedure Code___________					Procedure Code__________
1. Procedure Title and Description/Explanation of Change
1a. Name of Procedure to appear on Patient Account





1b. Description of Procedure/Explanation of Procedure Change





1c. Can this new charge be grouped as part of an existing TSI product number? (Example: Is it the same
kind of procedure, same RVU's) yes q no q . If yes, which TSI product number should it be grouped with?





2. Price/Volume

Price Type	q Standard		q As Priced			q Zero Charge

HCPCS Code_________________________________					CPT 4 Code__________________________________

Hospital Based Physician Charge Indicator				q Yes		q No

Effective Date of Service_____________________________________________________________________

Anticipated Volume Per Year_________________________________________________________________

Recommended Charge, if known______________________________________________________________

Request for Change to Charge Master

3. Resource Consumption

3a. Capital Equipment Used

SUI #

Cost

Is equipment used for this procedure only?

If no, estimate percentage (%) of time this equipment is used for this procedure

q Yes q No

3b. RVUs (for labor this is number of minutes; for Non-Labor this is the purchase price of the supplies/general expense)

Labor RVUs

Non-Labor RVUs **

Cost Category/Cost Type

VDL

VDS

VDO

PROF

OTHER

DRUGS

MED-SUP

PROSTH

CATH

IMPLANT

OTHER

� ** Identify the supply items used, their cost, and the institutional/org account each item will be expensed to:

Requestor _________________________________	Phone _____________________	Date ____________
For questions, contact: