SURGERY CENTER NAME

SUBJECT: SCHEDULING GUIDELINES (PAGE 1 OF 5)

POLICY #: DATE REVIEWED / REVISED:

PURPOSE
To establish guidelines for routine procedural scheduling.

POLICY
1. The Governing Body approves procedures appropriate for the facility. Procedures not on the approved list
may not be scheduled without approval and special determination by the Governing Body.

2. Only Medical Staff members with current clinical privileges may schedule procedures.

3. Medical Staff members may only schedule procedures for which they have been credentialed. If the
physician seeks to schedule a case but does not have privileges for this procedure, consult with the
administrator to see if they may have their privileges extended.

4. Care of specific patients or one-time admissions (temporary privileges) may be granted to an appropriately
licensed physician who is not an applicant for medical staff membership. These privileges shall be granted on
a case-by-case basis and shall require documentation. Single-admission privileges require the concurrence
of the Medical Director and the administrator and shall be granted in writing. If more than five patients shall
be cared for within a one-year period then the applicant shall need to apply for medical staff privileges. A
practitioner applying for temporary privileges must provide a copy of their medical license, DEA certificate,
proof of current malpractice insurance, and must complete a Delineation of Privileges before consideration for
approval of procedure to be performed.

5. The scheduler plays a pivotal role in attracting and retaining physician users and ensuring patient satisfaction.
The scheduler must be available for incoming calls, return calls, and completing arrangements promptly, and
handle all calls in a friendly, courteous, and helpful manner.

6. Patients are scheduled on an elective basis.

7. The facility utilizes physician block scheduling to maximize efficiency. The initial block schedule and any
subsequent changes to the block schedule must be approved by the Governing Body.

8. Patients may be scheduled outside of the physician’s designated block schedule with the permission of the
administrator.

9. Never tell the physician or physician’s scheduler that the facility is unable to schedule a case. Obtain
necessary information, advise the administrator, and work to rearrange schedule to accommodate the
case. If case is unable to be scheduled in requested time slot, the administrator will speak to the
physician and offer alternatives.

10. Procedure block times are between 0730 a.m. and 1500 p.m.

11. The scheduling phone lines are open between 0800 a.m. and 1700 p.m.

12. Only medical staff members or their designee may schedule patients at the facility.

13. All scheduled procedures are scheduled on the scheduling form (paper or computer). All demographic,
clinical, insurance information, special equipment requests, etc., must be recorded on the form at the time of
scheduling.

14. Arrangements may be made with the physician’s office to fax information. This is an efficient method. The
office may fax a legible copy of their demographic sheet or the facility can provide a form for them to
complete.

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 SURGERY CENTER NAME

SUBJECT: SCHEDULING GUIDELINES (PAGE 2 OF 5 )

POLICY #: DATE REVIEWED / REVISED:

15. All scheduling information received is to be entered into the scheduling module of computer software.

16. All demographic information received is to be entered into the patient demographic module of the computer
by the scheduler. If physician’s office is unable to provide complete information (see list of required
information in procedure below), the scheduler must contact the patient or patient’s representative (if minor) to
get required information to be entered into demographic area.

17. After completion of scheduling form and demographic entries, the scheduler provides a copy of the
scheduling form and insurance cards (paper or electronic) to the insurance verifier.

18. The Medical Staff member or designee designates the time to be allocated for the scheduled procedure. The
scheduler allots additional time for procedure room turnover per direction of the clinical director.

19. Patients who have special health problems such as diabetes, ASHD, COPD should be scheduled in the
morning. Insulin-dependent diabetic patients will be scheduled as the first case of the schedule.

20. Special equipment, personnel, or services must be coordinated at the time of scheduling the procedure and
the clinical director notified.

21. The Medical Staff member or designee specifies the type of anesthesia (e.g., local, general) at the time the
procedure is scheduled. This information is documented on the scheduling form (paper or electronic) and
reflected on the procedure schedule.

22. If desired, additional anesthesia services, i.e. pre-procedure and/or post-procedure blocks, PCA pumps, etc.
need to be requested at time of procedure scheduling.

23. The scheduler is responsible for requesting the applicable CPT and ICD-10 diagnosis codes for the
scheduled procedure from the physician’s office and entering it on the scheduling form. The scheduling form
is given to the insurance verifier. When insurance verification is completed and the patient notified of financial
responsibilities, this form will become part of the patient’s medical record.

24. Final review of the completed schedule is done on a daily basis by the clinical director and Anesthesiologist/
Anesthetist.

25. Any revisions to the schedule must be requested by the clinical director.

26. The procedure schedule is maintained in a confidential manner and is not posted in view of the public.

RESPONSIBILITIES
1. The facility scheduler is responsible for:
a) incoming calls on scheduling lines
b) scheduling procedures with physician’s office
c) accuracy of scheduled case, length of time, type of anesthesia, special equipment needed
d) entering in computer schedule
e) notifying clinical director of any special equipment requests
f) getting demographics and insurance information from offices and/or patients if necessary
g) entering demographics/insurance information required in scheduling module of computer
h) providing completed scheduling form to insurance verification clerk
i) Updating all changes in schedule in computer
j) Printing and distributing schedule daily or as updated

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 SURGERY CENTER NAME

SUBJECT: SCHEDULING GUIDELINES (PAGE 3 OF 5)

POLICY #: DATE REVIEWED / REVISED:

PROCEDURE
1. The scheduler maintains the following at the scheduling desk or in computer software:
a) A current list of procedures approved by the Governing Body
b) Active Medical Staff list
c) Delineation of privileges for current Medical Staff members

2. Medical Staff members or designee will schedule procedures with the scheduler.

3. Requests to schedule procedures not on the approved procedure list or not listed in the requesting Medical
Staff member’s delineation of privileges cannot be processed without approval by the Governing Body.

4. The scheduler informs the administrator of the request. The administrator reviews the approved procedure
list and/or medical staff member’s delineation of privileges and recent Governing Body meeting minutes for
any changes to the approved list. When it has been determined that the procedure is not approved, the
procedure is not scheduled until such time as approved by the Governing Body. The administrator will notify
the Medical Director who will, in turn, notify the requesting Medical Staff member of this decision.

5. If special privileges are granted to perform the requested procedure, the Medical Director will notify the
Medical Staff member of this decision. The administrator will document granting of special privileges in the
Medical Staff member’s confidential credentialing file.

6. Information required on the scheduling form (paper or electronic) includes:

a) Name of person scheduling the procedure
b) Date of procedure
c) Procedure time desired
d) Estimated time required for procedure
e) Type of anesthesia
f) Special anesthesia services requested
g) Physician
h) Patient’s name - last, first, middle
i) Gender
j) Social security number
k) Has patient previously been treated in this facility?
l) Home telephone number
m) Work telephone number
n) Other telephone number
o) Employer name
p) Parent or guardian, in case of minor or dependent
q) Date of birth
r) Planned procedure (both description and CPT code)
s) Procedure site
t) Special equipment requested
u) Special services requested, e.g., frozen section, etc.
v) Pre-procedure diagnosis and ICD-10 diagnosis code
w) Primary insurance information
x) Secondary insurance information
y) Copy of insurance card(s)
z) Accident information (if applicable)

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 SURGERY CENTER NAME

SUBJECT: SCHEDULING GUIDELINES (PAGE 4 OF 5)

POLICY #: DATE REVIEWED / REVISED:

7. Record all information on scheduling form (paper or electronic).

8. If physician’s office is unable to provide all of the above information, contact the patient directly to request
needed information.

9. Enter all information received from physician’s office and patient into the scheduling and demographic
modules of computer program.

10. Copy scheduling form (if using paper) and give to insurance verification specialist immediately after
scheduling process is completed. If using electronic scheduling form, notify insurance verifier when complete.

11. The procedure schedule is printed and distributed at ___________ (i.e., 2 p.m., 3 p.m.) to the following areas
daily for facility staff members who work directly with the schedule:
a) Administrator
b) Clinical Director
c) Anesthesia Service
d) Admitting Receptionist
e) Nursing Desk
f) Pre-admission/Post-procedure Area
g) Each Procedure Room
h) Medical Records
i) Business Office

12. Any cases added on to the schedule on the day of procedure will be handwritten on the schedule.
a) The scheduler is responsible for notifying all areas where printed schedule has been distributed of these
changes.
b) The scheduler will immediately notify the Clinical Director and Anesthesiologist/Anesthetist about
schedule changes.

8. If any cases are added on for the next day but after the printed schedule has been distributed, a revised
schedule will be printed and distributed to the areas listed above.

Sample Forms: Scheduling form

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 SURGERY CENTER NAME

DATE SCHEDULED: _______________________

DATE OF SURGERY: PHYSICIAN: PRE-ADMIT VISIT DATE & TIME:

TIME: ANESTHESIA GEN MAC LOC SPECIAL EQUIPMENT:

PRE-ADM VISIT: PROCEDURE (Including CPT Code):

Date: Time:

SCHEDULER: DIAGNOSIS: PROCEDURE SITE:

LEFT RIGHT BILATERAL

CHART #: PATIENT NAME (Last, First, Middle):

PATIENT ADDRESS:
MALE FEMALE MARITAL STATUS: M S W D DATE OF BIRTH: AGE:
SS #: HERE BEFORE? DATE: HOME PHONE ( )
EMPLOYER: WORK PHONE ( )
EMERGENCY CONTACT (Name): OTHER PHONE ( )
RESPONSIBLE PARTY: ACCIDENT: YES NO W/C
ADJUSTER:
ADDRESS: DATE: TIME:
RELATIONSHIP: TELEPHONE: DESCRIPTION OF ACCIDENT:

INSURANCE COMPANY #1: INSURANCE COMPANY #2:

NAME OF INSURED: NAME OF INSURED:
ADDRESS: ADDRESS:

TELEPHONE #: TELEPHONE #:
GROUP #: ID #: GROUP #: ID #:

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