Confirmation of Services (COS)
If study team will be obtaining the COS, study team requests COS using the following form(s):
- COS Radiology Request Form – Version 01/02/2020
Study Short Name (nickname)
- In the free-text field, enter the study short name (nickname) that will be used by the investigator and study coordinators when they reference the study. This short name will be used as an identifier for this study on all forms and will be used as the searchable “study name” when the study is in Epic ( limited to 20 characters).
Study Long Title
- In the free-text field, enter the study title (limited to 256 characters). Note: This should match the study title as it will be submitted to your IRB and as it will be indicated on the OCR Study Registration & Initiation Checklist.
- In the free-text field, enter the full name of the Principal Investigator. Note: This should be the same as the Principal Investigator as it will be submitted to your IRB and as it will be indicated on the OCR Study Registration & Initiation Checklist.
Other Study Investigators/Providers
- In the free-text field enter the name of any other investigators or physicians that may be providing services for this study.
Study Contact Person Submitting Form
- In the free-text field, enter the name and contact information for the study team member who is submitting this COS form.
Box for Radiology Technical Codes and Pricing
- This box can either be filled out by the study team OR the Shands Radiology contact.
- Enter the name and date information pertaining to the request for confirmation of Shands technical CPT and EAP codes and Shands technical list prices.
Box for Radiology Professional Codes and Pricing
- This box can either be filled out by the study team OR UFHP professional COS contact.
- Enter the name and date information pertaining to your request for confirmation of UFHP professional CPT codes and professional list and research prices.
Special Considerations Box
- Mark any of the special considerations boxes that apply to this study:
- Amendment to COS pricing issued prior to 09/27/10
- Federally Funded Study
- Pediatric patients
- Adult patients
- For budgetary purposes on multi-year studies, plan for a 5% price increase each year. Research rates are estimates. Actual charges will be the rate current on day of service.
- Enter the name for the service you need confirmed and priced.
- Note: If you are not sure of the service name, you will want to contact Shands Radiology staff early on to get help to determine the correct service required by the study protocol. See COS Contacts (gatorlink login required).
- If more rows are required, please add more rows via Word 2016 menu Review > Restrict Editing > “Stop Protection” button > copy more rows (do not add data yet), then >”Yes, Start Enforcing” > “OK” (no password) > add row data
Anticipated Number of Participants
- Enter the number of anticipated participants that will receive this service while enrolled in the study.
Number of Times per Participant
- Enter the number of times this service will be provided to each participant while enrolled in the study.
- Enter the CPT code for the service you need confirmed and priced.
- Note: If you are not 110% sure of the CPT code, leave this blank and work with the Shands Radiology COS contacts to ensure that you get the right code for the service that the protocol is requiring.
Technical List Price and Research Rate Estimate
- If the service generates a technical fee, the Shands Radiology COS contact will fill in the technical list price for the service.
Professional List Price and Research Rate Estimate
- If the service generates a professional fee billed through UF Health Physicians (UFHP), the UFHP Radiology COS contact will fill in the professional prices (list and research) for the service.
- The study team should use this field to explain any special requests or circumstances.
Additional Special Instructions From Coding/Pricing Contacts
- The RADIOLOGY staff should use this field to explain any extra information needed when ordering the radiology services.
EAP Codes and CPT Codes – What is the difference?
- Orderable EAP: Epic site-specific code used to request a service or procedure. Orderables can be generic or specific.
- Performable EAP: Epic site-specific code for the actual procedure that a clinician performs. Performables are more specific versions of the associated orderables.
- Chargeable EAP: Epic site-specific code that is used to determine final charge for the service.
- CPT: Current Procedural Terminology code used outside of Epic to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT codes are used in conjunction with ICD-9-CM or ICD-10-CM numerical diagnostic coding during the electronic medical billing process.
- Note: If you are not 110% sure of the three EAP codes, leave these blank and work with the Shands Radiology COS contacts to ensure that you get the right codes for the service that the protocol is requiring.