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  1. 1. Office of Oregon Health Policy and Research Oregon Ambulatory Surgery Centers 2004 Annual Reporting January 2005
  2. 2. The Report Purpose of the Report: The submission of this report is required under ORS 442.463. The report provides planners and policy makers state-wide information on health services, staff and facilities. Information from this report will be available to the public. As such, it is important that reporting be clear, accurate and complete. Do not omit data/information. Scope of the Report: Report the utilization information for your ambulatory surgical center. Reporting Period: Use YOUR FACILITY’S 2004 FISCAL YEAR as your reporting period. Please complete all questions. Remember to read the instructions and explanations on each page. This is an electronic Microsoft Word form. Once you have entered your data on this form, please e-mail to Katya.Medvedeva@state.or.us. If submitting in paper format, please TYPE or PRINT LEGIBLY in INK
  3. 3. DO NOT USE PENCIL PLEASE REMEMBER TO READ ALL DIRECTIONS ENCLOSED!
  4. 4. 2004 ANNUAL REPORT FOR OREGON AMBULATORY SURGERY CENTERS I. GENERAL INFORMATION A. Name of Facility       B. Address       C. City/Zip Code       D. County       E. Owner of Facility       F. Administrator’s Name       G. Administrator’s Telephone Number       H. Administrator’s e-mail       In an average week: How many I. licensed operating rooms are in use       in your facility? REPORTER’S INFORMATION A. Person Completing Report/Title       B. Telephone Number       C. Address       D. Facility web address (if applicable)      
  5. 5. DEFINITIONS Operation: A visit by a patient to the surgical suite for major or minor surgery (including endoscopic surgical procedures), regardless of the number of procedures performed. Surgical Procedure: A separate and distinct surgical act, more than one of which may be performed during an operation and performed in a “qualified” operating room (as defined by JCAHO) upon a patient who was not admitted as an inpatient or did not stay in the hospital over 24 hours.
  6. 6. II. UTILIZATION OF SURGICAL OUTPATIENT SERVICES PLEASE USE THE FACILITY 2004 FISCAL YEAR AS THE REPORTING PERIOD. Report the number of specific outpatient surgical procedures and operations in each category listed below. In cases of more than one procedure category: The operation is associated with the PRIMARY procedure category. Include all locations where that outpatient service was provided. Total the procedures and operations performed in each category. Both CPT and ICD-9-CM codes are listed for reference. If figures are not available for the specific surgical procedures, please provide figures for the surgical categories.
  7. 7. ICD-9-CM No. of No. of Surgical Category/Procedure Equivalent Procedures Operations (Series) Cardiology Surgery (CPT 33010-39999) 35-37             Digestive System Surgery (CPT 43020-44979, 42-47,50-54             45300-45387, 47000-49999) Endocrine System Surgery (CPT 60000-60699) 06-07             Gynecological Surgery (CPT 56000-59999) 65-71             Hemic And Lymphatic System Surgery (CPT 40-41             38100-38999) Integumentary Surgery (CPT 10040-19499) 85-86             Neurological Surgery (CPT 61000-64999) 01-05             Ophthalmologic Surgery (CPT 65091-68899) 08-16             Oral Surgery (CPT 40490-42299) 23-24             Orthopedic Surgery (CPT 20000-29999) 76-84             Otolaryngological Surgery (CPT 30000-31599, 18-22,25-31             69000-69990) Proctology Surgery (CPT 45000-45190, 48-49             45500-46999) Thoracic Surgery (CPT 31600-32999, 32-34             39000-39599) Urological Surgery (CPT 50010-55980) 55-64             Vascular Surgery (CPT 34001-37799) 38-39             Other Outpatient Surgery             TOTAL       Average OR Time Per Case (In Minutes)       Average Length Of Stay (In       Hours)      
  8. 8. III. STAFFING Please indicate the number of personnel on payroll at your ASC facility on the last day of your reporting period. REPORT both full-time equivalents (FTE) and total personnel. FTE is calculated by dividing the hours an employee works weekly by 40. Number of Category FTE Personnel Registered Nurse             Nurse Anesthetist             Nurse Practitioner             Physician Assistant             Licensed Practical Nurse             Certified Nurse’s Assistant             Other Health-Related Staff             Other Non Health-Related Staff             TOTAL            
  9. 9. IV: REIMBURSEMENT A. What were your initial effective dates for: 1. State Licensure       2. Medicare Certification      
  10. 10. B. Report the number of patients reimbursed by each source and the total amount billed for the services delivered in your facility during the fiscal year. Total charges should equal the gross revenue generated by ambulatory surgery. Number of Primary source of Payment Charges Operations 1. Medicare             2. Medicaid             3. Title V             4. Other Government Source             5. Workers’ Compensation             6. Blue Cross             7. Other Insurance Companies             8. Self Pay             9. Other Source of Payment             10. No Charge/Uncompensated             TOTAL            
  11. 11. Thank you for your response!! Return completed survey to: Katya Medvedeva Office for Oregon Health Policy and research 255 Capitol St NE 5th Floor Salem, OR 97301 Katya.Medvedeva@state.or.us (503) 378-2422 x 415 If you have any questions about this report, please contact: Tina Edlund Office for Oregon Health Policy and Research (503) 378-2422 x 400 Tina.D.Edlund@state.or.us

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