Office of Oregon Health
Policy and Research
2004 Annual Reporting
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
Scope of the Report: Report the utilization information for your ambulatory
Reporting Period: Use YOUR FACILITY’S 2004 FISCAL YEAR as your
Please complete all questions. Remember to read the instructions and explanations on
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
DO NOT USE PENCIL
PLEASE REMEMBER TO READ ALL DIRECTIONS ENCLOSED!
2004 ANNUAL REPORT FOR OREGON AMBULATORY SURGERY CENTERS
I. GENERAL INFORMATION
A. Name of Facility
C. City/Zip Code
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?
A. Person Completing Report/Title
B. Telephone Number
D. Facility web address (if applicable)
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.
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.
No. of No. of
Surgical Category/Procedure Equivalent
Cardiology Surgery (CPT 33010-39999) 35-37
Digestive System Surgery (CPT 43020-44979,
Endocrine System Surgery (CPT 60000-60699) 06-07
Gynecological Surgery (CPT 56000-59999) 65-71
Hemic And Lymphatic System Surgery (CPT
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,
Proctology Surgery (CPT 45000-45190,
Thoracic Surgery (CPT 31600-32999,
Urological Surgery (CPT 50010-55980) 55-64
Vascular Surgery (CPT 34001-37799) 38-39
Other Outpatient Surgery
Average OR Time Per Case (In
Average Length Of Stay (In
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.
Licensed Practical Nurse
Certified Nurse’s Assistant
Other Health-Related Staff
Other Non Health-Related Staff
A. What were your initial effective dates for:
1. State Licensure
2. Medicare Certification
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.
Primary source of Payment Charges
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
Thank you for your response!!
Return completed survey to:
Office for Oregon Health Policy and research
255 Capitol St NE 5th Floor
Salem, OR 97301
(503) 378-2422 x 415
If you have any questions about this report, please contact:
Office for Oregon Health Policy and Research
(503) 378-2422 x 400