2016 Open Heart Surgery Survey. Part A : General Information. Part B : Survey Contact Information. 1. Identification UID: 2.
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1 Part A : General Information 2016 Open Heart Surgery Survey 1. Identification UID: Facility Name: County: Street Address: City: Zip: Mailing Address: Mailing City: Mailing Zip: Medicare Provider Number: Medicaid Provider Number: 2. Report Period Report Data for the full twelve month period, January 1, December 31, 2016 (365 days). Do not use a different report period. Check the box to the right if your facility was not operational for the entire year. If your facility was not operational for the entire year, provide the dates the facility was operational. Part B : Survey Contact Information Person authorized to respond to inquiries about the responses to this survey. Contact Name: Contact Title: Phone: Fax: Page 1 of 6
2 Part C : Utilization Data 1. Open Heart Surgery Operations Report the total number of open heart surgery operations performed during the report period by age and type of operation. Do not include any closed heart surgeries or cardiac catheterization procedures. Coronary bypass Coronary bypass plus valves Aortic valve replacement Mitral valve replacement Heart transplant Atrial septal defect Ventricular septal defect Tetralogy of fallot Type of Operation Ages 0-14 Ages Close Heart Surgery Operations Report the total number of closed heart surgery operations performed during the report year by age and type of operation. Do not include any open heart surgeries or procedures performed by cardiac catheterization. Type of Operation Ages 0-14 Ages 15+ Coronary bypass Coarctation of the aorta Closure of patent ductus arteriosus, age>28 days, by CHS Closure of patent ductus arteriosus, age<28 days, by CHS Palliative shunts for cyanotic heart disease 3. Coronary Angioplasties Resulting in Emergency Open Heart Surgery Operations During the report period, how many coronary angioplasties performed at your hospital resulted in immediate emergency open heart surgery operations? (Estimate, if necessary.) Check box if Estimated. Page 2 of 6
3 4. Open Heart Surgery Patients by Race/Ethnicity Please report the number of unduplicated open heart surgery patients your facility served during the report period using the following race and ethnicity categories. Race/Ethnicity American Indian/Alaska Native Asian Black/African American Hispanic/Latino Pacific Islander/Hawaiian White Multi-Racial Number of Patients 5. Open Heart Surgery Patients by Gender Please report the number of open heart surgery patients by gender served during the report period. Male Female Gender Number of Patients Part D : Financials and Average Charges 1. For the report period, report the average total hospital charge, length of stay and number of cases from admissions to discharge, excluding Medicare outliers, for each of the following DRGs. Use the blank lines to specify other DRGs, not included in the table. Average Average Length Number of Cases Actual Selected DRGs Hospital of Stay Included in Calculation Hospital Charge (in Days) of Averages Cases Heart Transplant (MS-DRG 001 & 002) Cardiac valve with cardiac catheterization (MS-DRG 216, 217, & 218) Cardiac valve without cardiac catheterization (MS-DRG 219, 220, & 221) Coronary bypass with PTCA (MS-DRG 231 & 232) Major cardiovascular procedures with CC (MS-DRG ) Major cardiovascular procedures without CC (MS-DRG ) Other cardiothoracic procedures (MS-DRG 228, 229 & 230) Page 3 of 6
4 2. Heart Surgery Patients and Operations by Primary Payment Source Please report the total number of unduplicated open heart surgery patients and operations by primary payment source. Report Peachcare for Kids patients under Third-Party. Number of Open Heart Surgery Patients Number of Operations Primary Payment Source Medicare Medicaid Third Party Self-Pay (Including Peachcare) 3. Charges and Actual Reimbursement for Open Heart Surgeries Please report the total charges for open heart surgeries provided during the report period. Also, report the actual reimbursement received for charges for open heart surgeries provided during the report period. Charges Actual Reimbursement 4. Uncompensated Charges and Uncompensated Patients Please report the uncompensated charges for open heart surgeries for patients that are indigent or covered by charity care services. Also, report the number of patients. Uncompensated Charges Uncompensated Patients 5. Adjusted Gross Revenue Please report the adjusted gross revenue for open heart surgery services during the report period. Adjusted Gross Revenue Part E : Peer Review 1. Check the box to the right if your program/facility participates in an external or national peer review and outcomes reporting system. If you indicated yes above, please provide the name(s) of the peer review/outcomes reporting organization(s) below: 2. How many community education programs did your program/facility participate in during the reporting period? Page 4 of 6
5 Part F : Patient Origin Please report the number of open heart surgery patients by county and age category. The grand totals must agree with the calculated totals of open heart operations by race and gender found in Part C, Questions 4 and 5. County Ages 0-14 Ages 15+ Page 5 of 6
6 Electronic Signature Please note that the survey WILL NOT BE ACCEPTED without the authorized signature of the Chief Executive Officer or Executive Director (principal officer) of the facility. By law, the signatory is attesting under penalty of law that the information is accurate and complete. I state, certify and attest that to the best of my knowledge upon conducting due diligence to assure the accuracy and completeness of all data, and based upon my affirmative review of the entire completed survey, this completed survey contains no untrue statement, or incaccurate data, nor omits requested material information or data. I further state, certify and attest that I have reviewed the entire contents of the completed survey with all appropriate staff of the facility. I further understand that inaccurate, incomplete or omitted data could lead to sanctions against me or my facility. I further understand that a typed version of my name is being accepted as my original signature pursuant to the Georgia Electronic Records and Signature Act. Authorized Signature: Date: Title: Comments: Page 6 of 6
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