Annual Utilization Report of Primary Care Clinic
Facility Name:ST. JOSEPH DENTAL CLINIC
OSHPD ID:306494085Report Status:Submitted
License Category:Community ClinicReport Year:2005
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Clinic Services
Section 3 - Patient Demographics
Section 4 - Encounters by Principal Diagnosis
Section 5 - Encounters by Principal Service
Section 6 - Revenue and Utilization by Payer
Section 7 - Income Statement
Section 8 - Capital Projects and Funds
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:ST. JOSEPH DENTAL CLINIC
2.OSHPD ID Number:306494085
3.Street Address:751 LOMBARDI COURT, SUITE A
4.City:SANTA ROSA
5.Zip:95407
6.Facility Phone No.:(707) 547 - 2221 ext.
7.Administrator Name:Kathy Ficco
8.Administrator E-mail Address:pckf@stjoe.org
9.Was this clinic in operation at any time during the year?:Yes
10.Operation Open From:1/1/2005
11.Operation Open To:12/31/2005
12.Name of Parent Corporation:Santa Rosa Memorial Hospital
13.Corporate Business Address:1165 Montgomery Drive
14.City:Santa Rosa
15.State:CA
16.Zip:95405 -
17.Person Completing Report:Kathy Ficco
18.Phone No.:707-546-5899
19.Fax No.:707-524-2473
20.E-mail Address:pckf@stjoe.org
30.Submitted by:36f1b99b
31.Submitted Date and Time:2/8/2006 7:29:49 AM
Section 2 - Clinic Services
1.License Category:Community Clinic
Federally Qualified Health Clinic (FQHC)
Line
No.		Federally Qualified Health Clinics and Rural Clinics(1)
2.Indicate clinic type, if applicable:Neither
Rural Health Clinic
Line
No.		Rural Health Clinic(1)
3.Is this a 95-210 Rural Health Clinic?No
Table 2.1 - Community Services
Check one or more boxes for each service provided.
Line
No.		Community Services(1)
Offered
10.Adult Day CareNo
11.Child CareNo
12.Community EducationYes
13.Community NutritionNo
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessNo
17.LegalNo
18.OutreachYes
19.Social ServicesNo
20.Substance AbuseNo
21.TransportationNo
22.Vocational Training PlacementNo
23.Other (See Survey)No
Table 2.2 - Languages Spoken By
Check the staff box if one or more staff members speaks the listed language. Check the patients box if 100 patients (or more than 1% of your patient population) are best served in a listed language. Estimates are acceptable if exact counts are not available.
Line
No.		Language Spoken By(1)
Staff		(2)
Patients
30.ArabicNoYes
31.ArmenianNoNo
32.CambodianNoYes
33.ChineseNoYes
34.HindustaniNoYes
35.HmongNoNo
36.JapaneseNoYes
37.KoreanNoNo
38.LaotianNoNo
39.PortugeseYesNo
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageNoNo
43.SpanishYesYes
44.TagalogNoNo
45.VietnameseNoYes
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):88%
56.Primary non-English language spoken by patients (from list above):Spanish
FTE's and Encounters by Primary Care Provider
Line
No.		Primary Care Provider(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Encounters
60.Physicians0.000
61.Physician Assistants0.000
62.Family Nurse Practitioners0.000
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists1.400.401.805,367
66.
67.Psychiatrist0.000
68.Clinical Psychologist0.000
69.Licensed Clinical Social Worker (LCSW)0.000
70.Other Providers billable to Medi-Cal**0.000
74.Other Certified CPSP providers not listed above***0.000
75.Subtotal1.400.000.401.805,367
** Other Provider billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists, Acupuncturists and any other professional who is able to be reimbursed through the Medi-Cal program.
*** Comprehensive Perinatal Services Program - List all other professional not listed above that are certified by the CPSP program to render services and can be reimbursed.
FTE's and Contacts by Primary Care Provider
Line
No.		Primary Care Provider(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Contacts
80.Registered Dental Hygienists (not Alternative Practice)0.000
81.Registered Dental Assistants4.004.005,367
82.Dental Assistants - Not licensed0.000
83.Marriage and Family Therapists (MFT) - from above0.000
84.Registered Nurses0.000
85.Licensed Vocational Nurses0.000
86.Medical Assistants - Not licensed (1)0.000
87.Non-Licensed Patient Education Staff0.000
88.Substance Abuse Counselors (2)0.000
89.Billing Staff (3)0.00
90.Other Administrative Staff (3)0.00
94.Other Providers not listed above0.00
95.Subtotal4.000.000.004.005,367
(1) Also includes Certified Medical Assistants
(2) Does not include substance abuse counseling performed by providers listed elsewhere
(3) Staff must spend 80% of time on billing
(4) Includes Executive Directors, CFO's, Medical & Dental Records staff, Medical & Dental Receptionists & other management staff
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)1,918
2.Black21
3.Native American / Alaskan Native6
4.Asian / Pacific Islander24
9.Other / Unknown18
10.Total Patients *1,987
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic1,748
12.Non-Hispanic221
13.Unknown18
15.Total Patients *1,987

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%1,312
21.100 - 200%579
22.Above 200%96
23.Unknown0
24.Total Patients *1,987
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
#
30.Total Patients303
31.Total Encounters942
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year10
41.1 - 4 years147146
42.5 - 12 years453473
43.13 - 14 years8578
44.15 - 19 years119123
45.20 - 34 years56172
46.35 - 44 years2447
47.45 - 64 years2233
48.65 and over35
55.Total Patients *9101,077
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare0
61.Medicare - Managed Care0
62.Medi-Cal863
63.Medi-Cal - Managed Care0
64.County Indigent / CMSP / MISP0
65.Healthy Families488
66.Private Insurance0
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.San Diego Co. Medical Plan0
70.Self-Pay / Sliding Fee388
71.Free13
74.All Other Payers235
75.Total Patients *1,987
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP0
81.CHDP0
82.EAPC0
83.Family PACT0
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)0
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments231
Section 4 - Encounters By Principal Diagnosis
Encounters by Principal Diagnosis
Report the diagnosis (or symptom, condition, problem or complaint) as the main reason for the encounter. Do not report the secondary diagnosis(es). There should be only one principal diagnosis for each encounter.
Line
No.		Classification of Diseases and/or Injuries
for each Principal Diagnosis		ICD-9-CM Codes(1)
# of Encounters
1.Infectious and Parasitic Diseases001 - 1390
2.Neoplasms140 - 2390
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 2790
4.Blood and Blood Forming Disorders280 - 2890
5.Mental Disorders290 - 3190
6.Nervous System and Sense Organs Diseases320 - 3890
7.Circulatory System Diseases390 - 4590
8.Respiratory System Diseases460 - 5190
9.Digestive System Diseases, excluding dental diagnosis530 - 5790
10.Genitourinary System Diseases580 - 6290
11.Pregnancy, Childbirth & the Puerperium630 - 6770
12.Skin and Subcutaneous Tissue Diseases680 - 7090
13.Musculoskeletal System and Connective Tissue Diseases710 - 7390
14.Congenital Anomalies740 - 7590
15.Certain Conditions Originating in the Perinatal Period760 - 7790
16.Symptoms, Signs, and Ill-defined Conditions780 - 7990
17.Injury and Poisoning800 - 9990
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V840
19.Dental Diagnosis520-5295,367
20.Family Planning S-Codes0
21.Other0
25.Total5,367
Section 5 - Encounters By Principal Service
Encounters by Principal Service
Classify each encounter by the principal CPT code that was reported on the billing document for this encounter. Do not report secondary procedures. There should be one and only one procedure code reported for each encounter.
Line
No.		Evaluation and Management ServicesCPT Codes - 2005(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 992050
2.Evaluation and Management (established patient)99211 - 992150
3.Hospital Related Services99217 – 99223
99231 - 99239		0
4.Consultations99241 - 992750
5.Other Evaluation and Management Services99281 - 99285
99354 - 99360
99420 - 99429
99450 - 99456
99499		0
6.Nursing Facility Related Services99301 - 993160
7.Case Management Services99361 - 993730
8.Preventive Medicine (infant, child, adolescent)99381 - 99384
99391 - 99394
99431 - 99440		0
9.Preventive Medicine (adult)99385 - 99387
99395 - 99397		0
10.Counseling99401 - 994120
All Other Services
11.Anesthesia00100 – 01999
99100
99116
99135
99140		0
12.Integumentary System10021 - 194990
13.Musculoskeletal System20000 - 299990
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 499990
19.Urinary System50010 - 538990
20.Male Genital System54000 - 558990
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 589990
23.Maternal Care and Delivery59000 - 598990
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 699900
28.Radiology70010 - 799990
29.Pathology / Laboratory80048 – 893560
30.Medicine - Special Services90281 – 99091
99141 – 99199		0
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encounters (CDT codes)D0100-D09995,367
33.CPT Category III Codes0003T - 0111T0
44.Any other encounters0
45.Total5,367
Selected Procedure Code
Report the number of procedures for each code (or range of codes) regardless of whether it is the principal or secondary procedure code.
Line
No.		Evaluation and Management ServicesCPT Codes - 2005(1)
# of
Procedures
50.Mammogram76082 – 76083
76090 - 76092		0
51.HIV Testing86689
86701 - 86703
87390 - 87391		0
52.Pap Smear88141 - 88155
88164 - 88167
88174 - 88175		0
53.Contraceptive Management11975 - 11977
55250, 55450, 57170,
58300 - 58301
58600 - 58611		0
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90700 – 90701
90718		0
61.Hemophilus Influenza B (Hib)90645 - 906480
62.Hepatitis A90632 – 90634
90636		0
63.Hepatitis B90740, 90743, 90744, 90746 - 907470
64.HepB and Hib907480
65.Influenza Virus Vaccine90655 – 90658
90660		0
66.Measles, Mumps and Rubella (MMR)907070
67.Pneumococcal906690
68.Poliovirus90712 - 907130
69.Varicella907160
Section 6 - Revenue and Utilization by Payer
Line
No.		(1)
Medicare		(2)
Medicare
Managed		(3)
Medi-Cal		(4)
Medi-Cal
Managed		(5)
County/
CMSP/MISP		(6)
Healthy
Families
1.Encounters002,196001,424
2.Gross Revenue
(Charges at 100% Rate)		$299,495$235,001
3.Sliding Fee Scale
Write-offs		$0$0
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$0$0$203,294$0$0$118,436
6.Bad Debts$0$0
7.Grants
enter positive numbers
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$0$0$203,294$0$0$118,436
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$0$0$96,201$0$0$116,565
Line
No.		(7)
Private
Insurance		(8)
Self-Pay/
Sliding Fee		(9)
Free		(10)
Breast
Cancer*		(11)
CHDP		(12)
EAPC
1.Encounters09041402310
2.Gross Revenue
(Charges at 100% Rate)		$116,350$2,224$36,432
3.Sliding Fee Scale
Write-offs		$54,894
4.Free/Complimentary
Write-offs		$2,224
5.Contractual Adjustments$25,123
6.Bad Debts
7.Grants
enter positive numbers
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$0$54,894$2,224$0$25,123$0
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$0$61,456$0$0$11,309$0
*  These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program
Line
No.		(13)
Family
PACT		(14)
San Diego
Med Plan		(15)
LA - PPP		(16)
Alameda
Alliance		(17)
Other
County		(18)
All Other
Payers
1.Encounters00003595
2.Gross Revenue
(Charges at 100% Rate)		$1,353$93,582
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$662$71,163
6.Bad Debts
7.Grants
enter positive numbers
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$0$0$0$0$662$71,163
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$0$0$0$0$691$22,419
Line
No.		(19)
Grand Totals
1.Encounters5,367
2.Gross Revenue
(Charges at 100% Rate)		$784,437
3.Sliding Fee Scale Write-offs$54,894
4.Free/Complimentary Write-offs$2,224
5.Contractual Adjustments$418,678
6.Bad Debts$0
7.Grants, enter positive numbers( $0 )
8.Other Adjustments$0
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$475,796
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$308,641
Section 7 - Income Statement
Income Statement
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$784,437
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$475,796
3.Net Patient Revenue (from Sec 6, line 15, column 19)$308,641
Other Operating Revenue
4.Federal Funds$0
5.State Funds$0
6.County Funds$0
7.Local (City or District) Funds$0
8.Private$41,688
9.Donations/Contributions$0
19.Other$289,467
20.Total Other Operating Revenue (Sum Lines 4 through 19)$331,155
25.Total Operating Revenue (Line 3 + Line 20)$639,796

Line
No.		Operating Expenses(1)
30.Salaries, Wages, and Emplyee Benefits$555,207
31.Contract Services - Professional$16,746
32.Supplies - Medical and Dental$44,289
33.Supplies - Office$6,660
34.Outside Patient Care Services$0
35.Rent / Depreciation / Mortgage Interest$0
36.Utilities$2,274
37.Professional Liability Insurance$0
38.Other Insurance$0
39.Continuing Education$2,528
44.All Other Expenses$38,587
45.Total Operating Expenses (Sum Lines 30 through 44)$666,291
50.Net from Operations (Line 25 - Line 45)-$26,495
Section 8 - Major Capital Expenditures
Section 127285(3) of the Health and Safety Code requires each clinic to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)."
Diagnostic and Therapeutic Equipment Acquired During The Report Period
1.Did your clinic acquire any diagnostic or therapeutic equipment that had a value in excess of $500,000?
(If 'Yes', fill out lines 2 through 11, as necessary, below.)		No
Diagnostic and Therapeutic Equipment Detail
Line
No.		(1)
Description of Equipment		(2)
Value		(3)
Date of Aquisition
MM/DD/YYYY		(4)
Means of Acquisition
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Building Projects Commenced During Report Period Costing Over $1,000,000
Section 127285(4) of the Health and Safety Code requires each clinic to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)."
25.Did your clinic commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000?
(If 'Yes', fill out lines 26 through 30, as necessary, below.)		No
Detail of Capital Expenditures
Line
No.		(1)
Description of Project		(2)
Projected Total Capital Expenditure		(3)
OSHPD Project No. (if applicable)
26.
27.
28.
29.
30.
Capital Fund
Line
No.		Capital Fund(1)
40.Beginning Fund Balance
41.Current Year Contribution
42.Current Year Interest Earnings
43.Current Year Expenditures
44.Ending Fund Balance
(Line 40 + Line 41 + Line 42 - Line 43)		$0
General Comments:
Errors and Warnings