Annual Utilization Report of Primary Care Clinic
Facility Name:CHOC CLINIC - COSTA MESA
OSHPD ID:306304347Report 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:CHOC CLINIC - COSTA MESA
2.OSHPD ID Number:306304347
3.Street Address:136 BROADWAY
4.City:COSTA MESA
5.Zip:92863
6.Facility Phone No.:(714) 289 - 4851 ext.
7.Administrator Name:Bonnie Heri
8.Administrator E-mail Address:bheri@choc.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:Childrens Hospital of Orange County
13.Corporate Business Address:455 S Main St
14.City:Costa Mesa
15.State:CA
16.Zip:92627 - 2818
17.Person Completing Report:GINA CADOGAN
18.Phone No.:714-558-9175
19.Fax No.:714-558-9314
20.E-mail Address:GCADOGAN@CHOC.ORG
30.Submitted by:d88c6180
31.Submitted Date and Time:3/13/2006 2:48:10 PM
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.OutreachNo
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.ArabicNoNo
31.ArmenianNoNo
32.CambodianNoNo
33.ChineseNoNo
34.HindustaniNoNo
35.HmongNoNo
36.JapaneseNoNo
37.KoreanNoNo
38.LaotianNoNo
39.PortugeseNoNo
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageNoNo
43.SpanishYesYes
44.TagalogNoNo
45.VietnameseNoNo
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):75%
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.Physicians1.001.002,963
61.Physician Assistants0.000
62.Family Nurse Practitioners1.001.002,081
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.000
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.Subtotal2.000.000.002.005,044
** 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 Assistants0.000
82.Dental Assistants - Not licensed0.000
83.Marriage and Family Therapists (MFT) - from above0.000
84.Registered Nurses1.001.001,680
85.Licensed Vocational Nurses1.001.001,680
86.Medical Assistants - Not licensed (1)1.001.001,684
87.Non-Licensed Patient Education Staff1.001.000
88.Substance Abuse Counselors (2)0.000
89.Billing Staff (3)1.001.00
90.Other Administrative Staff (3)2.002.00
94.Other Providers not listed above0.00
95.Subtotal7.000.000.007.005,044
(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)1,459
2.Black10
3.Native American / Alaskan Native3
4.Asian / Pacific Islander11
9.Other / Unknown45
10.Total Patients *1,528
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic1,276
12.Non-Hispanic207
13.Unknown45
15.Total Patients *1,528

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%1,020
21.100 - 200%463
22.Above 200%45
23.Unknown0
24.Total Patients *1,528
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
#
30.Total Patients0
31.Total Encounters0
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year6954
41.1 - 4 years215190
42.5 - 12 years387317
43.13 - 14 years6264
44.15 - 19 years9278
45.20 - 34 years00
46.35 - 44 years00
47.45 - 64 years00
48.65 and over00
55.Total Patients *825703
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare0
61.Medicare - Managed Care0
62.Medi-Cal125
63.Medi-Cal - Managed Care397
64.County Indigent / CMSP / MISP0
65.Healthy Families450
66.Private Insurance1
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.San Diego Co. Medical Plan0
70.Self-Pay / Sliding Fee555
71.Free0
74.All Other Payers0
75.Total Patients *1,528
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP0
81.CHDP266
82.EAPC271
83.Family PACT0
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)537
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments539
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 - 139290
2.Neoplasms140 - 2399
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 279153
4.Blood and Blood Forming Disorders280 - 28942
5.Mental Disorders290 - 31951
6.Nervous System and Sense Organs Diseases320 - 389577
7.Circulatory System Diseases390 - 4591
8.Respiratory System Diseases460 - 519987
9.Digestive System Diseases, excluding dental diagnosis530 - 579173
10.Genitourinary System Diseases580 - 62966
11.Pregnancy, Childbirth & the Puerperium630 - 6770
12.Skin and Subcutaneous Tissue Diseases680 - 709243
13.Musculoskeletal System and Connective Tissue Diseases710 - 73946
14.Congenital Anomalies740 - 75922
15.Certain Conditions Originating in the Perinatal Period760 - 77921
16.Symptoms, Signs, and Ill-defined Conditions780 - 799604
17.Injury and Poisoning800 - 999135
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V841,624
19.Dental Diagnosis520-5290
20.Family Planning S-Codes0
21.Other0
25.Total5,044
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 - 99205625
2.Evaluation and Management (established patient)99211 - 992153,049
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		1,273
9.Preventive Medicine (adult)99385 - 99387
99395 - 99397		1
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		96
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encounters (CDT codes)D0100-D09990
33.CPT Category III Codes0003T - 0111T0
44.Any other encounters0
45.Total5,044
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		496
61.Hemophilus Influenza B (Hib)90645 - 90648308
62.Hepatitis A90632 – 90634
90636		348
63.Hepatitis B90740, 90743, 90744, 90746 - 9074792
64.HepB and Hib907486
65.Influenza Virus Vaccine90655 – 90658
90660		222
66.Measles, Mumps and Rubella (MMR)90707182
67.Pneumococcal90669341
68.Poliovirus90712 - 90713115
69.Varicella90716107
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.Encounters005711,75701,465
2.Gross Revenue
(Charges at 100% Rate)		$41,851$155,611$149,258
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$26,443$121,221$109,933
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$26,443$121,221$0$109,933
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$0$0$15,408$34,390$0$39,325
Line
No.		(7)
Private
Insurance		(8)
Self-Pay/
Sliding Fee		(9)
Free		(10)
Breast
Cancer*		(11)
CHDP		(12)
EAPC
1.Encounters13400539677
2.Gross Revenue
(Charges at 100% Rate)		$110$4,323$78,827$99,928
3.Sliding Fee Scale
Write-offs		$1,441$94,211
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$86$45,403
6.Bad Debts
7.Grants
enter positive numbers
8.Other Adjustments$2,174
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$86$3,615$0$0$45,403$94,211
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$24$708$0$0$33,424$5,717
*  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.Encounters000000
2.Gross Revenue
(Charges at 100% Rate)
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments
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$0$0
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$0$0$0$0$0$0
Line
No.		(19)
Grand Totals
1.Encounters5,044
2.Gross Revenue
(Charges at 100% Rate)		$529,908
3.Sliding Fee Scale Write-offs$95,652
4.Free/Complimentary Write-offs$0
5.Contractual Adjustments$303,086
6.Bad Debts$0
7.Grants, enter positive numbers( $0 )
8.Other Adjustments$2,174
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$400,912
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$128,996
Section 7 - Income Statement
Income Statement
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$529,908
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$400,912
3.Net Patient Revenue (from Sec 6, line 15, column 19)$128,996
Other Operating Revenue
4.Federal Funds
5.State Funds$869,881
6.County Funds
7.Local (City or District) Funds
8.Private
9.Donations/Contributions
19.Other
20.Total Other Operating Revenue (Sum Lines 4 through 19)$869,881
25.Total Operating Revenue (Line 3 + Line 20)$998,877

Line
No.		Operating Expenses(1)
30.Salaries, Wages, and Emplyee Benefits$797,518
31.Contract Services - Professional$960
32.Supplies - Medical and Dental$27,730
33.Supplies - Office
34.Outside Patient Care Services$41,706
35.Rent / Depreciation / Mortgage Interest$122,294
36.Utilities$1,129
37.Professional Liability Insurance
38.Other Insurance
39.Continuing Education
44.All Other Expenses$18,042
45.Total Operating Expenses (Sum Lines 30 through 44)$1,009,379
50.Net from Operations (Line 25 - Line 45)-$10,502
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