General Surgery Center of Excellence “Accreditation” Application Step 1 of 4 25% Date* MM slash DD slash YYYY CONTACT INFORMATIONHospital / Institute Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Hospital PhoneWebsite CEO PhoneExt. COO PhoneExt. Contact Representative (person completing application) PhoneEmail FaxOther Please Describe Academic AffiliationsMedical School How many medical students? Do you have a residency? Yes No If so, which specialties?ListSpecialtyNumber of Residents Is your Hospital? (Choose all that apply) Community Based (Corporate Chain) Community Base (Locally Owned) Private Academic County City University / State Owned Academic For profit Non-profit If Other, please explain Hospital-Based General Surgeries:**Procedure (CPT-Codes): Completed in 2017Cholecystectomy - All Codes TotalLaparoscopicRobotAppendectomy - All Codes TotalLaparoscopicRobotSmall Bowel Resection - All Codes TotalLaparoscopicRobotColon - All Codes TotalLaparoscopicRobotNissen Fundoplication - All Codes TotalLaparoscopicRobotVentral Hernia Repair - All Codes TotalLaparoscopicRobotInguinal Hernia Repair - All Codes TotalLaparoscopicRobotPlease complete the above data collection for AIMIS review. We would like to collect the following: Total number of procedures, conversions to open, readmissions (note this will be first admits for same day surgery) and complications. As you can see, some of the complication data collection has been streamlined utilizing ICD 998 codes. Please detail what injury was obtained when utilizing 998.2 code since this code convers three complications we are looking for. Please report robotics procedures separately if possible. Hospital Name: Year of 2017 Lap/Robot Cholecystectomy# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total ComplicationsLap/Robot Appendectomy# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total ComplicationsLap/Robot Small Bowel Resection# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total ComplicationsLap/Robot Nissen Fundoplication# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total ComplicationsLap/Robot Colon# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total ComplicationsLap/Robot Ventral Hernia Repair# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total ComplicationsLap/Robot Inguinal Hernia Repair# of CasesConverted to Open: ICD9 Code V64.41Re-AdmissionPelvic Abscess 614.4, 998.59Hematoma 665.70Hemorrhage 998.11Post Op Infection/Cystitis 998.51, 998.59Puncture/Laceration Ureter 998.2Puncture/Laceration Bladder 998.2Puncture/Laceration Bowel 998.2Dehiscence 998.32Total Complications GENERAL SURGERY- MEMBERSHIP LEVELS1. COE (Center of Excellence) – Physician/Hospital – Once an accredited AIMIS surgeon and hospital (or surgical center) has combined efforts and meets MIS standards, the center is recognized as a COE. The COE will have international recognition. Health plans provide unique financial rewards. • Member in “Good Standing” • Laparoscopic Designated Operating Room(s) • MEC to uphold designated surgeon minimum standards • Technology: Meets AI-MIS standards • Patient Care: Meets AI-MIS standards • Code of Conduct: Adheres to AI-MIS policies Authorization I understand that this information will be maintained for internal review purposes and will not be shares outside of the AIMIS organization without written authorization from the applicant, except to officers, directors, agents, attorneys, accountants, financial partners and lenders of AIMIS, to third parties who must gain access to such information in order to assist AIMIS in the conduct of its business (provided, however, such third parties acknowledge and agree to maintain the confidentiality of such information), and in order for AIMIS to comply with legal proceedings or court process. With my signature, I proclaim that all the information provided is accurate to the best of my knowledge. This application is valid for 12 months from date of receipt and with the option to renew membership. Hospital BiographyAccepted file types: pdf, doc, Max. file size: 256 MB. (maximum size: 2 MB)Current MIS Delineation of Privileges (if available)Accepted file types: pdf, doc, Max. file size: 256 MB. (maximum size: 2 MB)
