General Surgery COE Application

General Surgery Center of Excellence “Accreditation” Application

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Date*
MM slash DD slash YYYY
CONTACT INFORMATION
Hospital / Institute Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hospital Phone
Website
CEO
Phone
Ext.
COO
Phone
Ext.
Contact Representative (person completing application)
Phone
Email
Fax
Other
Please Describe

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Hospital-Based General Surgeries:
**Procedure (CPT-Codes): Completed in 2017
Cholecystectomy - All Codes Total
Laparoscopic Robot
Appendectomy - All Codes Total
Laparoscopic Robot
Small Bowel Resection - All Codes Total
Laparoscopic Robot
Colon - All Codes Total
Laparoscopic Robot
Nissen Fundoplication - All Codes Total
Laparoscopic Robot
Ventral Hernia Repair - All Codes Total
Laparoscopic Robot
Inguinal Hernia Repair - All Codes Total
Laparoscopic Robot
Please 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 Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

Lap/Robot Appendectomy

# of Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

Lap/Robot Small Bowel Resection

# of Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

Lap/Robot Nissen Fundoplication

# of Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

Lap/Robot Colon

# of Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

Lap/Robot Ventral Hernia Repair

# of Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

Lap/Robot Inguinal Hernia Repair

# of Cases	Converted to Open: ICD9 Code V64.41	Re-Admission	Pelvic Abscess 614.4, 998.59	Hematoma 665.70	Hemorrhage 998.11	Post Op Infection/Cystitis 998.51, 998.59	Puncture/Laceration Ureter 998.2	Puncture/Laceration Bladder 998.2	Puncture/Laceration Bowel 998.2	Dehiscence 998.32	Total Complications

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GENERAL SURGERY- MEMBERSHIP LEVELS
1. 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 Biography
Accepted 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)

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General Surgery Physician Membership Application

General Surgery Center of Excellence “Accreditation” Application

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Hospital-Based General Surgeries:

GENERAL SURGERY- MEMBERSHIP LEVELS

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