Form Cms-216-94 - Organ Procurement Organization-Histo-Compatibility Lab Statement Of Reimbursable Costs Page 2
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183390 (Cont.)
Form CMS 216-94
11-05
ORGAN PROCUREMENT ORGANIZATION/
MEDICARE
PERIOD:
HISTOCOMPATIBILITY LABORATORY
NUMBER
FROM_______________
WORKSHEET S
IDENTIFICATION DATA
___________________
TO________________
PART I-OPO STATISTICS
1
2
3
Local
Imported
Total (Columns 1 & 2)
1 Total number of kidneys retrieved (viable and non-viable)
1
2 Total number of kidneys included in line 1 that were non-viable.
2
3 Net number of kidneys for which payment should
3
have been received (line 1 minus line 2).
USA
Foreign Country
Total
4 Total number of kidneys included in line 3, column 3 that
4
were exported out of local retrieval areas
Military
VA
Total
5 Total number of kidneys sent to military or DVA
5
hospitals that were included in line 3,column 3.
Number
6 Amount received for kidneys listed in line 5.
Amount Received
6
Number of Kidneys
Amount Received
7 Was payment received for kidneys furnished to foreign countries and included
7
on line 4,column 2. Enter "Y" for yes or "N" for no. If yes, enter the total number
of kidneys and amount received in columns 2 and 3, respectively.
Total number of organs/tissue other than kidneys retrieved and administratively processed. In the amount received column enter
the total amount of payment received for each type of organ.
Organ
Total
Nonviable
Amount Received
8 Cornea
8
8.01 Liver
8.01
8.02 Pancreas
8.02
8.03 Pancreas Islet
8.03
8.04 Heart
8.04
8.05 Heart Valves
8.05
8.06 Heart/Lung
8.06
8.07 Bone
8.07
8.08 Skin
8.08
8.09 Lung
8.09
8.10 Other
8.10
8.20 Total
8.20
PART II-LAB STATISTICS
1 Total number of tests performed- all laboratory.
1
2 Total number of tests performed-tissue typing laboratory.
2
3 Total number of pre-transplant tests performed for kidney transplantation that are included in line 2.
3
Tissue typing pre-transplant tests performed for kidney transplant:
Test Name
Number of Tests
4
4
4.01
4.01
4.02
4.02
4.03
4.03
4.04
4.04
4.05
4.05
4.06
4.06
4.07
4.07
4.08
4.08
4.09
4.09
4.10
4.10
4.20 Total Tests
4.20
PART III-FTEs
Number of full-time equivalent employees
Administrative
OPO
Histo-Lab
1
2
3
4
5
6
1 Medical Director
Medical Director
Lab Director
1
1.01 Exec. Director
Procurement Coordinator
Technicians
1.01
1.02 Clerical
Preservation Technicians
Tissue Typing Tech.
1.02
1.03 Other
Other
Other
1.03
2 Total FTEs
2
FORM CMS 216-94 (11-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II SECTIONS 3303, 3303.1, 3303.2 and 3303.3)
33-304
Rev. 4
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