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					NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE


 1 Practice Type:                                                                               Yes or No
   Single Specialty
   Multispecialty
   Academic based (If yes, please complete supplemental Academic Tab)


 2 Practice Ownership:
   Private Practice
   Hospital/Health System
   Academic


 3 Gross accounts receivable as of end of reporting period                                  $


 4 Accounts receivable in the following categories (based on date of service):                     $$
   Current to 30 days
   31 to 60 days
   61 to 90 days
   91 to 120 days
   121 to 180 days
   Over 180 days
   Total                                                                                             -


 5 Gross accounts receivable as of beginning of reporting period                            $


 6 Total gross charges for reporting period (based on date of service)                      $


 7 Total cash collections for reporting period                                              $


 8 Total uncompensated care write-off percentage for the reporting period                          %
        (If this statistic is not monitored by the practice, please indicate "N/A")


 9 Total bad debt recovery (from collection agencies) percentage for the reporting period          %
        (If this statistic is not monitored by the practice, please indicate "N/A")


10 Zip Code of Primary Location




                                                     General Practice Information
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

SUPPLEMENTAL ACADEMIC INFORMATION

A1 Academic Practice Ownership                              %

          Physicians
          Hospital/Health System
          University
          Other

          Total (must = 100%)                                      0%


A2 Provide the amount of support, in total dollars, your practice/department receives in the following
   areas from the affiliated teaching hospital and/or medical school. If you receive support in
   additional areas, please include the total dollar support in the Other category.

          Support Area                                  Hospital                 Medical School

          Medical Director
          Mid-Level Practitioners
          Research
          Faculty Member Start-Up
          Malpractice
          Dept. of Neurosurgery Administrator
          General Administrative Staff
          Other

          Total                                                     0                           0




A3 Indicate the contribution margin, in total dollars and as a percent, of the neurosurgery service line
   in the affiliated teaching hospital.

                                                 $:

                                                %:




                                            Academic Practice Information
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

   NEUROSURGEON COMPENSATION                                                             1                2                     3                    4                5                6                7                8                9                10            Total
11 Estimated Clinical Full-Time Equivalent (FTE)                                                                                                                                                                                                                                 0
12 Owner? (Indicate Y or N)
13 Estimated Percent of Practice
        Cranial Neurosurgery                                                                     %                %                     %                    %                %                %                %                %                %                 %
        Spinal Neurosurgery                                                                      %                %                     %                    %                %                %                %                %                %                 %
        Pediatric Neurosurgery                                                                   %                %                     %                    %                %                %                %                %                %                 %
        Other                                                                                    %                %                     %                    %                %                %                %                %                %                 %
        Total (must equal 100%)                                                                  0%               0%                    0%                   0%               0%               0%               0%               0%               0%                0%
14 Total Compensation                                                                $                $                $                     $                    $                $                $                $                $                $
   If 100% of compensation is derived from professional services only, check here:
   If not, indicate portion of Neurosurgeon compensation attributable to:
        Neurosurgery Professional Services                                           $                $                $                     $                    $                $                $                $                $                $
        Call Pay                                                                     $                $                $                     $                    $                $                $                $                $                $
        Ancillary Net Income: Ambulatory Surgery Center                              $                $                $                     $                    $                $                $                $                $                $
        Ancillary Net Income: Imaging                                                $                $                $                     $                    $                $                $                $                $                $
        Ancillary Net Income: Physical or Occupational Therapy                       $                $                $                     $                    $                $                $                $                $                $
        Ancillary Net Income: Other                                                  $                $                $                     $                    $                $                $                $                $                $
        Research                                                                     $                $                $                     $                    $                $                $                $                $                $
        Medical Directorships                                                        $                $                $                     $                    $                $                $                $                $                $
        Teaching/Education: Department Chair                                         $                $                $                     $                    $                $                $                $                $                $
        Teaching/Education: Professor                                                $                $                $                     $                    $                $                $                $                $                $
        Teaching/Education: Associate Professor                                      $                $                $                     $                    $                $                $                $                $                $
        Teaching/Education: Assistant Professor                                      $                $                $                     $                    $                $                $                $                $                $
        Teaching/Education: Instructor                                               $                $                $                     $                    $                $                $                $                $                $
        Other                                                                        $                $                $                     $                    $                $                $                $                $                $
        TOTAL- MUST EQUAL COMPENSATION REPORTED ABOVE                                $       -        $       -        $            -        $           -        $       -        $       -        $       -        $       -        $       -        $        -


15 Total Benefits                                                                    $                $                $                     $                    $                $                $                $                $                $
16 Number of Years in Specialty
        1-5
        6 - 15
        15 +




                                                                                                                           Neurosurgery 1 - Page 2
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY



   NEUROSURGEON PRODUCTION                                                                      1       2            3                    4       5       6       7       8       9       10
17 Total Professional Charges for Most Recent Fiscal Year                                   $       $       $                    $            $       $       $       $       $       $
18 Collections for Gross Charges for Most Recent Fiscal Year                                $       $       $                    $            $       $       $       $       $       $
19 Total Contractual Adjustments for Most Recent Fiscal Year                                $       $       $                    $            $       $       $       $       $       $
20 Total Bad Debt Adjustments/Write-Offs for Most Recent Fiscal Year                        $       $       $                    $            $       $       $       $       $       $
21 Total Uncompensated Care Adjustments/Write-Offs for Most Recent Fiscal Year              $       $       $                    $            $       $       $       $       $       $
22 Total Number of Primary Surgeries Performed in Most Recent Fiscal Year
23 Total Number of Assisted Surgeries Performed in Most Recent Fiscal Year
24 Total Number of Relative Value Units (RVUs) - if available
25 Total Number of Physician Work Relative Value Units (WRVUs) - if available
26 Total Number of New Patients in Most Recent Fiscal Year - as defined by CPT codes


27 TOTAL NUMBER OF PRIMARY NEUROSURGERY PROCEDURES PERFORMED                                                                                                                                           Total Collections
   IN MOST RECENT FISCAL YEAR - SEE INSTRUCTIONS                                                1       2            3                    4       5       6       7       8       9       10   Total    per CPT Code
     1                                                                     X-Stop 0171T                                                                                                            -   $
     2                                                 Cervical disc replacement 0090T                                                                                                             -   $
     3                                                           Neck spine fusion 22554                                                                                                           -   $
     4                                                         Lumbar spine fusion 22612                                                                                                           -   $
     5                                                         Lumbar spine fusion 22630                                                                                                           -   $
     6                                                  Lumbar disc replacement 22857                                                                                                              -   $
     7                                                 Pierce skull & remove clot 61154                                                                                                            -   $
     8                                                      Open skull for drainage 61314                                                                                                          -   $
     9                                                  Incise skull (press relief) 61343                                                                                                          -   $
    10                                                      Removal of brain lesion 61510                                                                                                          -   $
    11                                             Removal of brain lining lesion 61512                                                                                                            -   $
    12                                                Removal of pituitary gland 61548                                                                                                             -   $
    13                                                   Excision of skull/sutures 61559                                                                                                           -   $
    14                                               Craniofacial approach, skull 61583                                                                                                            -   $
    15                                               Orbitocranial approach/skul 61584                                                                                                             -   $
    16                                                Resect/excise cranial lesion 61600                                                                                                           -   $
    17                                                Resect/excise cranial lesion 61601                                                                                                           -   $
    18                                               Brain aneurysm repr, simple 61700                                                                                                             -   $
    19                                                Brain biopsy w/ct/mr guide 61751                                                                                                             -   $
    20                                                        Focus radiation beam 61793                                                                                                           -   $
    21                                                Establish brain cavity shunt 62223                                                                                                           -   $
    22                                                 Replace/revise brain shunt 62230                                                                                                            -   $
    23                                               Implant spine infusion pump 62362                                                                                                             -   $
    24                                                      Neck spine disk surgery 63020                                                                                                          -   $
    25                                                       Low back disk surgery 63030                                                                                                           -   $
    26                                                Laminotomy, single lumbar 63042                                                                                                              -   $
    27                                                  Removal of spine lamina 63045                                                                                                              -   $
    28                                                  Removal of spine lamina 63047                                                                                                              -   $


                                                                                                                Neurosurgery 1 - Page 3
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

   29                                           Decompress spinal cord 63056                                  -   $
   30                                           Neck spine disk surgery 63075                                 -   $
   31                                             Release of spinal cord 63200                                -   $
   32                                           Implant neuroelectrodes 63655                                 -   $
   33                                       Revise ulnar nerve at elbow 64718                                 -   $
   34                                              Carpal tunnel surgery 64721                                -   $
   35                       Office/outpatient visit, new patient - Level 3 99203                              -   $
   36                       Office/outpatient visit, new patient - Level 4 99204                              -   $
   37                       Office/outpatient visit, new patient - Level 5 99205                              -   $
   38                Office/outpatient visit, established patient - Level 3 99213                             -   $
   39                Office/outpatient visit, established patient - Level 4 99214                             -   $
   40                Office/outpatient visit, established patient - Level 5 99215                             -   $
   41                                      Office consultation - Level 3 99243                                -   $
   42                                      Office consultation - Level 4 99244                                -   $
   43                                      Office consultation - Level 5 99245                                -   $
   44                             Initial inpatient consultation - Level 3 99253                              -   $
   45                             Initial inpatient consultation - Level 4 99254                              -   $
   46                             Initial inpatient consultation - Level 5 99255                              -   $




                                                                                    Neurosurgery 1 - Page 4
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY



                                                                         Out-
28 SUPPORT STAFF FULL-TIME EQUIVALENTS                FTEs         Sourced?
                                                                        Y or N
       Administrative
       Billing & Accounts Receivable
       Accounting
       Managed care
       Information systems
       Maintenance & housekeeping
       Medical receptionists
       Transcriptionists
       Medical records
       Other administrative support
       Registered Nurses
       Licensed Practical Nurses
       Medical Assistants
       Clinical laboratory
       Radiology and imaging
       Other medical support


       Total Support Staff Full-Time Equivalents             0


   OPERATING COSTS
29 Support Staff Costs                                 $$
       Clinical Staff Costs (Excluding NPs and PAs)
       Administrative Costs
       Total                                                 0


30 Malpractice Insurance Premiums

       Per Occurrence $$ Limit:
       Aggregate $$ Limit:


31 Other Operating Costs

       Total                                                 0




                                                                       Neurosurgery 1 - Page 5
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

ALL OTHER PROVIDERS                                                                                                            PHYSICIANS                                                                      NON-PHYSICIAN PROVIDERS

                                                                                                                                                              Interventional
                                                                                                       Orthopaedic           Pain                               Radiology            Other          Physical         Nurse          Physician
   PROVIDER COMPENSATION                                                                   Neurology       Spine           Mgmt.                  Physiatry   (Prof. Only)         Physicians       Therapist    Practitioner       Assistant       Other       Total
32 Estimated Number of Clinical Full-Time Equivalents (FTE)                                                                                                                                                                                                         -
33 Number of FTEs Who Are Owners                                                                                                                                                                                                                                    -
34 Total Compensation for Each Provider Category                                       $               $              $                       $               $                $                $                $                              $           $       -
35 Total Benefits for Each Provider Category                                           $               $              $                       $               $                $                $                $              $               $           $       -



                                                                                                                                                              Interventional
                                                                                                       Orthopaedic           Pain                                 Radiology          Other          Physical         Nurse          Physician
   PROVIDER PRODUCTION                                                                     Neurology       Spine           Mgmt.                  Physiatry   (Prof. Only)         Physicians       Therapist    Practitioner       Assistant       Other       Total
36 Total Professional Charges for Most Recent Fiscal Year                              $               $              $                       $               $                $                $                $              $               $           $       -
37 Total Collections for Gross Charges for Most Recent Fiscal Year                     $               $              $                       $               $                $                $                $              $               $           $       -
38 Total Contractual Adjustments for Most Recent Fiscal Year                           $               $              $                       $               $                $                $                $              $               $           $       -
39 Total Bad Debt Adjustments/Write-Offs for Most Recent Fiscal Year                   $               $              $                       $               $                $                $                $              $               $           $       -
40 Total Uncompensated Care Adjustments/Write-Offs for Most Recent Fiscal Year
41 Total Number of Physician Work Relative Value Units (WRVUs) - if available                                                                                                                                                                                       -
42 Total Number of New Patients in Most Recent Fiscal Year - as defined by CPT codes                                                                                                                                                                                -




                                                                                                               All Other Providers - Page 6
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

ADMINISTRATIVE LEADERSHIP - SEE INSTRUCTIONS

ADMINISTRATOR/CEO
                                                                                                        Yes/No
43 Does your practice employ an Administrator/CEO?

44 Does your Administrator/CEO have an employment contract?

45 What is the Administrator/CEO's base salary?                                                           $

46 Is your Administrator/CEO eligible for a bonus?
   If yes, how much?                                                                                      $
   If yes, how is it calculated?
     % of Ancillary Net Income                                                                      %
     % of Total Net Income before Physician Expenses                                                %
     % of Total Net Income before Physician Expenses Over Budget                                    %
     % of Salary                                                                                    %
     Achievement of Predetermined Goals
     Discretionary
     Other - Specify:

47 Does the practice pay the Administrator/CEO's health insurance premium?

48 Is the Administrator/CEO provided with a disability policy?

49 Does the practice have a retirement plan for which the Administrator/CEO is eligible?

50 Is the Administrator/CEO provided with paid vacation time off?
   If yes, how many weeks per year?                                                                       #

51 Is the Administrator/CEO provided with a company car?

52 Is there a provision for a severance package for the Administrator/CEO?

OFFICE MANAGER

43 Does your practice employ an Office Manager?

44 Does your Office Manager have an employment contract?

45 What is the Office Manager's base salary?                                                              $

46 Is your Office Manager eligible for a bonus?
   If yes, how much?                                                                                      $
   If yes, how is it calculated?
     % of Ancillary Net Income                                                                      %
     % of Total Net Income before Physician Expenses                                                %
     % of Total Net Income before Physician Expenses Over Budget                                    %
     % of Salary                                                                                    %
     Achievement of Predetermined Goals
     Discretionary
     Other - Specify:

47 Does the practice pay the Office Manager's health insurance premium?

48 Is the Office Manager provided with a disability policy?

49 Does the practice have a retirement plan for which the Office Manager is eligible?

50 Is the Office Manager provided with paid vacation time off?
   If yes, how many weeks per year?                                                                       #

51 Is the Office Manager provided with a company car?

52 Is there a provision for a severance package for the Office Manager?




                                                                          Administration - Page 7
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

RELEVANT ISSUES
                                                                                                                      Yes/No
  1 Does your practice utilize relative value units (RVUs) for compensation purposes?

  2 Does your practice utilize relative value units (RVUs) for practice management?

  3 Does your practice compensate physician leaders for practice management?

  4 Is non-RVU based outside income allocated differently/separately from RVU based clinical income, e.g. MRI,
    research, medical directorships?

  5 Does your practice plan on recruiting new physicians or non-physician providers in the next 12 months?

  6 Does your practice provide any of the following ancillary services, i.e. within the practice?
    Facility, e.g. ambulatory surgery center or specialty hospital
    MRI
    CT
    Fluoroscopy
    General X-Ray
    Sleep Studies
    Physical Therapy
    Occupational Therapy
    EEG/EMG/Doppler
    Visual/Neuro-Ophthalmologic
    Other (Specify)

  7 Are your physicians investors/owners in any of the following ancillary services, i.e. outside of the practice?
    Facility, e.g. ambulatory surgery center or specialty hospital
    MRI
    CT
    Fluoroscopy
    General X-Ray
    Sleep Studies
    Physical Therapy
    Occupational Therapy
    EEG/EMG/Doppler
    Visual/Neuro-Ophthalmologic
    Other (Specify)

  8 Does your practice participate in any of the following capital equipment joint ventures with a hospital?
    If so, please also indicate the practice's ownership percentage:                                     Own %
    Cyber Knife                                                                                              %
    Gamma Knife                                                                                              %
    Novalis                                                                                                  %
    Endo-Vascular Interventional                                                                             %
    Bi-Planer                                                                                                %
    Other (Specify)                                                                                          %

  9 Does your practice utilize a remote access imaging system, e.g. PACS?

 10 Has your practice limited any emergency room coverage in the last 12 months?

 11 Has your practice limited any services provided in the last 12 months, e.g. head trauma or pediatrics?

 12 Has your practice imposed any limits on accepting Medicare patients in the last 12 months?

 13 Has your practice imposed any limits on accepting Medicaid patients in the last 12 months?

 14 Has your practice cancelled any other third-party contracts in the last 12 months?

 15 Is your practice considering an investment in a facility, e.g. ASC or specialty hospital in the next 12 months?


                                                                       Relevant Issues
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

RELEVANT ISSUES
                                                                                                                          Yes/No

 16 Are your physicians currently investors in a facility, e.g. ambulatory surgery center, specialty hospital,
    outside of the practice?

 17 Does your practice employ certified professional coders?

 18 Does your practice currently utilize electronic medical records (EMR)?
    If yes, what system?
    Is your practice contemplating implementing an EMR system in the next 12 months?
    If yes, what system?

 19 Does your practice utilize any of the following non-traditional/alternative sources for malpractice coverage?
    Self-insured
    Captive
    Bond
    Line of Credit
    Other (Specify)

 20 Is your practice considering alternative or non-traditional sources for malpractice coverage in the next 12 months?

 21 What was your practice's staff turnover rate for the past 12 months?                                                    %

 22 How long has your practice administrator/CEO been employed by the practice?                                                      years

 23 What is the average number of years for an associate physician to attain partnership in the practice?                            years

 24 Does your practice participate in any research activities?

 25 Please provide the following percentage breakdown of professional revenues:
    Medicare                                                                                                                %
    Medicaid                                                                                                                %
    Fee-for-Service - Fee Schedule: Commercial Payers                                                                       %
    Fee-for-Service - % of Gross Charge: Commercial Payers                                                                  %
    Fee-for-Service - Fee Schedule: Workers' Compensation                                                                   %
    Fee-for-Service - % of Gross Charge: Workers' Compensation                                                              %
    Other                                                                                                                   %
    Total (must equal 100%)                                                                                                     0%

 26 Does your practice increase its fee schedule on a regular basis?
    If so, how often?        (Semi-annually = twice a year; Annually; or Bi-annually = every other year)

 27 Does your practice use an outside coding service?

 28 Does your practice use an outside billing service?




                                                                        Relevant Issues
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

                                                                                                Yes/No
C1   Are your practice and/or physicians paid additional fees for emergency room coverage?

     If so, complete the following for each call pay contract:

                                                  Contract #1     Contract #2   Contract #3   Contract #4   Contract #5

C2   Trauma or Non-Trauma Pay?

C3   Number of Facilities Covered

C4   Level of Trauma Center Covering

C5   Annual Number of Visits

C6   Annual Number of Cases

C7   Daily Call Pay Rate

C8   Number of Hours of Coverage per Day




                                                                 Call Pay
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

   NEUROSURGEON COMPENSATION                                                             11                12                  13                14                15                16                17                18                19                20            Total
11 Estimated Clinical Full-Time Equivalent (FTE)                                                                                                                                                                                                                                   0
12 Owner? (Indicate Y or N)
13 Estimated Percent of Practice
        Cranial Neurosurgery                                                                      %                 %                   %                 %                 %                 %                 %                 %                 %                 %
        Spinal Neurosurgery                                                                       %                 %                   %                 %                 %                 %                 %                 %                 %                 %
        Pediatric Neurosurgery                                                                    %                 %                   %                 %                 %                 %                 %                 %                 %                 %
        Other                                                                                     %                 %                   %                 %                 %                 %                 %                 %                 %                 %
        Total (must equal 100%)                                                                   0%                0%                  0%                0%                0%                0%                0%                0%                0%                0%
14 Total Compensation                                                                $                 $                  $                  $                 $                 $                 $                 $                 $                 $
   If 100% of compensation is derived from professional services only, check here:
   If not, indicate portion of Neurosurgeon compensation attributable to:
        Neurosurgery Professional Services                                           $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Call Pay                                                                     $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Ancillary Net Income: Ambulatory Surgery Center                              $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Ancillary Net Income: Imaging                                                $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Ancillary Net Income: Physical or Occupational Therapy                       $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Ancillary Net Income: Other                                                  $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Research                                                                     $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Medical Directorships                                                        $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Teaching/Education: Department Chair                                         $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Teaching/Education: Professor                                                $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Teaching/Education: Associate Professor                                      $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Teaching/Education: Assistant Professor                                      $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Teaching/Education: Instructor                                               $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        Other                                                                        $                 $                 $                   $                 $                 $                 $                 $                 $                 $
        TOTAL- MUST EQUAL COMPENSATION REPORTED ABOVE                                $        -        $        -         $         -        $        -        $        -        $        -        $        -        $        -        $        -        $        -




                                                                                                                         Neurosurgery 2 - Page 11
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

15 Total Benefits                                                                           $        $         $              $          $        $        $        $        $        $
16 Number of Years in Specialty
         1-5
         6 - 15
         15 +



   NEUROSURGEON PRODUCTION                                                                      11       12         13             14        15       16       17       18       19       20
17 Total Professional Charges for Most Recent Fiscal Year                                   $        $         $              $          $        $        $        $        $        $
18 Collections for Gross Charges for Most Recent Fiscal Year                                $        $         $              $          $        $        $        $        $        $
19 Total Contractual Adjustments for Most Recent Fiscal Year                                $        $         $              $          $        $        $        $        $        $
20 Total Bad Debt Adjustments/Write-Offs for Most Recent Fiscal Year                        $        $         $              $          $        $        $        $        $        $
21 Total Uncompensated Care Adjustments/Write-Offs for Most Recent Fiscal Year              $        $         $              $          $        $        $        $        $        $
22 Total Number of Primary Surgeries Performed in Most Recent Fiscal Year
23 Total Number of Assisted Surgeries Performed in Most Recent Fiscal Year
24 Total Number of Relative Value Units (RVUs) - if available
25 Total Number of Physician Work Relative Value Units (WRVUs) - if available
26 Total Number of New Patients in Most Recent Fiscal Year - as defined by CPT codes


27 TOTAL NUMBER OF PRIMARY NEUROSURGERY PROCEDURES PERFORMED                                                                                                                                           Total Collections
   IN MOST RECENT FISCAL YEAR - SEE INSTRUCTIONS                                                11       12         13             14        15       16       17       18       19       20   Total    per CPT Code
     1                                                                     X-Stop 0171T                                                                                                            -   $
     2                                                 Cervical disc replacement 0090T                                                                                                             -   $
     3                                                           Neck spine fusion 22554                                                                                                           -   $
     4                                                         Lumbar spine fusion 22612                                                                                                           -   $
     5                                                         Lumbar spine fusion 22630                                                                                                           -   $
     6                                                  Lumbar disc replacement 22857                                                                                                              -   $
     7                                                 Pierce skull & remove clot 61154                                                                                                            -   $
     8                                                      Open skull for drainage 61314                                                                                                          -   $
     9                                                  Incise skull (press relief) 61343                                                                                                          -   $
    10                                                      Removal of brain lesion 61510                                                                                                          -   $
    11                                             Removal of brain lining lesion 61512                                                                                                            -   $
    12                                                Removal of pituitary gland 61548                                                                                                             -   $
    13                                                   Excision of skull/sutures 61559                                                                                                           -   $
    14                                               Craniofacial approach, skull 61583                                                                                                            -   $
    15                                               Orbitocranial approach/skul 61584                                                                                                             -   $
    16                                                Resect/excise cranial lesion 61600                                                                                                           -   $
    17                                                Resect/excise cranial lesion 61601                                                                                                           -   $
    18                                               Brain aneurysm repr, simple 61700                                                                                                             -   $
    19                                                Brain biopsy w/ct/mr guide 61751                                                                                                             -   $
    20                                                        Focus radiation beam 61793                                                                                                           -   $
    21                                                Establish brain cavity shunt 62223                                                                                                           -   $
    22                                                 Replace/revise brain shunt 62230                                                                                                            -   $


                                                                                                              Neurosurgery 2 - Page 12
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

   23                                      Implant spine infusion pump 62362                                   -   $
   24                                           Neck spine disk surgery 63020                                  -   $
   25                                             Low back disk surgery 63030                                  -   $
   26                                        Laminotomy, single lumbar 63042                                   -   $
   27                                          Removal of spine lamina 63045                                   -   $
   28                                          Removal of spine lamina 63047                                   -   $
   29                                           Decompress spinal cord 63056                                   -   $
   30                                           Neck spine disk surgery 63075                                  -   $
   31                                             Release of spinal cord 63200                                 -   $
   32                                           Implant neuroelectrodes 63655                                  -   $
   33                                       Revise ulnar nerve at elbow 64718                                  -   $
   34                                              Carpal tunnel surgery 64721                                 -   $
   35                       Office/outpatient visit, new patient - Level 3 99203                               -   $
   36                       Office/outpatient visit, new patient - Level 4 99204                               -   $
   37                       Office/outpatient visit, new patient - Level 5 99205                               -   $
   38                Office/outpatient visit, established patient - Level 3 99213                              -   $
   39                Office/outpatient visit, established patient - Level 4 99214                              -   $
   40                Office/outpatient visit, established patient - Level 5 99215                              -   $
   41                                      Office consultation - Level 3 99243                                 -   $
   42                                      Office consultation - Level 4 99244                                 -   $
   43                                      Office consultation - Level 5 99245                                 -   $
   44                             Initial inpatient consultation - Level 3 99253                               -   $
   45                             Initial inpatient consultation - Level 4 99254                               -   $
   46                             Initial inpatient consultation - Level 5 99255                               -   $




                                                                                    Neurosurgery 2 - Page 13
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

   NEUROSURGEON COMPENSATION                                                             21                22                    23                 24                25                26                27                28                29                30            Total
11 Estimated Clinical Full-Time Equivalent (FTE)                                                                                                                                                                                                                                      0
12 Owner? (Indicate Y or N)
13 Estimated Percent of Practice
        Cranial Neurosurgery                                                                      %                 %                     %                  %                 %                 %                 %                 %                 %                 %
        Spinal Neurosurgery                                                                       %                 %                     %                  %                 %                 %                 %                 %                 %                 %
        Pediatric Neurosurgery                                                                    %                 %                     %                  %                 %                 %                 %                 %                 %                 %
        Other                                                                                     %                 %                     %                  %                 %                 %                 %                 %                 %                 %
        Total (must equal 100%)                                                                   0%                0%                    0%                 0%                0%                0%                0%                0%                0%                0%
14 Total Compensation                                                                $                 $                 $                     $                  $                 $                 $                 $                 $                 $
   If 100% of compensation is derived from professional services only, check here:
   If not, indicate portion of Neurosurgeon compensation attributable to:
        Neurosurgery Professional Services                                           $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Call Pay                                                                     $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Ancillary Net Income: Ambulatory Surgery Center                              $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Ancillary Net Income: Imaging                                                $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Ancillary Net Income: Physical or Occupational Therapy                       $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Ancillary Net Income: Other                                                  $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Research                                                                     $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Medical Directorships                                                        $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Teaching/Education: Department Chair                                         $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Teaching/Education: Professor                                                $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Teaching/Education: Associate Professor                                      $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Teaching/Education: Assistant Professor                                      $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Teaching/Education: Instructor                                               $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        Other                                                                        $                 $                 $                     $                  $                 $                 $                 $                 $                 $
        TOTAL- MUST EQUAL COMPENSATION REPORTED ABOVE                                $        -        $        -        $            -        $         -        $        -        $        -        $        -        $        -        $        -        $        -




                                                                                                                             Neurosurgery 3 - Page 14
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

15 Total Benefits                                                                           $        $        $                $          $        $        $        $        $        $
16 Number of Years in Specialty
         1-5
         6 - 15
         15 +



   NEUROSURGEON PRODUCTION                                                                      21       22       23                 24       25       26       27       28       29       30
17 Total Professional Charges for Most Recent Fiscal Year                                   $        $        $                $          $        $        $        $        $        $
18 Collections for Gross Charges for Most Recent Fiscal Year                                $        $        $                $          $        $        $        $        $        $
19 Total Contractual Adjustments for Most Recent Fiscal Year                                $        $        $                $          $        $        $        $        $        $
20 Total Bad Debt Adjustments/Write-Offs for Most Recent Fiscal Year                        $        $        $                $          $        $        $        $        $        $
21 Total Uncompensated Care Adjustments/Write-Offs for Most Recent Fiscal Year              $        $        $                $          $        $        $        $        $        $
22 Total Number of Primary Surgeries Performed in Most Recent Fiscal Year
23 Total Number of Assisted Surgeries Performed in Most Recent Fiscal Year
24 Total Number of Relative Value Units (RVUs) - if available
25 Total Number of Physician Work Relative Value Units (WRVUs) - if available
26 Total Number of New Patients in Most Recent Fiscal Year - as defined by CPT codes


27 TOTAL NUMBER OF PRIMARY NEUROSURGERY PROCEDURES PERFORMED                                                                                                                                            Total Collections
   IN MOST RECENT FISCAL YEAR - SEE INSTRUCTIONS                                                21       22       23                 24       25       26       27       28       29       30   Total    per CPT Code
     1                                                                     X-Stop 0171T                                                                                                             -   $
     2                                                 Cervical disc replacement 0090T                                                                                                              -   $
     3                                                           Neck spine fusion 22554                                                                                                            -   $
     4                                                         Lumbar spine fusion 22612                                                                                                            -   $
     5                                                         Lumbar spine fusion 22630                                                                                                            -   $
     6                                                  Lumbar disc replacement 22857                                                                                                               -   $
     7                                                 Pierce skull & remove clot 61154                                                                                                             -   $
     8                                                      Open skull for drainage 61314                                                                                                           -   $
     9                                                  Incise skull (press relief) 61343                                                                                                           -   $
    10                                                      Removal of brain lesion 61510                                                                                                           -   $
    11                                             Removal of brain lining lesion 61512                                                                                                             -   $
    12                                                Removal of pituitary gland 61548                                                                                                              -   $
    13                                                   Excision of skull/sutures 61559                                                                                                            -   $
    14                                               Craniofacial approach, skull 61583                                                                                                             -   $




                                                                                                              Neurosurgery 3 - Page 15
NEUROSURGERY EXECUTIVES' RESOURCE VALUE & EDUCATION SOCIETY (NERVES)
PRODUCTION, COMPENSATION AND COST SURVEY
2009 SURVEY QUESTIONNAIRE

NEUROSURGERY

   15                                       Orbitocranial approach/skul 61584                                  -   $
   16                                        Resect/excise cranial lesion 61600                                -   $
   17                                        Resect/excise cranial lesion 61601                                -   $
   18                                       Brain aneurysm repr, simple 61700                                  -   $
   19                                        Brain biopsy w/ct/mr guide 61751                                  -   $
   20                                              Focus radiation beam 61793                                  -   $
   21                                        Establish brain cavity shunt 62223                                -   $
   22                                         Replace/revise brain shunt 62230                                 -   $
   23                                      Implant spine infusion pump 62362                                   -   $
   24                                           Neck spine disk surgery 63020                                  -   $
   25                                             Low back disk surgery 63030                                  -   $
   26                                        Laminotomy, single lumbar 63042                                   -   $
   27                                          Removal of spine lamina 63045                                   -   $
   28                                          Removal of spine lamina 63047                                   -   $
   29                                           Decompress spinal cord 63056                                   -   $
   30                                           Neck spine disk surgery 63075                                  -   $
   31                                             Release of spinal cord 63200                                 -   $
   32                                           Implant neuroelectrodes 63655                                  -   $
   33                                       Revise ulnar nerve at elbow 64718                                  -   $
   34                                              Carpal tunnel surgery 64721                                 -   $
   35                       Office/outpatient visit, new patient - Level 3 99203                               -   $
   36                       Office/outpatient visit, new patient - Level 4 99204                               -   $
   37                       Office/outpatient visit, new patient - Level 5 99205                               -   $
   38                Office/outpatient visit, established patient - Level 3 99213                              -   $
   39                Office/outpatient visit, established patient - Level 4 99214                              -   $
   40                Office/outpatient visit, established patient - Level 5 99215                              -   $
   41                                      Office consultation - Level 3 99243                                 -   $
   42                                      Office consultation - Level 4 99244                                 -   $
   43                                      Office consultation - Level 5 99245                                 -   $
   44                             Initial inpatient consultation - Level 3 99253                               -   $
   45                             Initial inpatient consultation - Level 4 99254                               -   $
   46                             Initial inpatient consultation - Level 5 99255                               -   $




                                                                                    Neurosurgery 3 - Page 16
Trauma Call Pay
Non-Trauma Call Pay

                  1
                  2
                  3
                  4
N/A

Yes
No

Semi-annually
Annually
Bi-annually
PRACTICE                                                                                     TYPE
      10                                                                             1


                        total phys total NS       total NNS total NPP
zipcode       georegion FTEs       FTEs           FTEs      FTEs      pracsize   Single    Multi    Academic

          0                      0            0           0         0             FALSE     FALSE    FALSE



ADMIN

                                           total NNS
                                total NS   Phys       total NPP
zipcode   georegion total phys FTEs        FTEs       FTEs       pracsize        Single    Multi    Academic
        0                     0          0          0          0                   FALSE    FALSE    FALSE




NEUROSURGEONS
                      total phys total NS   total NNS total NPP
zipcode     georegion FTEs        FTEs      FTEs       FTEs      pracsize        Single    Multi    Academic
          0                     0         0          0         0                   FALSE    FALSE    FALSE
          OWNERSHIP
    2                                   3         4
                                End A/R
                               (per
                               responde              31-60         61-90        91-120        121-180        180+
Private    Hospital   Academic nt)        0-30 days days          days         days          days           days

 FALSE      FALSE      FALSE          -           0           0            0             0              0           0




                                          45     46          47 48a            48b           48c            48d

                                            CEO empl              CEO    CEO       %Ancillary
Private    Hospital   Academic CEO?         contr?   CEO$$?       BONUS? bonus $$? ?          %NIBPE?
 FALSE      FALSE      FALSE              0        0$                   0$                  0       0




Private    Hospital   Academic
 FALSE      FALSE      FALSE
                                                                                 RELEVANT ISSUES
                      5             6             7           8              9         1        2                         3

                          Total                     Uncomp.       Bad Debt
Total                     Gross         Total       Care          Recovery       RVUs for       RVUs for       Comp
Aging       Beg A/R       Charges       Collections W/O%          %              comp?          mgmt?          leaders?

        0         -             -             -       %           %                         0              0              0




48e         48f           48g           48h           48i                   49          50             51 52a

%NIBPE>                   Discretiona                             HEALTH       CEO                             CEO
Budget? %Salary? Goals?   ry?         Other?                      INS PD?      disability? R/P?                PTO?
       0        0       0           0                         0              0            0                0              0
         4           5 6a              6b          6c            6d            6e           6f           6g        6h


O/S inc     Recruiting                                                         Gen X-
alloc diff? ?          Facility?       MRI?        CT?           Fluro?        ray?         Sleep?       PT?       OT?

         0           0             0          0             0              0            0            0         0         0




52b                 53         54             45            46            47 48a            48b          48c       48d
                                                   MGR
WEEKS        CEO       CEO SEV                     empl                        MGR    MGR       %Ancillary
PTO?         CAR?      PKG?     MGR?               contr?    MGR$$?            BONUS? bonus $$? ?          %NIBPE?
#                    0        0               0             0$                       0$                  0       0
6i          6j          6k           7a              7b         7c        7d           7e            7f           7g


EEG/EMG                                                                                Gen X-
/Doppler? Visual?       Other?       Facility?       MRI?       CT?       Fluro?       ray?          Sleep?       PT?

        0           0            0               0          0         0            0             0            0         0




48e         48f         48g          48h             48i            49          50              51 52a            52b
                                                              MGR
%NIBPE>                   Discretion                          HEALTH MGR                             MGR       WEEKS
Budget? %Salary? Goals?   ary?       Other?                   INS PD? disability? R/P?               PTO?      PTO?
       0        0       0          0                        0        0           0               0            0#
7h          7i          7j                       8a         8b         8c            8d         8e        8f


            EEG/EMG                                        Gamma       Novalis       Endo-Vas Bi-Planer
OT?         /Doppler? Visual?       Other?       Cyber JV? JV?         JV?           Intrv JV? JV?      Other JV?

       0            0           0            0          0          0             0          0         0         0




       53          54

MGR      MGR SEV
CAR?     PKG?
       0       0
           9             10          11         12        13         14         15         16           17 18a

                                                            Cancelled Future       Current
Remote         Limited        Limited   Limited   Limited   3rd       investors Investors                    Current
imaging?       ER?            services? Medicare? Medicaid? parties?  in Facility? in Facility? CPCs?        EMR?

           0             0            0          0          0         0          0          0            0             0
18b           18c          18d           19a            19b            19c         19d        19e                 20         21

                                                                                                           Alt
              Future                     Self-                                                             Malpractic Staff
System?       EMR?         System?       insured?       Captive?       Bond?       LOC?       Other?       e?         turnover?

          0            0             0              0              0           0          0            0           0%
      22        23       24 25a      25b       25c       25d     25e    25f       25g

CEO                                            Comm      Comm
employed Avg yrs to Research %Medicar %Medicai FFS fee   FFS %   WC FFS WC FFS
# Mos?   ptr?       activities? e     d        sched     chg     fee sched %chg   Other

       0         0        0%         %         %         %       %      %         %
             26a          26b                 27              28

             Update                    O/S
             fee          How          Coding         O/S Billing
Total        sched?       often?       Service?       Service?

        0%            0            0              0            0

				
DOCUMENT INFO
Description: Ceo Employment Contract document sample