Form E "New Jersey Acute Care Hospitals Cost Reports - Patient Care Gross Revenue" - New Jersey

What Is Form E?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

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NEW JERSEY ACUTE CARE HOSPITALS
E
2020
Page 1 of 2
COST REPORTS
Hospital: __________________________________________
Do not change any preprinted
PATIENT CARE GROSS REVENUE
Hospital Number: |_____|_____|_____|_____|
wording on this form.
($000’S)
A
B
C
D
E
F
G
H
I
J
K
L
Same
Off-Site
Outpat.
Skilled
Same
Out-
Home
Revenue Center
Emer.
Clinics
Private
Inpatient
Day
Health
Dialysis
Nursing
Day
Patient
Dialysis
TOTAL
Serv.
(1)
Referred
Surgery
Services
Serv. (2)
Facility
Psych.
Surgery
(2)
1
MSA
Medical/Surgical Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
2
PED
Pediatric Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
3
OBS
Obstetric Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
4
PSA
Psychiatric Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
5
ICU
Intensive Care (3)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
6
CCU
Coronary Care
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
7
NNI
Neo-Natal Intensive
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
8
NBN
Newborn Nursery
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
9
SNF
Skilled Nursing Facility
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
10
SAC
Sub Acute Care
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
11
CLN
Clinics (1)
/ / / / / / / /
/ / / / / / / /
12
EMR
Emergency Room
13
OHS
Off-Site Health Service
/ / / / / / / /
/ / / / / / / /
14
ANS
Anesthesiology
15
BBK
Blood Bank
16
CCA
Cardiac Catheterization
17
MSS
Medical and Surgical Supply
18
DEL
Delivery Room
19
DIA
Dialysis
Footnotes – See Page 2 of 2.
NEW JERSEY ACUTE CARE HOSPITALS
E
2020
Page 1 of 2
COST REPORTS
Hospital: __________________________________________
Do not change any preprinted
PATIENT CARE GROSS REVENUE
Hospital Number: |_____|_____|_____|_____|
wording on this form.
($000’S)
A
B
C
D
E
F
G
H
I
J
K
L
Same
Off-Site
Outpat.
Skilled
Same
Out-
Home
Revenue Center
Emer.
Clinics
Private
Inpatient
Day
Health
Dialysis
Nursing
Day
Patient
Dialysis
TOTAL
Serv.
(1)
Referred
Surgery
Services
Serv. (2)
Facility
Psych.
Surgery
(2)
1
MSA
Medical/Surgical Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
2
PED
Pediatric Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
3
OBS
Obstetric Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
4
PSA
Psychiatric Acute
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
5
ICU
Intensive Care (3)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
6
CCU
Coronary Care
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
7
NNI
Neo-Natal Intensive
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
8
NBN
Newborn Nursery
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
9
SNF
Skilled Nursing Facility
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
10
SAC
Sub Acute Care
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
11
CLN
Clinics (1)
/ / / / / / / /
/ / / / / / / /
12
EMR
Emergency Room
13
OHS
Off-Site Health Service
/ / / / / / / /
/ / / / / / / /
14
ANS
Anesthesiology
15
BBK
Blood Bank
16
CCA
Cardiac Catheterization
17
MSS
Medical and Surgical Supply
18
DEL
Delivery Room
19
DIA
Dialysis
Footnotes – See Page 2 of 2.
NEW JERSEY ACUTE CARE HOSPITALS
E
2020
Page 2 of 2
COST REPORTS
Hospital: __________________________________________
PATIENT CARE GROSS REVENUE
Do not change any preprinted
wording on this form.
($000’S)
Hospital Number: |_____|_____|_____|_____|
A
B
C
D
E
F
G
H
I
J
K
L
Same
Off-Site
Outpat.
Skilled
Same
Out-
Home
Revenue Center
Emer.
Clinics
Private
Inpatient
Day
Health
Dialysis
Nursing
Day
Patient
Dialysis
TOTAL
Serv.
(1)
Referred
Surgery
Services
Serv. (2)
Facility
Psych.
Surgery
(2)
20
EDG
Electrodiagnosis
21
LAB
Laboratory
22
NMD
Nuclear Medicine
23
ORR
Operating and Recovery Rooms
24
OPM
Other Physical Medicine
25
DRU
Drugs Sold to Patients
26
PHT
Physical Therapy
27
RAD
Radiology, Diagnostic
28
RSP
Respiratory Therapy
29
THR
Therapeutic Radiology
30
Sub-Total
(4) (5)
31
Services Not Related to Patient Care (6)
32
MICU (7)
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
33
TOTALS (8)
(1)
Inpatient CLN revenue should be reported under Clinics (Column E).
(2)
Report these revenues above Line 30.
(3)
Report Burn Care Revenue in ICU. Provide detailed listing.
(4)
Columns B through K, Line 30 should agree with Form E-6, Column M, Line 1.
(5)
Report Rebundled Service Revenue in the above receiving revenue centers Lines 1 through 29 and not on Line 31.
(6)
Refer to Financial Elements, NJAC 8:31B-4.61, 4.64 and 4.65 for items to be included on Line 31 and attach itemized schedule.
(7)
Should agree with Form E-4, Line 1, Column D.
(8)
Total Line 33, Column L should agree with Form E-4, Line 1, Column A.
Page of 2