Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106

CHAPTER 35

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-96

Section

General 3500

Rounding Standards for Fractional Computations 3500.1

Acronyms and Abbreviations 3500.2

Recommended Sequence for Completing an SNF Cost Report 3504

Recommended Sequence for Completing an SNF or SNF

Health Care Complex - Full Cost Report 3504.1

Recommended Sequence for Completing an SNF Cost Report

Under The Simplified Method - Less Than 1500 Medicare Days 3504.2

Sequence of Assembly 3505

Worksheet S - Skilled Nursing Facility and Skilled

Nursing Facility Health Care Complex Cost Report

Certification and Settlement Summary 3506

Part I - Certification 3506.1

Part II - Settlement Summary 3506.2

Worksheet S-2 - Skilled Nursing Facility and Skilled Nursing

Facility Health Care Complex Identification Data 3508

Worksheet S-3 - Skilled Nursing Facility and Skilled Nursing

Facility Health Care Complex Statistical Data 3509

Part II - SNF Wage Index Information 3509.1

Part III - Overhead Cost - Direct Salaries 3509.2

Worksheet S-4 - SNF-Based Home Health Agency Statistical

Data 3511

Part I - Home Health Agency Visits 3511.1

Part II - Employment Data 3511.2

Part III - Compilation of PPS Activity Data 3511.3

Worksheet S-5 - SNF-Based Rural Health Clinic / Federally Qualified

Health Center Statistical Data 3512

Worksheet S-6 - Skilled Nursing Facility-Based

Outpatient Rehabilitation Statistical Data 3513

Worksheet S-7 - NHCMQ Demonstration and PPS Statistical Data 3514

Part I - NHCMQ Demonstration Statistical Data 3514.1

Part II - PPS Statistical Data 3514.2

Part III - PPS Statistical Data 3514.3

Part IV - PPS Statistical Data for Electronic Filing 3514.4

Worksheet S-8 - Hospice Identification Data 3515

Part I - Enrollment Days Based on Level of Care 3515.1

Part II - Census Data 3515.2

Worksheet A - Reclassification and Adjustment of Trial

Balance of Expenses 3516

Worksheet A-6 - Reclassifications 3517

Worksheet A-7 - Analysis of Changes During Cost Reporting

Period in Capital Asset Balances 3518

Worksheet A-8 - Adjustments to Expenses 3519

Rev. 11 35-1

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-96

Section

Worksheet A-8-1 - Statement of Costs of Services From

Related Organizations 3520

Worksheet A-8-2 - Provider-Based Physician Adjustments 3521

Worksheet A-8-3 - Reasonable Cost Determination for Physical

Therapy Services Furnished by Outside Suppliers 3522

Part I - General Information 3522.1

Part II - Salary Equivalency Computation 3522.2

Part III - Standard Travel Allowance and Standard

Travel Expense Computation - Provider Site 3522.3

Part IV - Standard Travel Allowance and Standard

Travel Expense Computation - HHA Services

Outside Provider Site 3522.4

Part V - Overtime Computation 3522.5

Part VI - Computation of Therapy

Limitation and Excess Cost Adjustment 3522.6

Part VII - Allocation of Therapy Excess

Cost Over Limitation for Non-Shared

Therapy Department Services 3522.7

Worksheet A-8-4 - Reasonable Cost Determination for

Respiratory Therapy Services

Furnished by Outside Suppliers 3523

Part I - General Information 3523.1

Part II - Salary Equivalency Computation 3523.2

Part III - Travel Allowance and Travel

Expense Computation 3523.3

Part IV - Overtime Computation 3523.4

Part V - Computation of Respiratory Therapy

Limitation and Excess Cost Adjustment 3523.5

Worksheet B, Part I - Cost Allocation - General

Service Costs and Worksheet B-1 - Cost Allocation -

Statistical Basis 3524

Worksheet B, Part III - Cost Allocation - General Service Costs and

Worksheet B-1, Part II - Cost Allocation - Statistical Basis (With Less

Than 1500 Medicare Days 3524.1

Worksheet B, Part II - Allocation of Capital-Related

Costs 3525

Worksheet B-2 - Post Step Down Adjustments 3526

Worksheet C - Computation of Rate of Cost to Charges 3527

Worksheet D - Apportionment of Ancillary and Outpatient Cost and

Reduction of Therapy Cost 3530

Part I - Calculation of Ancillary Cost and Outpatient

Cost Apportionment 3530.1

Part II - Apportionment of Vaccine Cost 3530.2

Part III - Calculation of Interns and Residents Pass

Through for PPS SNF 3530.3

35-2 Rev. 11

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-96

Section

Worksheet D-1 - Computation of Inpatient Routine Costs 3531

Part I - Calculation of Inpatient Routine Costs 3531.1

Part II - Calculation of Inpatient Intern and Resident

Cost for PPS Passthrough 3531.2

Worksheet D-2 - Apportionment of Cost of Services

Rendered By Interns and Residents 3532

Part I - Not in Approved Teaching Program 3532.1

Part II - In Approved Teaching Program (Title

XVIII, Part B Inpatient Routine Costs Only) 3532.2

Worksheet E - Calculation of Reimbursement Settlement 3534

Part I - Part A - Inpatient Services 3534.1

Part II - Part B - Medical and Other Health Services 3534.2

Part III - SNF Reimbursement Under PPS 3534.3

Part V - SNF Reimbursement Under NHCHQ Demonstration 3534.4

Worksheet E-1 - Analysis of Payments to Providers for

Services Rendered 3535

Worksheet G - Balance Sheet 3536

Worksheet G-1 - Statement of Changes in Fund

Balances 3536.1

Worksheet G-2 - Statement of Patient Revenues and

Operating Expenses 3536.2

Worksheet G-3 - Statement of Revenues and Expenses 3536.3

Worksheet H - Analysis of Provider-Based

Home Health Agency Costs 3539

Worksheet H-1 - Compensation Analysis -

Salaries and Wages 3540

Worksheet H-2 - Compensation Analysis -

Employee Benefits (Payroll-Related) 3541

Worksheet H-3 - Compensation Analysis -

Contracted Services/Purchased Services 3542

Worksheet H-4 - Allocation of HHA Administrative and

General Costs 3543

Part I - Allocation of HHA Administrative and

General Costs 3543.1

Part II - Apportionment of Cost of HHA Services

Furnished by Shared Skilled Nursing Facility

Departments 3543.2

Worksheet H-5 - Apportionment of Patient

Service Costs 3544

Part I - Aggregate Agency Cost Per Visit Computation 3544.1

Part II - Computation of Aggregate Medicare Cost and the

Aggregate of the Medicare Limitation 3544.2

Part III - Supplies and Drugs Cost Computation 3544.3

Part IV - Comparison of the Lesser of the Aggregate Medicare Cost,

The Aggregate of the Medicare Cost Per Visit Limitation and the

Aggregate Per Beneficiary Cost Limitation 3544.4

Part V - Outpatient Therapy Reduction Computation 3544.5

Rev. 10 35-3

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-96

Section

Worksheet H-6 - Calculation of HHA Reimbursement

Settlement - Part A and Part B Services 3545

Part I - Computation of Lesser of Reasonable

Cost or Customary Charges 3545.1

Part II - Computation of HHA Reimbursement

Settlement 3545.2

Worksheet H-7 - Analysis of Payments to

Provider-Based Home Health Agencies for Services

Rendered to Program Beneficiaries 3546

Worksheet J-1 - Allocation of General

Service Costs to Outpatient Rehabilitation Provider Cost

Centers 3551

Part I - Allocation of General Service Costs to

Outpatient Rehabilitation Provider Cost Centers 3551.1

Part II - Computation of Unit Cost Multiplier for

Allocation of Outpatient Rehabilitation Provider

Administrative and General Costs 3551.2

Part III - Allocation of General Service Costs to

Outpatient Rehabilitation Provider Cost Centers -

Statistical Basis 3551.3

Worksheet J-2 - Computation of Component Costs 3552

Part I - Apportionment of Outpatient Rehabilitation

Provider Cost Centers 3552.1

Part II - Apportionment of Cost of Outpatient

Rehabilitation Services Furnished by Shared

Skilled Nursing Facility Departments 3552.2

Part III - Total Rehabilitation Costs 3552.3

Worksheet J-3 - Calculation of Reimbursement

Settlement of Outpatient Rehabilitation Services 3553

Part I - Calculation of Reimbursement Settlement for SNF-based

Provider Not Subject to the computation of the Lesser of

Reasonable Cost or Customary Charges 3553.1

Part II - Computation of Customary Charges for Rehab Services 3553.2

Part III - Computation of Reimbursement Settlement 3553.3 Worksheet J-4 - Analysis of Payments to

Provider-Based Component for Services Rendered to

Program Beneficiaries 3554

Worksheet I-1 - Analysis of SNF-Based Rural Health Clinic/Federally

Qualified Health Center Costs. 3556

Worksheet I-2 - Allocation of Overhead to RHC/FQHC Services 3558

Part I - Visits and Productivity. 3558.1

Part II - Determination of Total Allowable Cost Applicable to RHC/FQHC 3558.2

Worksheet I-3 - Calculation of Reimbursement Settlement for RHC/FQHC

Services 3560

Part I - Determination of Rate for RHC/FQHC Services 3560.1

Part II - Calculation of Settlement 3560.2

Worksheet I-4 - Do not use this worksheet 3562

Worksheet I-5 - Analysis of Payments to SNF-Based Rural Health Clinic

And Federally Qualified Health Centers 3563

35-4 Rev. 10

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-96

Section

Worksheet A-8-5 - Reasonable Cost Determination For Therapy Services

Furnished By On Or After April 10, 1998 By Outside Suppliers. 3564

Part I - General Information 3564.1

Part II - Salary Equivalency Computation 3564.2

Part III - Standard and Optional Travel Allowance and Travel

Expense Computation - Provider Site 3564.3

Part IV - Standard and Optional Travel Allowance and

Travel Expense Computation - Provider Off Site 3564.4

Part V - Overtime Computation 3564.5

Part VI - Computation of Therapy

Limitation and Excess Cost Adjustment 3564.6

Part VII - Allocation of Therapy Excess Cost Over

Limitation for Non-shared Therapy Department Services. 3564.7

W orksheet K – A nalysis of SNF - Based Hospice Cost 3565 Worksheet K-1 – Hospice Compensation Analysis Salaries and Wages 3566

W orksheet K-2 – Hospice Compensation Analysis - Employee Benefits

(Payroll Related) 3567

W orksheet K-3 – Hospice Compensation Analysis - Contracted Services/

Purchased Services 3568

W orksheet K-4, Part I - Cost Allocation – Hospice General Service Cost

and Part II - Cost Allocation - Hospice Statistical Basis 3569

W orksheet K-5, Allocation of General Service Costs to Hospice Cost Centers 3570

Part I - Allocation of General Service Costs to Hospice Cost Centers 3570.1

Part II - Allocation of General Service Costs to Hospice Cost Centers -

Statistical Basis 3570.2

Part III – Apportionment of Hospice Shared Services 3570.3

W orksheet K-6, Calculation of Per Diem Cost 3571

Exhibit 1- Form CMS 2540-96 Worksheets 3590

Electronic Reporting Specifications for Form CMS 2540-96 3595

Rev 10 35-4.1