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

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE OF CONTENTS

	Topic	Pages
Table 1:	Record Specifications	35-503 -35-508
Table 2:	Worksheet Indicators	35-509 - 35-512
Table 3:	List of Data Elements with Worksheet, Line, and Column Designations	35-513 - 35-541
Table 3A:	Worksheets Requiring No Input	35-542
Table 3B:	Tables to Worksheet S-2	35-542
Table 3C:	Lines That Cannot Be Subscripted (Beyond Those Preprinted)	35-542 - 35-544
Table 3D:	Permissible Payment Mechanisms	35-545
Table 3E:	Subscripting Correlation between Wksts A, A-8, and A-8-5	35-545.1 - 35-545.2
Table 4:	Numbering Convention for Multiple Components	35-546 - 35-548
Table 5:	Cost Center Coding	35-549 - 35-554
Table 6:	Edits
	Level I Edits	35-555 - 35-559
	Level II Edits	35-560 - 35-563

Rev. 10 35-501

04-06

FORM CMS 2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

Table 1 specifies the standard record format to be used for electronic cost reporting. Each electronic cost report submission (file) has four types of records. The first group (type 1 records) contains information for identifying, processing, and resolving problems. The text used throughout the cost report for variable line labels (e.g., Worksheet A) and variable column headers (Worksheet B‑1) is included in the type 2 records. Refer to Table 5 for cost center coding. The data detailed in Table 3 are identified as type three records. The encryption coding at the end of the file, records 1, 1.01, and 1.02, are type 4 records.

The medium for transferring cost reports submitted electronically to fiscal intermediaries is 3" diskette. These disks must be in IBM format. The character set must be ASCII. Seek approval from your fiscal intermediary regarding alternate methods of submission to ensure that the method of transmission is acceptable.

The following are requirements for all records:

1. All alpha characters must be in upper case.

2. For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence.

3. No record may exceed 60 characters.

Below is an example of a Type 1 record with a narrative description of its meaning.

1 2 3 4 5

1234567890123456789012345678901234567890123456789012345678

1 1 010123199927420003053C99P00520000202000305

Record #1: This is a cost report file submitted by Provider 010123 for the period from October 1, 1999 (1999274) through October 31, 2000, (2000305). It is filed on Form CMS-2540‑96. It is prepared with vendor number C99's PC based system, version number 1. Position 38 changes with each new test case and/or approval and is alpha. Positions 39 and 40 will remain constant for approvals issued after the first test case. This file is prepared by the skilled nursing facility on January 20, 2000, (2000020). The electronic cost report specification, dated October 31, 2000, (2000305), is used to prepare this file.

FILE NAMING CONVENTION

Name each cost report file in the following manner:

SNNNNNNN.YYL, where

1. SN (SNF electronic cost report) is constant;

2. NNNNNN is the 6 digit Medicare skilled nursing facility provider number;

3. YY is the year in which the provider's cost reporting period ends; and

4. L is a character variable (A‑Z) to enable separate identification of files from skilled nursing facilities with two or more cost reporting periods ending in the same calendar year.

Rev. 14 35-503

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 1 Records ‑ Record Number 1

		Size	Usage	Loc.	Remarks
1.	Record Type	1	X	1	Constant "1"
2.	NPI	10	9	2-11	Numeric only
3.	Spaces	1	X	12
4.	Record Number	1	X	13	Constant "1"
5.	Spaces	3	X	14-16
6.	SNF Provider Number	6	9	17-22	Field must have 6 numeric characters
7.	Fiscal Year Beginning Date	7	9	23-29	YYYYDDD - Julian date; first day covered by this cost report
8.	Fiscal Year Ending Date	7	9	30-36	YYYYDDD - Julian date; last day covered by this cost report
9.	MCR Version	1	9	37	Constant "3" (for Form CMS 2540-96)
10.	Vendor Code	3	X	38-40	To be supplied upon approval. Refer to page 35-503.
11.	Vendor Equipment	1	X	41	P = PC; M = Main Frame
12.	Version Number	3	X	42-44	Version of extract software, e.g., 001=1st, 002=2nd, etc. or 101=1st, 102=2nd. The version number must be incremented by 1 with each recompile and release to client(s).
13.	Creation Date	7	9	45-51	YYYYDDD - Julian date; date on which the file was created (extracted from the cost report)
14.	ECR Spec. Date	7	9	52-58	YYYYDDD - Julian date; date of electronic cost report specifications used in producing each file. Valid for cost reporting periods beginning on and after 2005274 (October 1, 2005). Prior approval(s) are for cost reporting periods ending on or after 2002365 (12/31/02), 2001059, 2000274, 1999334, 1998273, 1997273, and 1996274.

504. Rev. 14

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 1 Records ‑ Record Numbers 2 - 99

		Size	Usage	Loc.	Remarks
1.	Record Type	1	9	1	Constant "1"
2.	Spaces	10	X	2-11
3.	Record Number	2	9	12-13	#2 to #99 - Reserved for future use.
4.	Spaces	7	X	14-20	Spaces (optional)
5.	ID Information	40	X	21-60	Left justified to position 21.

RECORD NAME: Type 2 Records for Labels

		Size	Usage	Loc.	Remarks
1.	Record Type	1	9	1	Constant "2"
2.	Wkst. Indicator	7	X	2-8	Alphanumeric. Refer to Table 2.
3.	Spaces	2	X	9-10
4.	Line Number	3	9	11-13	Numeric
5.	Subline Number	2	9	14-15	Numeric
6.	Column Number	3	X	16-18	Alphanumeric
7.	Subcolumn Number	2	9	19-20	Numeric
8.	Cost Center Code	4	9	21-24	Numeric. Refer to Table 5 for appropriate cost center codes.
9.	Labels/Headings
	a. Line Labels	36	X	25-60	Alphanumeric, left justified
	b. Column Headings Statistical Basis & Code	10	X	21-30	Alphanumeric, left justified

The type 2 records contain text that appears on the pre‑printed cost report. Of these, there are three groups: (1) Worksheet A cost center names (labels); (2) column headings for step-down entries; and (3) other text appearing in various places throughout the cost report. The standard cost center labels are listed below.

A Worksheet A cost center label must be furnished for every cost center with cost or charge data anywhere in the cost report. The line and subline numbers for each label must be the same as the line and subline numbers of the corresponding cost center on Worksheet A. The columns and subcolumn numbers are always set to zero.

Rev. 12 35-505

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

TYPE 2 COST CENTER DESCRIPTIONS

The following type 2 cost center descriptions must be used for all Worksheet A standard cost center lines.

Line	Used when a FULL cost report is filed	Used when a SIMPLIFIED cost report is filed
1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 18 18.1 19 21 22 23 24 25 26 27 28 29 30 31 32 34 35 37 38 39 40 41 42 43 44 45 46 47 4 7.1 48 49 52 53 54 55 56 58 59 60 61 62	CAP REL COSTS - BLDGS & FIXTURES CAP REL COSTS - MOVEABLE EQUIPMENT EMPLOYEE BENEFITS ADMINISTRATIVE & GENERAL PLANT OPERATION, MAINT. & REPAIRS LAUNDRY & LINEN SERVICE HOUSEKEEPING DIETARY NURSING ADMINISTRATION CENTRAL SERVICES & SUPPLY PHARMACY MEDICAL RECORDS & LIBRARY SOCIAL SERVICE INTERNS & RESIDENTS (APPRVD PROG) SKILLED NURSING FACILITY NURSING FACILITY INTERMEDIATE CARE FACILITY - MENTALLY RETARDED OTHER LONG TERM CARE RADIOLOGY LABORATORY INTRAVENOUS THERAPY OXYGEN (INHALATION) THERAPY PHYSICAL THERAPY OCCUPATIONAL THERAPY SPEECH PATHOLOGY ELECTROCARDIOLOGY MEDICAL SUPPLIES CHARGED TO PATIENTS DRUGS CHARGED TO PATIENTS DENTAL CARE - TITLE XIX ONLY SUPPORT SURFACES CLINIC RURAL HEALTH CLINIC ADMINISTRATIVE & GENERAL - HHA SKILLED NURSING CARE - HHA PHYSICAL THERAPY - HHA OCCUPATIONAL THERAPY - HHA SPEECH PATHOLOGY - HHA MEDICAL SOCIAL SERVICES - HHA HOME HEALTH AIDE - HHA DME RENTED - HHA DME SOLD - HHA HOME DELIVERED MEALS - HHA OTHER HOME HEALTH SERVICES – HHA TELEMEDICINE AMBULANCE INTERNS & RESIDENTS (NOT APPROVED) MALPRACTICE PREMIUMS & PAID LOSSES INTEREST EXPENSE UTILIZATION REVIEW - SNF HOSPICE OTHER SPECIAL PURPOSE COST GIFT, FLOWER, COFFEE SHOPS &CANTEEN BARBER & BEAUTY SHOP PHYSICIANS’ PRIVATE OFFICES NONPAID WORKERS PATIENTS’ LAUNDRY	CAP REL COSTS - BLDGS & FIXTURES CAP REL COSTS - MOVEABLE EQUIPMENT EMPLOYEE BENEFITS ADMINISTRATIVE & GENERAL PLANT OPERATION, MAINT. & REPAIRS LAUNDRY & LINEN SERVICE HOUSEKEEPING DIETARY NURSING ADMINISTRATION SKILLED NURSING FACILITY NURSING FACILITY OTHER LONG TERM CARE RADIOLOGY LABORATORY INTRAVENOUS THERAPY OXYGEN (INHALATION) THERAPY PHYSICAL THERAPY OCCUPATIONAL THERAPY SPEECH PATHOLOGY ELECTROCARDIOLOGY MEDICAL SUPPLIES CHARGED TO PATIENTS DRUGS CHARGED TO PATIENTS DENTAL CARE - TITLE XIX ONLY SUPPORT SURFACES UTILIZATION REVIEW – SNF OTHER SPECIAL PURPOSE COST BARBER & BEAUTY SHOP

35-505.1 Rev. 12

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

Column headings for the General Service cost centers on Worksheets B, Parts I and II, B-1, and J‑1, Part III (lines 1‑3) are supplied once. They consist of one to three records. Each statistical basis shown on Worksheet B‑1, Worksheet J-1, Part III, and Worksheet K-5 is also reported. The statistical basis consists of one or two records (lines 4 and 5). Statistical basis code is supplied only to Worksheet B‑1 columns and is recorded as line 6. This code is applied to all general service cost centers and subscripts as applicable. The statistical code must agree with the statistical bases indicated on lines 4 and 5, i.e., code 1 = square footage; code 2 = dollar value; code 3 = other basis, as preprinted on Worksheet B-1, Worksheet J-1, and Worksheet K-5; and code 4 = other than the preprinted basis, as permitted by your fiscal intermediary. When a column is subscripted and an "other" statistical basis is used, if the basis matches the preprinted basis of the main line, use code 3. When the basis of the subscripted line does not match the preprinted basis of the main line, use code 4. Refer to Table 2 for the special worksheet identifier used with column headings and statistical basis and to Table 3 for line and column references.

For the full cost report, use the exact formatting displayed below for column headings for Worksheets B‑1, B, Parts I and II, Worksheet J-1, Part III (lines 1-3), and Worksheet K-5, Part II, statistical bases used in cost allocation on Worksheet B-1 Worksheet J-1, Part III (lines 4 and 5), and Worksheet K-5, Part II, and statistical codes used for Worksheet B‑1 (line 6). Type 2 records for J-1, columns 1-14, are listed below as well. The numbers at the top of the columns represent the line number of the type 2 record. The numbers running vertical to line 1 descriptions are the general service cost center line designation.

LINE

	1	2	3	4	5	6
1	CAP REL	BUILD &	FIXTURES	SQUARE	FEET	1
2	CAP REL	MOVEABLE	EQUIPMENT	SQUARE	FEET	1
3	EMPLOYEE	BENEFITS		GROSS	SALARIES	3
4	ADMINIS-	TRATIVE &	GENERAL	ACCUM.	COST	3
5	PLANT OPER	MAINT. &	REPAIR	SQUARE	FEET	1
6	LAUNDRY	& LINEN	SERVICE	POUNDS OF	LAUNDRY	3
7	HOUSE-	KEEPING		HOURS OF	SERVICE	3
8	DIETARY			MEALS	SERVED	3
9	NURSING	ADMINIS-	TRATION	DIRECT	NURSING	3
10	CENTRAL	SERVICES &	SUPPLY	COSTED	REQUIS.	3
11	PHARMACY			COSTED	REQUIS.	3
12	MEDICAL	RECORDS &	LIBRARY	TIME	SPENT	3
13	SOCIAL	SERVICE		TIME	SPENT	3
14	INTERNS &	RESIDENTS		ASSIGNED	TIME	3

Rev. 12 35-505.2

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

U se the exact formatting displayed below for column headings for Worksheet K-4, Part II. The numbers at the top of the columns represent the line number of the type 2 record. The numbers running vertical to line 1 descriptions are the general service cost center line designation.

L INE

	1	2	3	4	5	6
2	CAP REL	COST	MOVABLE	EQUIPMENT	$ VALUE	1
3	PLANT	OPERATION	& MAINT.	SQ. FT.		3
4	TRANS-	PORTATION	MILEAGE			3
5	VOLUNTEER	SERV.	COORDI-	NATOR	HOURS	3

For the simplified cost report, use the exact formatting displayed below for column headings for Worksheets B‑1, Part II, and B, Part III,. The numbers at the top of the columns represent the line number of the type 2 record. The numbers running vertical to line 1 descriptions are the general service cost center line designation.

LINE

	1	2	3	4	5	6
1	CAP REL	COST		SQUARE	FEET	1
2	EMPLOYEE	BENEFITS		GROSS	SALARIES	3
3	PATIENT	SERVICES	COST	PATIENT	DAYS	3
4	ADMINIS-	TRATIVE &	GENERAL	ACCUM.	COST	3

Cost centers included in the line one (CAP REL COST) caption are: Capital Related Costs; Plant Operation Maintenance & Repair; and Housekeeping. Cost centers included in the line three (PATIENT SERVICES COST) caption are: Laundry; Diet; Nursing Administration; Central Supply; Pharmacy; and Social Services.

Examples:

Worksheet A line labels with embedded cost center codes:

* 2A000000 1 0100CAP REL COSTS - BLDGS & FIXTURES

* 2A000000000000100000000101CAP REL COSTS - WEST WING

2A000000 2 0200CAP REL COSTS - MOVABLE EQUIPMENT

2A000000 4 0400ADMINISTRATIVE & GENERAL

2A000000 8 0800DIETARY

2A000000 21 2100RADIOLOGY

2A000000 21 1 2101RADIOLOGY - DIAGNOSTIC

2A000000 27 2700SPEECH PATHOLOGY

35-506

Rev. 12

12-99 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

Examples of column headings for Worksheets B‑1, B, Parts I and II, and Worksheet J-1, Part III (lines 1-3), statistical bases used in cost allocation on Worksheet B-1 and Worksheet J-1, Part III (lines 4 and 5), and statistical codes used for Worksheet B‑1 (line 6) are displayed below.

2B10000* 1 1 CAP REL

2B10000* 2 1 BLDGS &

2B10000* 3 1 FIXTURES

2B10000* 4 1 (SQUARE

2B10000* 5 1 FEET)

2B10000* 6 1 1

2B10000* 1 3 EMPLOYEE

2B10000* 2 3 BENEFITS

2B10000* 4 3 (GROSS

2B10000* 5 3 SALARIES)

2B10000* 6 3 3

RECORD NAME: Type 3 Records for Nonlabel Data

		Size	Usage	Loc.	Remarks
1.	Record Type	1	9	1	Constant "3"
2.	Wkst. Indicator	7	X	2-8	Alphanumeric. Refer to Table 2.
3.	Spaces	2	X	9-10
4.	Line Number	3	9	11-13	Numeric
5.	Subline Number	2	9	14-15	Numeric
6.	Column Number	3	X	16-18	Alphanumeric
7.	Subcolumn Number	2	9	19-20	Numeric
8.	Field Data
	a. Alpha Data	36	X	21-56	Left justified. (Y or N for yes/no answers; dates must use MM/DD/YYYY format - slashes, no hyphens.) Refer to Table 6 for additional requirements for alpha data.
		4	X	57-60	Spaces (optional).

Rev. 7 35-506.1

11-98 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

RECORD NAME: Type 3 Records for Nonlabel Data

b. Numeric Data

16

9

21-36

Right justified. May contain embedded decimal point. Leading zeros are suppressed; trailing zeros to the right of the decimal point are not. (See example below.) Positive values are presumed; no "+" signs are allowed. Use leading minus to specify negative values. Express percentages as decimal equivalents, i.e., 8.75% is expressed as .087500. All records with zero values are dropped. Refer to Table 6 for additional requirements regarding numeric data.

A sample of type 3 records and a number line for reference are below.

123456789 5 8 6

3A000000 4 1 32961

3A000000 13 1 1336393

3A000000 13 1 1 185599

3A000000 1 2 10147750

3A000000 2 2 14596

The line numbers are numeric. In several places throughout the cost report (see list below), the line numbers themselves are data. The placement of the line and subline numbers as data must be uniform.

Worksheet A-6, column 3 and 7

Worksheet A-8, column 4

Worksheet A-8-1, Part B, column 1

Worksheet A-8-2, column 1

Worksheet B-2, column 3

Examples of records (*) with a Worksheet A line number as data and a number line for reference are below.

1 1 2

123456789 3 8 1

3A600001 13 0 TO SPREAD INTEREST EXPENSE

3A600001 13 1 G

* 3A600001 13 3 1

3A600001 13 5 221409

* 3A600001 13 7 51

3A600001 13 9 225321

3A600001 14 0 BETWEEN CAPITAL‑RELATED COST

3A600001 14 1 G

* 3A600001 14 3 4

3A600001 14 5 3912

3A600001 15 0 BUILDING & FIXTURES AND

Rev. 4 35-507

595 (Cont.) FORM CMS 2540-96 11-98

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 1 - RECORD SPECIFICATIONS

3A600001 16 0 ADMINISTRATIVE AND GENERAL

3A800000 23 0 RENUM APPLIC TO PHYS

3A800000 23 1 A

3A800000 23 2 ‑250935

* 3A800000 23 4 15

3A800000 23 1 0 STAND BY COST

3A800000 23 1 1 A

3A800000 23 1 2 ‑114525

3A800000 23 1 4 16

* 3A820010 3 1 2101

* 3A820010 4 1 2101

3A820010 4 2 DR. B

3A820010 4 3 126292

3A820010 4 4 94719

3A820010 4 5 31573

3A820010 4 6 124900

3A820010 4 7 741

3A820010 4 1 2 6860

3A820010 4 1 4 12000

RECORD NAME: Type 4 Records - File Encryption

This type 4 record consists of 3 records: 1, 1.01, and 1.02. These records are created at the point in which the ECR file has been completed and saved to disk and insures the integrity of the file.

35-508 Rev. 4

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 2 - WORKSHEET INDICATORS

This table contains the worksheet indicators that are used for electronic cost reporting. A worksheet indicator is provided only for those worksheets from which data are to be provided.

The worksheet indicator consists of seven digits in positions 2‑8 of the record identifier. The first two digits of the worksheet indicator (positions 2 and 3 of the record identifier) always show the worksheet. The third digit of the worksheet indicator (position 4 of the record identifier) is used in several ways. First, it may be used to identify worksheets for multiple SNF-based components. Alternatively, it may be used as part of the worksheet, e.g., A81. The fourth digit of the worksheet indicator (position 5 of the record identifier) represents the type of provider, by using the keys below. Except for Worksheets A‑6 and A‑8 (to handle multiple worksheets), the fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record identifier) identify worksheets required by a Federal program (18 = Title XVIII, 05 = Title V, or 19 = Title XIX) or worksheet required for the facility (00 = Universal), and to identify on Worksheet H-5 the two digit identifier which corresponds to the two digit subscript of question 17 on Worksheet S-4 identifying the MSA in which the provider performed services during the cost reporting period. The seventh digit of the worksheet indicator (position 8 of the record identifier) represents the worksheet part.

Provider Type - Fourth Digit of the Worksheet Identifier

Worksheets

Universal..............................0 (Zero)

SNF......................................A

NF........................................B

CMHC.................................C

CORF...................................D

OPT......................................E

OOT......................................F J-1, J-2, J-3, J-4, S-6

OSP......................................G

ICF/MR................................I

HOSPICE.............................K K, K-1, K-2, K-3, K-4, K-5, K-6

FQHC...................................Q I-1, I-2, I-3, I-4, I-5, S-5

RHC......................................R I-1, I-2, I-3, I-4, I-5, S-5

Worksheets That Apply to the SNF Cost Report (Full or Simplified)

	Worksheet	Worksheet Indicator - Full Cost Report	Worksheet Indicator - Simplified Cost Report
	S, Part I	S000001	S000001
	S, Part II	S000002	S000002
	S-2	S200000	S200000
	S-3, Part I	S300001	S300001
	S-3, Part II	S300002	S300002
	S-3, Part III	S300003	S300003

Rev. 12 35-509

3595 (Cont.) FORM CMS 2540-96 02-03

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TABLE 2 - WORKSHEET INDICATORS

Worksheets That Vary by Component and/or Program

Worksheet	Title V	Title XVIII	Title XIX
S-4, Part I	S410051 (a)	S410181 (a)	S410191 (a)

Worksheets That Apply to the SNF Cost Report (Full or Simplified)

Worksheet	Worksheet Indicator Fill Cost Report		Worksheet Indicator Simplified Cost Report
S-4, Part II	S410002	(a)
S-4, Part III	S410003
S-5	S51?000	(h)
S-6	S61?000	(b)
S-7, Part I	S700001
S-7, Part II	S700002
S-7, Part III	S700003

S-7, Part IV	S700004		S700004
S -8	S800000	(a)
A	A000000		A000000
A-6	A600001	(c)	A600100
A-7	A700000		A700000
A-8	A800000		A800000
A-8-1, Part A	A81000A		A81000A
A-8-1, Part B	A81000B
A-8-1, Part C	A81000C
A-8-2	A820010	(c)
A-8-3	A830000	(d)	A830000
A-8-4	A840000	(d)	A840000
A-8-5	A85?000	(g)

35-510 Rev. 12

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 2 - WORKSHEET INDICATORS

Worksheets That Apply to the SNF Cost Report (Full or Simplified)

Worksheet	Worksheet Indicator Full Cost Report		Worksheet Indicator Simplified Cost Report
B-1 (For use in column headings)	B10000*
B, Part I	B000001
B, Part II	B000002
B, Part III			B000003
B-1, Part I	B100000
B-1, Part II			B100002
B-2	B200010	(c)
C	C000000		C000000

Worksheets That Vary by Component and/or Program –

Worksheet	Title V	Title XVIII	Title XIX
D, Part I (SNF)	D00A051 (f)	D00A181	D00A191
D, Part I (NF)	D00B051		D00B191
D, Part I (ICF/MR)			D00I191
D, Part II (SNF)	D00A052 (e), (f)	D00A182	D00A192 (e), (f)
D, Part II (NF)	D00B052 (e)		D00B192 (e)
D-1 (SNF)	D10A050 (f)	D10A180	D10A190 (f)
D-1 (NF)	D10B050		D10B190
D-1 (ICF/MR)			D10I190

Worksheet That Applies to the SNF Complex – Full Cost Report

D-2

D200000

(d)

Rev. 11

35-510.1

08-01 FORM CMS 2540-96 3595 (Cont.)

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TABLE 2 - WORKSHEET INDICATORS

Worksheets That Vary by Component and/or Program - Full Cost Report

Worksheet	Title V	Title XVIII	Title XIX
E, Part I (SNF)	E00A051 (f)	E00A181	E00A191 (f)
E, Part I (NF)	E00B051		E00B191
E, Part I (ICF/MR			E00I191
E, Part II		E00A182
E, Part III	E00A053	E00A183	E00A193
E, Part V		E00A185
E-1		E10A180

Worksheets That Vary by Component and/or Program –Simplified Cost Report

Worksheet	Title V	Title XVIII	Title XIX
E, Part III	E00A053	E00A183	E00A193
E-1		E10A180

Worksheet That Applies to the SNF Cost Report

	Worksheet Indicator Full Cost Report		Worksheet Indicator Simplified Cost Report

G	G000000		G000000
G-1	G100000		G100000
G-2, Part I	G200001		G200001
G-2, Part II	G200002		G200002
G-3	G300000		G300000
H	H010000	(a)
H-1	H110000	(a)
H-2	H210000	(a)
H-3	H310000	(a)
H-4, Parts I & II	H410002	(a)
H-5, Parts III- V	H510003	(a,d)

Rev. 11 35-511

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TABLE 2 - WORKSHEET INDICATORS

Worksheet That Varies by Program – Full Cost Report

Worksheet	Title V	Title XVIII	Title XIX
H-5, Parts I & II	H510052 (a,i)	H510082 (a,i)	H510092 (a,i)
H-6, Parts I & II	H610052 (a)	H610182 (a)	H610192 (a)

Worksheets That Apply to the SNF Complex _Full Cost Report

	Worksheet	Worksheet Indicator
	H-7	H710000	(a)
	I-1	I11?000	(h)
	I-2	I21?000	(h)
	I-5	I51?000	(h)

W orksheet That Varies by Program - Full Cost Report

Worksheet	Title V	Title XVIII	Title XIX
I-3	I3?052	I31?182	I31?192
I-4	I4?052	I41?182	I41?192

Worksheets That Vary by Component and/or Program - Full Cost Report

	Worksheets	Worksheet Indicator
	J-1, Part I	J11?001	(b)
	J-1, Part III	J11?003	(b)
	J-2	J21?000	(b)
	J-3, Part I	J31?000	(b, d)

Worksheet That Varies by Program - Full Cost Report

Worksheet	Title V	Title XVIII	Title XIX
J-3, Part II	J31?052	J31?182	J31?192
J-3, Part III	J31?053	J31?183	J31?193 (b)

Worksheets That Apply to the SNF Complex - Full Cost Report

	J-4	J41?000

35-511.1 Rev. 11

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 2 - WORKSHEET INDICATORS

Worksheets That Apply to the Hospice Complex

	K	K010000
	K-1	K110000	(j)
	K-2	K210000	(j)
	K-3	K310000	(j)
	K-4, Part I	K410001	(j)
	K-4, Part II	K410002	(j)
	K-5, Part I	K510001	(j)
	K-5, Part II	K510002	(j)
	K-5, Part III	K510003	(j)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 2 - WORKSHEET INDICATORS

FOOTNOTES:

(a) Multiple SNF‑Based Home Health Agencies (HHAs)

T he 3rd digit of the worksheet indicator (position 4 of the record) is numeric to identify the SNF-based HHA. If there is only one home health agency, the default is 1. This affects all H series worksheets, and Worksheet S-4.

b) Multiple Outpatient Rehabilitation Providers

The third digit of the worksheet indicator is numeric from 1 to 9 to accommodate multiple providers. If there is only one outpatient provider type, the default is 1. The fourth character of the worksheet indicator (position 5 of the record) indicates the outpatient rehabilitation provider as listed above. This affects all J series worksheets and Worksheet S-6.

(c) Multiple Worksheets for Reclassifications and Adjustments Before and After Step-down

The fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record) are numeric from 01‑99 to accommodate reports with more lines on Worksheets A-6, A-8-2, and/or B‑2. For reports that do not need additional worksheets, the default is 01. For reports that do need additional worksheets, the first page of each worksheet is numbered 01. The number for each additional page of each worksheet is incremented by 1.

(d) Worksheet with Multiple Parts using Identical Worksheet Indicator

Although this worksheet has several parts, the lines are numbered sequentially. This worksheet identifier is used with all lines from this worksheet regardless of the worksheet part. This differs from the Table 3 presentation which identifies each worksheet and part as they appear on the cost report. This affects Worksheets A-8-3, A-8-4, D-2, H-5, Parts III through V, and J-2.

(e) States Apportioning Vaccine Costs Per Medicare Methodology

If, for titles V and/or XIX, your state directs providers to apportion vaccine costs using Medicare’s methodology, show these costs on a separate Worksheet D, Part II for each title.

Rev. 12 35-511.2

3595 (Cont.) FORM CMS 2540-96 02-03

(f) States Licensing the Provider as an SNF Regardless of the Level of Care

These worksheet identifiers are for providers licensed as an SNF for Titles V and XIX.

(g) Multiple Worksheet A-8-5

This worksheet is used for occupational, physical, or respiratory therapy and speech pathology services furnished by outside suppliers. The fourth digit of the worksheet indicator (position 5 of the record) is an alpha character of O for occupational therapy, P for physical therapy, R for respiratory therapy, and S for speech pathology services.

(h) Multiple Health Clinic Programs

The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0 to accommodate multiple providers. If there is only one health clinic provider type, the default is 1. The fourth character of the worksheet indicator (position 5 of the record) indicates the health clinic provider. Q indicates Federally qualified health center, and R indicates rural health clinic.

(i) Multiple Worksheets H-5, Part II for Cost Limitations Based on the MSA

The fifth and sixth digits of the worksheet indicator (positions 6 and 7 or the record) is numeric from 00-24 and corresponds to the two digit subscript of line 17 on Worksheet S-4 (i.e. insert the identifier 02 for line 17.02) which identifies the 4 digit MSA code. If services are provided in only one MSA, the default is 00. Where an HHA provides services in multiple MSA’s, one Worksheet H-5, Part II must be completed for each MSA.

(j) Multiple SNF‑Based Hospices (HSPSs)

T he 3rd digit of the worksheet indicator (position 4 of the record) is numeric to identify the SNF-based hospice. If there is only one hospice, the default is 1. This affects all K series worksheets, and Worksheet S-8

35-512 Rev. 12

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

This table identifies those data elements necessary to calculate a skilled nursing facility cost report. It also identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 18) are needed to verify the mathematical accuracy of the raw data elements and to isolate differences between the file submitted by the skilled nursing facility complex and the report produced by the fiscal intermediary. Where an adjustment is made, that record must be present in the electronic data file. For explanations of the adjustments required, refer to the cost report instructions.

Table 3 "Usage" column is used to specify the format of each data item as follows:

9 Numeric, greater than or equal to zero.

-9 Numeric, may be either greater than, less than, or equal to zero.

9(x).9(y) Numeric, greater than zero, with x or fewer significant digits to the left of the decimal point, a decimal point, and exactly y digits to the right of the decimal point.

X Character.

Consistency in line numbering (and column numbering for general service cost centers) for each cost center is essential. The sequence of some cost centers does change among worksheets. Refer to Table 4 for line and column numbering conventions for use with complexes that have more components than appear on the preprinted FORM CMS 2540-96.

Table 3 refers to the data elements needed from a standard cost report. When a standard line is subscripted, the subscripted lines must be numbered sequentially with the first subline number displayed as "01" or "1" in field locations 14‑15. It is unacceptable to format in a series of 10, 20, or skip subline numbers (i.e., 01, 03), except for skipping subline numbers for prior year cost center(s) deleted in the current period or initially created cost center(s) no longer in existence after cost finding. Exceptions are specified in this manual. For “Other (specify)” lines, i.e., Worksheet settlement series, all subscripted lines must be in sequence and consecutively numbered beginning with subscripted line “01". Automated systems must reorder these numbers where the provider skips a line number in the series.

Drop all records with zero values from the file. Any record absent from a file is treated as if it were zero.

All numeric values are presumed positive. Leading minus signs may only appear in data with values less than zero that are specified in Table 3 with a usage of "-9". Amounts that are within preprinted parentheses on the worksheets, indicating the reduction of another number, are to be reported as positive values.

Rev. 14 35-513

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET S

Part II: Balances due provider or program:
Title V	1, 3-6	1	9	-9
Title XVIII, Part A	1, 4	2	9	-9
Title XVIII, Part B	1, 4-6	3	9	-9
Title XIX	1, 3-6	4	9	-9
In total	7	1-4	9	-9

WORKSHEET S-2

For the skilled nursing facility only:
Street	1	1	36	X
P.O. Box	1	2	9	X
City	2	1	36	X
State	2	2	2	X
Zip Code	2	3	10	X
County	3	1	36	X
MSA Code	3	2	4	X
CBSA Code	3	2.01	5	X
Urban/Rural	3	3	1	X
Facility Specific Rate	3.1	1	11	9(8).99
Transition period	3.1	2	3	9(3)
Wage Index Adjustment Factor – Before October 1	3.2	1	6	9.9(4)
Wage Index Adjustment Factor – After September 30	3.2	2	6	9.9(4)
For the skilled nursing facility and SNF-based components:
Component name	4, 6, 8, 10-12	1	36	X
Provider number (xxxxxx)	4, 6, 8, 10-12	2	6	X
Date certified (MM/DD/YYYY)	4, 6, 8, 10-12	3	10	X

35-514 Rev. 14

04-06

FORM CMS 2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-2 (Continued)

DESCRIPTION		LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
For the skilled nursing facility and SNF-based components (continued):
Title V payment system	4, 6, 8, 10-11			4	1		X
Title XVIII payment system	4, 8, 10-11			5	1		X
Title XIX payment system	4, 6, 8, 10-11			6	1		X
Cost reporting period beginning date (MM/DD/YYYY)	13			1	10		X
Cost reporting period ending date (MM/DD/YYYY)	13			2	10		X
Type of control (See Table 3B.)	14			1	2		9
Is this an entirely participating skilled nursing facility? (Y/N)	15			1	1		X
A notice published in the Federal Register Vol. 68 N. 149 which provided for an increase in the Rug payments for services beginning 10/01/2003. This increase is expected to be used for direct patient care and related expenses.
Enter the percentage of total expenses for each of the following categories to total SNF revenue from inpatient care service
Staffing Recruitment Retention of employees Training	15.01 15.02 15.03 15.04			1 1 1 1	4 4 4 4		999.99 999.99 999.99 999.99
Is the increases spending associated with direct patient care and related expenses reflects each of the following categories (Y/N)
Staffing Recruitment Retention of employees Training	15.01 15.02 15.03 15.04			2 2 2 2	1 1 1 1		X X X X

Rev. 14		35-515
3595 (Cont.)	FORM CMS 2540-96		04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-2 (Continued)

DESCRIPTION		LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Other (Specify)	15.05-15.20			0	36		X
Enter the percentage of total expenses for Other to total SNF revenue from inpatient care service	15.05-15.20			1	4		999.99
Is the increases spending associated with direct patient care and related expenses reflects Other (Y/N)	15.05-15.20			2	1		X
Is this a partially participating skilled nursing facility? (Y/N)	16			1	1		X
Is this skilled nursing facility unit of a domiciliary institution? (Y/N)	17			1	1		X
Is this skilled nursing facility unit of a rehabilitation center? (Y/N)	18			1	1		X
Text as needed for blank line	19			0	36		X
Other type (Y/N)	19			1	1		X
If this is a low or no Medicare utilization cost report, enter "L" for low or "N" for no Medicare utilization. (L/N)	20			1	1		X
If this is an all-inclusive provider, enter the method used. (See Table 3B.)	21			1	1		X
Is the difference between total interim payments and the net cost covered service included in the balance sheet? (Y/N)	22			1	1		X
Enter the amount of depreciation reported in this SNF for the method indicated:
Straight Line	23			1	9		9
Declining Balance	24			1	9		9
Sum of the Years’ Digits	25			1	9		9

35-516 Rev. 14

04-06

FORM CMS 2540-96

3595(Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-2 (Continued)

DESCRIPTION	LINE(S)	COLUMN(S)		FIELD SIZE		USAGE
If depreciation is funded, enter the balance as of the end of the period.	27		1		9		9
Were there any disposals of capital assets during the cost reporting period? (Y/N)	28		1		1		X
Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)	29		1		1		X
Was accelerated depreciation claimed on assets acquired on or after August 1, 1970? (Y/N)	30		1		1		X
Did you cease to participate in the Medicare program at the end of the period to which this cost report applies? (Y/N)	31		1		1		X
Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reporting periods? (Y/N)	32		1		1		X

Rev. 14

35-516.1

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-2 (Continued)

If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of costs or charges, enter "Y" for each component and type of service that qualifies for the exemption. Enter "N" for each component and type of service contained in this facility that does not qualify for the exemption.

DESCRIPTION		LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Skilled Nursing Facility	33			1-2	1		X
Nursing Facility	35			3	1		X
I C F - M R	35.1			3	1		X
SNF-Based OLTC	36			1-2	1		X
SNF-Based HHA	37			1-2	1		X
SNF-Based Outpatient Rehabilitation Providers	39			2	1		X
SNF-Based RHC	40			2	1		X
Is this nursing facility exempt from the cost limits? (Y/N)	42			1	1		X
Is the skilled nursing facility located in a state that certifies the provider as an SNF regardless of the level of care given for titles V and XIX patients? (Y/N)	43			1	1		X
Did the provider participate in the NHCMQ Demonstration during the cost reporting period? (Y/N)	44			1	1		X
If yes, enter phase number.	44			0	2		9
List malpractice premium and paid losses
Premium:	45			1	11		9
Paid Losses:	45			2	11		9
Self Insurance:	45			3	11		9
Are malpractice premiums and paid losses reported in other than the Administrative and General cost Center? If yes, check box, and submit supporting schedules listing cost centers and amounts contained therein.	46			1	1		X

Rev. 12 35-517

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-2 (Continued)

DESCRIPTION	LINE(S)		COLUMN(S)	FIELD SIZE	USAGE
Are you claiming ambulance costs? Enter Y or N in column 1. If column 1 is Y, and this is your first year of operation for rendering ambulance services, enter Y in column 2. If it is not enter N.		47	1 & 2	1	X
If line 47 column 1 is Y, and Column 2 is N, enter in column 1 the payment limit provided from your FI. If your fiscal year is OTHER than a year beginning on October 1st, enter in column 1 the payment limit for the period prior to October 1, and enter in column 2 the payment limit for the period beginning October 1.		48	1 & 2	9	9(6).99
E nter the applicable fee schedule amounts for the P eriod beginning on or after 04/01/2002.		48.01	1	9	9(6).99
E nter in column 1 the subsequent ambulance p ayment limit as required. Subscript if more than 2 limits apply. Enter in column 2, the fee s chedule amounts for the initial or subsequent p eriod as applicable.		48.02 48.03	1	9	9(6).99
Did you operate an Intermediate Care Facility for the Mentally Retarded (ICF/MR) under title XIX?		49	1	1	X
Did this facility report less than 1500 Medicare days in its previous year’s cost report?		50	1	1	X
If line 50 is yes, did you file your previous year’s cost report using the “simplified” step-down method of cost finding?		51	1	1	X
Is this cost report being filed under 42CFR 413.321, the simplified cost report?		52	1	1	X

518. Rev.12

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-3, PART I

DESCRIPTION		LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Number of beds	1, 3-4, 8-9			1	9		9
Bed days available	1, 3-4, 8-9			2	9		9
Title V inpatient days	1, 3, 8-9			3	9		9
Title XVIII inpatient days	1, 8-9			4	9		9
Ambulance trips	10			4	9		9
Title XIX inpatient days	1, 3, 8-9			5	9		9
Other inpatient days	1, 3-4, 8-9			6	9		9
Total inpatient days	1, 3-4, 8-9			7	9		9
Title V discharges	1, 3, 8-9			8	9		9
Title XVIII discharges	1, 8-9			9	9		9
Title XIX discharges	1, 3, 8-9			10	9		9
Other discharges	1, 3-4,8-9			11	9		9
Total discharges	1, 3-4, 8-9			12	9		9
Title V average length of stay	1, 3, 8-9			13	9		9(6).99
Title XVIII average length of stay	1, 8-9			14	9		9(6).99
Title XIX average length of stay	1, 3, 8-9			15	9		9(6).99
Total average length of stay	1, 3-4, 8-9			16	9		9(6).99
Title V admissions	1, 3, 8-9			17	9		9
Title XVIII admissions	1, 8-9			18	9		9
Title XIX admissions	1, 3, 8-9			19	9		9
Other admissions	1, 3-4, 8-9			20	9		9
Total admissions	1, 3-4, 8-9			21	9		9
Full time equivalent employees on payroll	1, 3-5, 7-9			22	9		9(6).99
Full time equivalent nonpaid workers	1, 3-5, 7-9			23	9		9(6).99

Rev. 14 35-518.1

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-3, PART II

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE
Reported salaries	2-21	1	9	9
Reclassification of salaries from Wkst. A-6	2-21	2	9	-9
Adjusted Salaries	16&22	3	9	9
Paid hours related to salary	1-21	4	9	9(7).99
Average Hourly Wage	1-18,23	5	9	9.99
Data source	2-5, 18	6	36	X
Subtotal (see instructions):
Reported salaries	22	1	9	9
Reclassification of salaries	22	2	9	-9
Total (see instructions):
Reported salaries	23	1	9	9
Reclassification of salaries	23	2	9	-9
Paid hours related to salary	23	4	9	9(7).99
Contract labor: physician services - Part A:
Reported salaries	24	1	9	9
Reclassification of salaries	24	2	9	-9
Paid hours related to salary	24	4	9	9(7).99
Data source	24	6	36	X

WORKSHEET S-3, PART III

DESCRIPTION	LINE(S)			COLUMN(S)		FIELD SIZE		USAGE
Reclassification of salaries from Worksheet A-6		1-13	2		9		-9
Paid hours related to salary		1-13	4		9		9(7).99
Total (sum of lines 1-13)
Reported salaries		14	1		9		9
Reclassification of salaries		14	2		9		-9
Paid hours related to salary		14	4		9		9(7).99

35-518.2 Rev 14

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-4, PART I

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE
Number of HHA visits, by discipline:
Program	1-6	2	9	9
Non-Program	1-7	5	9	9
Total	1-8	8	9	9
Patient count, by discipline:
Program	1-6	3	9	9
Non-Program	1-7	6	9	9
Total	1-7	9	9	9

Home health aide hours:
Program	6	1	9	9
Non-Program	6	4	9	9
Total	6	7	9	9
Unduplicated census count:
Program	9	3	9	9.99
Non-Program	9	6	9	9.99
Total	9	9	9	9.99
Unduplicated census count Pre October 1, 2000:
Program	9.01	3	9	9.99
Non-Program	9.01	6	9	9.99
Total	9.01	9	9	9.99
Unduplicated census count Post September 30, 2000
Program	9.02	3	9	9.99
Non-Program	9.02	6	9	9.99
Total	9.02	9	9	9.99

Rev. 12 35-519

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-4, PART II

Number of hours in a normal work week	0	0	6	9(3).99
Text as needed for blank lines	13-15	0	36	X
Number of full time equivalent employees:
Staff	1-15	1	6	9(3).99
Contract	1-15	2	6	9(3).99
How many MSA’s did you provide services to during this cost reporting period?	16	1	2	9
List those MSA code(s) serviced this period.	17	1	4	X

WORKSHEET S-4, Part III

Covered Home Health Visits by Discipline for each Payment Category	1,3,5,7, 9.11	1-6	9	9
HH Charges by Discipline for each Payment Category	2,4,6,8, 10,12	1-6	9	9
Total Visits	13	1-6	9	9
Other Charges	14	1-6	9	9
Total Charges	15	1-6	9	9
Total number of episodes	16	1, 3-6	9	9
Total number of outlier episodes	17	2, 4-6	9	9
Total non-routine Medical supply charges for each payment category	18	1-6	9	9
Total HH visits by discipline for each payment category	1,3,5,7,9,11	7	9	9
Total Medical supply charges for each payment category	2,4,6,8, 10,12	7	9	9
Total Visits	13	7	9	9
Other Charges	14	7	9	9
Total Charges	15	7	9	9
Total Number of Episodes	16	7	9	9
Total Number of Outlier Episodes	17	7	9	9
Total Medical Supply Charges	18	7	9	9

35-520 Rev. 12

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET S-5

RHC/FQHC Identification:
Street	1		1	36	X
County	1		2	36	X
City	2		1	36	X
State	2		2	2	X
Zip Code	2		3	10	X
Designation for FQHC’s only “R” for rural or “U” for urban	3		1	1	X
Source of Federal funds:
Amount of Federal Funds:		4-9	1	11	9
Award Date (MM/DD/YYYY)		4-9	2	10	X
Other (specify)		9	0	36	X
Physician(s) furnishing services at the clinic or under agreement
Physician Name		10	1	36	X
Billing Number		10	2	36	X
Supervision
Supervisory physician name		11	1	36	X
Number of hours of supervision during period		11	2	11	9(8).99
Does this facility operate as other than an RHC or FQHC?		12	1	1	X
Indicate number of operation(s)		12	2	2	9
Facility hours of operations *
Clinic - Hours: from/to		13	1-14	4	9

* List hours of operations based on a 24 hour clock. For example 8:00 is 0800, 6:30pm is 1830, and midnight is 2400.

Rev.11 35-521

3595 (Cont.) FORM CMS 2540-96 08-01

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET S-5 (Continued)

DESCRIPTION	LINE(S)		COLUMN(S)		FIELD SIZE		USAGE
Other operations	13.01-13.10	0		36		X
Other operations - Hours: from/to	13.01-13.10	1-14		4		9
Have you received an approval for an exception to the productivity standard?	14	1		1		X
Is this a consolidated cost report in accor- dance with CMS Pub. 27, section 508D	15	1		1		X
Enter the number of providers included in this report	15	2		2		9
Provider Name	15.01-15.10	1		36		X
Provider Number	15.01-15.10	2		6		X
Have you provided all or substantially all GME cost?	16	1		1		X
Enter the number of Medicare visits performed by Interns and Residents	16	2		5		9

WORKSHEET S-6

Number of hours in a normal work week	0	0	6	9(3).99
Text as needed for blank lines	18-19	0	36	X
Number of full time equivalent employees on staff	1-19	1	6	9(3).99
Number of full time equivalent contract personnel	1-19	2	6	9(3).99

WORKSHEET S-7, PART I

Title XVIII NHCMQ Demonstration Statistical Data

Rates (see instructions)	1-45	3, 4	6	9(3).99
Days (see instructions)	1-45	3.01, 4.01	6	9

WORKSHEET S-7, PART II

Rates (See instructions)	1-45	3,5	6	9(3).99
Medicare Days	1-45	4,6	6	9

35-521.1 Rev. 11

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

Worksheet S-7, Part III

Transition Period	0	1-4	1	X
Facility Specific Rate	1-45	2	6	9(8).99
Federal Case Mix Rate	1-45	3	6	9(8).99
Federal Case Mix Rate	1-6, 8,9, 12 – 14, 27 - 45	5	6	9(8).99
Federal Rate – High Cost Add On	7,10,11, 15-26	3.01& 5.01	6	9(8).99
Days (Prior to 10/01/XXXX)	1-45	4	6	9
Add On Days (Services on and after 04/01/2000, but prior to 10/01/2000)	7,10,11, 15-26	4.01	6	9
Days (After 09/30/XXXX)	1-45	6	6	9
Add On Days (Services on and after 10/01/2000)	7,10,11, 15-26	6.01	6	9
Federal Case Mix	1-45	7	9	9
Facility Specific	1-45	8	9	9
Blend Amounts	1-45	9 & 10	9	9

Worksheet S-7, Part IV

Rate (see instructions)	1-45	3, 4, & 4.02	6	9(3).99
D ays (see instructions)	1-45	3.01, 4.01, & 4.03	6	9
High Cost RUGs days	7,10-11 & 15-26	4.05	6	9
Total (see instructions)	1 - 45	5	11	9

Rev. 12		35-521.2
3595 (Cont.)	FORM CMS 2540-96		02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

Worksheet S-8

Part I Continuous Home Care	1	1-5	9	9
Routine Home Care	2	1-5	9	9
Inpatient Respite Care	3	1-5	9	9
General Inpatient Care	4	1-5	9	9
Part II Number of Patients Receiving Hospice Care	6	1 –5	9	9
T otal number of Unduplicated Continuous Care Hours	7	1 & 3	9	9(8).99
Unduplicated Census Count	9	1-5	9	9

WORKSHEET A

Direct salaries by department	3-16,18-19,21-51,54-56,58-63	1	9	-9
Total direct salaries	75	1	9	9
Other direct costs by department	1-16,18-19,21-51,52-56,58-63	2	9	-9
Total other direct costs	75	2	9	9
Net expenses for cost allocation by department	1-16,18-19,21-51,55-56,58-63	7	9	-9
Total net expenses for cost allocation	75	7	9	9

WORKSHEET A-6

For each expense reclassification:
Explanation	1-35	0	36	X
Reclassification code	1-35	1	2	X

35-522

Rev. 12

12-99 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-6 (Continued)

Increases:
Worksheet A line number	1-35	3	5	99.99
Salary amount	1-35	4	9	9
Non salary amount	1-35	5	9	9
Decreases:
Worksheet A line number	1-35	7	5	99.99
Salary amount	1-35	8	9	9
Non salary amount	1-35	9	9	9

WORKSHEET A-7

Analysis of changes in capital assets balances for land, land improvements, buildings and fixtures, building improvements, fixed and movable equipment, and in total:
Beginning balances	1-7	1	9	9
Purchases	1-7	2	9	9
Donations	1-7	3	9	9
Disposals and retirements	1-7	5	9	9

Rev. 7 35-523

3595 (Cont.) FORM CMS 2540-96 12-99

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-8

Description of adjustment	31	0	36	X
Basis (A or B)	1-7, 9-11, 13-21,28-31	1	1	X
Amount	1-7, 9-11, 13-21,28-31	2	9	-9
Worksheet A line number	1-7, 9-11, 13-21, 31	4	5	99.99

WORKSHEET A-8-1

Part A - Are there any costs included in Worksheet A that resulted from transactions with related organizations? If Yes, include a record containing an X. If No, include a record containing an X.	1 1	1 2	1 1	X X
Part B - For costs incurred and adjustments required as a result of transactions with related organization(s):
Worksheet A line number	1-9	1	5	99.99
Expense item(s)	1-9	3	36	X
Amount included in Wkst. A	1-9	4	9	-9
Amount allowable in reimbursable cost	1-9	5	9	-9

35-524 Rev. 7

12-97 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-8-1 (Continued)

Part C - For each related organization:
Type of interrelationship (A - G)	1-10	1	1	X
If type is G, specify description of relationship	1-10	0	36	X
Name of individual or partnership with interest in provider and related organization	1-10	2	15	X
Percent of ownership of provider	1-10	3	6	9(3).99
Name of related organization	1-10	4	15	X
Percent of ownership of related organization	1-10	5	6	9(3).99
Type of business	1-10	6	15	X

WORKSHEET A-8-2

By each cost center or physician:
Worksheet A line number	1-74	1	5	99.99
Physician identifier	1-74	2	36	X
Total physicians; remuneration	1-74	3	9	9
Physicians’ remuneration - professional component	1-74	4	9	9
Physicians’ remuneration - provider component	1-74	5	9	9
RCE amount	1-74	6	9	9
Number of physicians’ hours - provider component	1-74	7	9	9
Cost of memberships and continuing education	1-74	12	9	9

Rev. 3 35-525

3595 (Cont.) FORM CMS 2540-96 12-97

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-8-2 (Continued)

Physician cost of malpractice insurance	1-74	14	9	9
In total for the facility:
Total physicians’ remuneration	75	3	9	9
Physicians’ remuneration - professional component	75	4	9	9
Physicians’ remuneration - provider component	75	5	9	9
Number of physicians’ hours - provider component	75	7	9	9
Cost of memberships and continuing education	75	12	9	9
Physician cost of malpractice insurance	75	14	9	9

WORKSHEET A-8-3

Total number of weeks during which outside suppliers (excluding aides) worked	1	1	9	9
Number of unduplicated days - supervisors or therapists	3	1	9	9
Number of unduplicated days - therapy assistants	4	1	9	9
Number of unduplicated HHA visits - supervisors or therapists	5	1	9	9
Number of unduplicated HHA visits - therapy assistants	6	1	9	9
Standard travel expense rate	7	1	5	99.99
Optional travel expense rate per mile	8	1	3	.99

35-526 Rev. 3

12-97 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-8-3 (Continued)

Total hours worked by discipline	9	1-4	11	9(8).99
AHSEA by discipline	10	1-4	5	99.99
Number of travel hours (HHA only) by discipline	12	1-3	9	9
Number of miles driven (HHA only) by discipline	13	1-3	9	9
Travel allowance and expense - include only one	36,37, or 38	1	9	9
Overtime hours worked during period by discipline	39	1-3	7	9(4).99
Number of hours in provider’s standard work year	43	4	7	9(4).99
Equipment cost	53	1	9	9
Supplies	54	1	9	9
Total cost of outside supplier services	56	1	9	9
Cost of outside supplier services - SNF	58	1	9	9
Cost of outside supplier services - HHA	59	1	9	9

WORKSHEET A-8-4

Total number of weeks during which outside suppliers (excluding aides) worked	1	1	9	9
Unduplicated days - registered therapist	3	1	9	9
Unduplicated days - certified therapist	4	1	9	9
Unduplicated days - nonregistered, noncertified therapist	5	1	9	9
Standard travel expense rate	6	1	5	99.99

Rev. 4 35-527

3595 (Cont.) FORM CMS 2540-96 11-98

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-8-4 (Continued)

Total hours worked by discipline	7	1-8	11	9(8).99
AHSEA by discipline	8	1-8	5	99.99
Overtime hours worked during period by discipline	29	1-5	7	9(4).99
Number of hours in provider’s standard work year	33	6	7	9(4).99
Equipment cost	42	1	9	9
Supplies	43	1	9	9
Total cost of outside supplier services	45	1	9	9

W ORKSHEET A-8-5

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

Total number if weeks worked during which outside suppliers worked	1	1	11	9
Number of unduplicated days on which supervisor or therapist was on provider site (see instructions)	3	1	11	9
Number of unduplicated days on which therapy assistance was on provider site but neither supervisor nor therapist was on provider site (see instructions)	4	1	11	9
Number of unduplicated HHA visits - supervisors or therapist (see instructions)	5	1	11	9
Number of unduplicated HHA visits - therapy assistants (include only visits made by therapy assistant and on which supervisor and/or therapist was not present during the visit(s)) (see instructions)	6	1	11	9

35-528 Rev. 4

02-03

FORM CMS 2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET A-8-5 (CONTINUED)

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

Standard travel expense rate	7	1	5	99.99
Optional travel expense rate per mile	8	1	3	.99
Total hours worked by discipline	9	1-5	11	9(8).99
ASHEA by discipline	10	1-5	5	99.99
Number of travel hours by discipline	12	1-3	11	9
Number of miles driven by discipline	13	1-3	11	9
Weighted average rate excluding aides and trainees (see instructions)	21	1	11	9(8).99
W eighted allowance excluding aides and trainees (see instructions)	22	1	11	9
T otal salary equivalency (see instructions)	23	1	11	9
Travel allowance and expense - include only one	44, 45, 46	1	11	9
Overtime hours worked during period by discipline (see instructions)	47	1-4	11	9(8).99
A llocation of provider’s standard workyear for one full-time employee times the percentages on line 50 (see instructions)	51	5	7	9(4).99
Equipment cost (see instructions)	61	1	11	9
Supplies (see instructions)	62	1	11	9
Total cost of supplier services (from your records)	64	1	11	9
Cost of outside supplier services - SNF (from your records)	66	1	11	9
Cost of outside supplier services - CORF (from your records)	67	1	11	9

Rev. 12 35-528.1

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET A-8-5 (CONTINUED)

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

Cost of outside supplier services - CMHC (from your records) Cost of outside supplier services - OPT (from your records) Cost of outside supplier services - HHA (from your records

68 69 70

1 1 1

11 11 11

9 9 9

*Line designation for SNF and components; SNF = 66.00, CORF = 66.10-6610, CMHC = 66.11-66.20, OPT = 66.21-66.30, HHA = 66.31-66.40, OOT = 66.41-66.50, OSP, 66.51-66.60.

This sequence should be used on lines 68 and 69.

WORKSHEETS B-1; B, PARTS I-II; AND J-1, PARTS I AND III

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

Column heading (cost center name)	1-3 *	1-3, 4-15	10	X
Statistical basis	4, 5 *	1-3, 4-15	10	X

* Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings. There may be up to five type 2 records (3 for cost center name and 2 for the statistical basis) for each column. However, for any column that has less than five type 2 record entries, blank records or the word "blank" is not required to maximize each column record count.

WORKSHEET B, PART I

Total adjustments after cost finding	75	17	9	-9
Costs after cost finding and post step-down adjustments by department	16, 18-19, 21-51, 55, 56, 58-65	18	9	-9
Total costs after cost finding and post step-down adjustments	75	18	9	9

WORKSHEET B, PART II

Directly assigned capital related costs by department	1-16, 18-19, 21-51, 55, 56, 58-63	0	9	9
Total directly assigned capital related costs	75	0	9	9
Total adjustments after cost finding	75	17	9	-9
Total capital related costs after cost finding by department	16, 18-19, 21-51, 55, 56, 58-65	18	9	9
Total capital related costs after cost finding in total	75	18	9	9

35-528.2 Rev. 12

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET B, PART III

Total Cost

16, 18-19, 21-33, 56, 59, 63

5

9

9

WORKSHEET B-1, PART I

For each cost allocation using accumulated costs as the statistic, include a record containing an X.	0	4-15	1	X
All cost allocation statistics	1-16, 18-19, 21-51, 55-56, 58- 63, 66**	1-15*	9	9
Reconciliation	4-16, 18-19, 21-51, 55-56, 58-63**	4A-15A	9	-9

* In each column using accumulated costs as the statistical basis for allocating costs, identify each cost center that is to receive no allocation with a negative 1 placed in the accumulated cost column. You may elect to indicate total accumulated cost as a negative amount in the reconciliation column. However, there should never be entries in both the reconciliation column and accumulated cost column simultaneously on the same line. For those cost centers that are to receive partial allocation of costs, provide only the cost to be excluded from the statistic as a negative amount on the appropriate line in the reconciliation column. If line 4 is fragmented, delete it and use subscripts of line 4.

** Line 34 in column 8 is shaded and is not used.

WORKSHEET B-1, PART II

All cost allocation statistics	16, 18-19, 21-33, 56 59, 63	1-4	9	9

WORKSHEET B-2

For post step-down adjustment:
Description	1-58*	1	30	X
Worksheet B part number	1-58*	2	1	9
Worksheet A line number	1-58*	3	5	99.99
Amount of adjustment	1-58*	4	9	-9

* On Worksheet B-2, if there are more than 58 lines needed, use multiple worksheets. (Refer to footnote (c) in Table 2.)

Rev. 11 35-529

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET C

Total cost from Worksheet B, Part I, column 18, lines 21-36	75	1	9	9
Total charges by department	21-48	2	9	9
Total charges	75	2	9	9

WORKSHEET D, PART I

Ancillary cost apportionment
Part A program charges by department	21-48	2**	9	9
Part B program charges by department	21-36	3 *	9	9
Title XVIII charges on and after 1/1/98	25, 26, 27	6	9	9
Total program charges	75	2, 3 *	9	9
Total program costs	75	4, 5 *	9	9

* When completing Worksheet D, Part I, for titles V and/or XIX, do not use columns 3 and 5.

** Line 48 column 2 is ONLY used by titles V and XIX.

WORKSHEET D, PART II

Vaccine cost apportionment
Program vaccine charges	2	1	9	9

35-530 Rev. 11

11-98 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET D-1

Private room days	2	1	9	9
Medically necessary private room days	4	1	9	9
General inpatient routine service charges	6	1	9	9
Private room charge	8	1	9	9
Semi private room charges	10	1	9	9
Aggregate charges to beneficiaries for excess costs	24	1	9	9
Inpatient routine service cost per diem limitation	26	1	9	9(6).99
Reimbursable inpatient routine service costs	28	1	9	9

WORKSHEET D-2, PART I

Percent of assigned time of interns and residents not in approved program	2, 4-6, 8-10, 12-15	1	6	9(3).99
Title V inpatient days	2, 4	5	9	9
Title XVIII inpatient days	2	6	9	9
Title XIX inpatient days	2, 4	7	9	9
Title V charges	13, 14	5	9	-9
Title XVIII Part B charges	13, 14	6	9	‑9
Title XIX	13, 14	7	9	-9
Subtotals	12, 15	2, 8-10	9	9

WORKSHEET D-2, PART II

Title XVIII Part B inpatient days	17	4	9	9

Rev. 4 35-531

3595 (Cont.) FORM CMS 2540-96 11-98

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET E, PART I

Outpatient services (titles V and XIX)	3	1	9	9
Utilization review – physicians’ compensation	5	1	9	9
Charge differential	7	1	9	9
Inpatient primary payer amount	9	1	9	9
Inpatient ancillary service charges	11	1	9	9
Intern and resident charges	12	1	9	9
Outpatient service charges	13	1	9	9
Inpatient routine service charges	14	1	9	9
Charge differential	15	1	9	9
Aggregate amount collected	17	1	9	9
Amount collectible	18	1	9	9
Deductibles (Title V and Title XIX only)	22	1	9	9
Coinsurance	24	1	9	9
Reimbursable bad debt	26	1	9	9
Unrefunded excess charges	28	1	9	9
Recovery of excess depreciation	29	1	9	9
Other adjustments (specify)	30	0	36	X
Other adjustments (see instructions)	30	1	9	-9
Amounts applicable to prior periods resulting from disposition of depreciable assets	31	1	9	-9
Sequestration adjustment	33	1	9	9
Interim payments (titles V and XIX only)	35	1	9	9
Protested amounts	37	1	9	-9

35-532 Rev. 4

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET E, PART II

DESCRIPTION	LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Primary payer amount	6		1	9		9
Inpatient ancillary service charges	8		1	9		9
Intern and resident charges	10		1	9		9
Aggregate amount collected	12		1	9		9
Amount collectible	13		1	9		9
Deductibles and coinsurance	17		1	9		9
Reimbursable bad debt	19		1	9		9
Recovery of excess depreciation	21		1	9		9
Other adjustments (specify)	22		0	36		X
Other adjustments (see instructions)	22		1	9		-9
Amounts applicable to prior periods resulting from disposition of depreciable assets	23		1	9		-9
Sequestration adjustment (see instructions)	25		1	9		9
Protested amounts	29		1	9		-9

WORKSHEET E, PART III

Part A - Inpatient service PPS provider computation of reimbursement of lesser of cost or charges
Intern and resident charges	5	1	9	9
Inpatient routine PPS amount (see instructions)	7	1	9	9
Primary payer amounts	8	1	9	9
Coinsurance	9	1	9	9

Rev. 14 35-533

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET E, PART III (Continued)

DESCRIPTION	LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Reimbursable bad debts	10		1	9			-9
Reimbursable bad debts	10.01		1	9			-9
Reimbursable bad debts	10.02		1	9			-9
Utilization review	11		1	9			9
Recovery of excess depreciation	12		1	9			9
Amounts applicable to prior periods resulting from disposition of depreciable assets	13		1	9			-9
Sequestration adjustment (see instructions)	15		1	9			9
Protested amounts	18		1	9			-9
Part B - Ancillary service computation of reimbursement of lesser of cost or charges (title XVIII only)
Intern and resident charges	24		1	9			9
Primary payer amounts	26		1	9			9
Coinsurance and deductibles	27		1	9			9
Reimbursable bad debts	28		1	9			9
Recovery of excess depreciation	31		1	9			9
Other adjustments (specify)	32		0	36			X
Other adjustments	32		1	9			-9
Amounts applicable to prior periods resulting from disposition of depreciable assets	33		1	9			-9
Sequestration adjustment	35		1	9			9
Protested amounts	38		1	9			-9

35-534 Rev. 14

11-98 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET E, PART V

Total demonstration cost	25	1	9	9

WORKSHEET E-1

For title XVIII only:
Total interim payments paid to provider	1	2 & 4	9	9
Interim payments payable	2	2 & 4	9	9
Date of each retroactive lump sum adjustment (MM/DD/YYYY)	3.01-3.98	1 & 3	10	X
Amount of each lump sum adjustment
Program to provider	3.01-3.49	2 & 4	9	9
Provider to program	3.50-3.98	2 & 4	9	9

WORKSHEET G

For all skilled nursing facilities (see note):
Balance sheet account balances	1-10, 12-26,28-31, 33-41,43-48, 51, 59	1	9	-9
For skilled nursing facilities using fund accounting (see note):
Specific purpose fund account balances	1-10, 12-26,28-31, 33-38, 40-41,43-48, 52, 59	2	9	-9

NOTE: For contra accounts (reported on lines 6, 14, 16, 18, 20, 22, and 24), the usage is 9.

Rev. 4 35-535

3595 (Cont.) FORM CMS 2540-96 11-98

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET G (Continued)

Endowment fund account balances	1-10, 12-26,28-31, 33-38, 40-41, 43-48, 53-55, 59	3	9	‑9
Plant fund account balances	1-10, 12-26,28-31, 33-38, 40-41,43-48, 56, 57, 59	4	9	‑9
Text as needed for blank line	48	0	36	X

WORKSHEET G-1

For SNFs using fund accounting:
Text as needed for blank lines	4-9, 12-17	0	36	X
Beginning fund balances	1	2,4,6,8	9	-9
Additions to beginning fund balances	4-9	1,3,5,7	9	9
Reductions to beginning fund balances	12-17	1,3,5,7	9	9

WORKSHEET G-2

Part I: Patient revenues
Inpatient routine care services	1, 3-5	1	9	9
Ancillary services	6	1, 2	9	9
Clinic	7	1, 2	9	9
Home health agency	8	2	9	9
Ambulance	10	1, 2	9	9
Hospice	11	1, 2	9	9

35-536 Rev. 4

02-03

FORM CMS 2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET G-2 (Continued)

Outpatient rehabilitation provider	12	2	9	9
Text as needed for blank line	13	0	36	X
Other	13	1, 2	9	9
Total patient revenues	14	1,2	9	9
Part II: Text as needed for blank lines	2-7, 9-13	0	36	X
Increases to operating expenses Reported on Worksheet A	2-7	1	9	9
Decreases to operating expenses Reported on Worksheet A	9-13	1	9	9
Total operating expenses	15	2	9	9

WORKSHEET G-3

Contractual allowance and discounts on patients’ accounts	2	1	9	9
Other revenues	7-25	1	9	9
Other expenses	28-30	1	9	9
Text as needed for blank lines	25, 28-30	0	36	X
Net income (loss)	32	1	9	-9

WORKSHEET H

Salaries	3-24	1	9	9
Employee Benefits	3-24	2	9	9
Transportation costs	3-24	3	9	9
Contracted/Purchased Services	3-24	4	9	9
Other costs	1-24	5	9	9
Text as needed for blank lines	22-24	0	36	X

Rev. 12 35-537

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET H-1

Salaries and wages by discipline	3-11, 15-24	1-2, 4-7	9	9
Other salaries and wages	3-24	8	9	9

WORKSHEET H-2

Employee benefits by discipline	3-11, 15-24	1-2, 4-7	9	9
Other employee benefits	3-24	8	9	9

WORKSHEET H-3

Contracted/purchased services by discipline	3-11, 15-24	1-7	9	9
Other contracted/purchased services	3-24	8	9	9

WORKSHEET H-4, PART II

Charges for home health services furnished by shared ancillary departments

1-7

1

9

9

W ORKSHEET H-5, PARTS II, AND III

Medicare visits - Parts A and B	1-6		5-6	9	9
Total charges for DME rented and sold and medical supplies	15, 16	3		9	9
Charges for medical supplies - Medicare Parts A and B	15,	5-7		9	9
Charges for drugs - Medicare Part B	16	6-7		9	9

35-538		Rev. 12
04-06	FORM CMS-2540-96		3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET H-5 PART V

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE
Medicare visits for services rendered before 1/1/98	26-28	3	9	9
Medicare visits for services rendered on and after 1/1/98	26-28	5	9	9
Medicare visits for services rendered 1/1/99 to 9/30/00	26-28	5.01	9	9
Medicare visits for services rendered on and after 10/1/00	26-28	5.02	9	9

WORKSHEET H-6, PART I

Total charges for title XVIII - Parts A and B services	2, 2.01	1-3	9	9
Amount collected from patients	3	1-3	9	9
Amount collectible from patients	4	1-3	9	9
Primary payer payments	7	1-3	9	9

WORKSHEET H-6, PART II

PPS Reimbursement Amounts	8.01– 8.14	1,2	9	9
Part B deductibles billed to Medicare patients	9	2	9	9
Coinsurance billed to Medicare patients	11	2	9	9
Reimbursable bad debts	13	1-2	9	9
Amounts applicable to prior periods	15	1-2	9	9
Recovery of excess depreciation	16	1-2	9	-9
Non-refunded excess charges to beneficiaries	17	1-2	9	9
Other adjustments	18.01	1-2	9	9
Sequestration adjustment	19	1-2	9	9
Interim payments (titles V and XIX only)	21	1	9	9
Protested amounts	23	1-2	9	-9

Rev. 14 35-539

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET H-7

DESCRIPTION	LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Total interim payments paid to provider	1		2 & 4	9		9
Interim payments payable	2		2 & 4	9		9
Date of each retroactive lump sum adjustment (MM/DD/YYYY)	3.01-3.98		1 & 3	10		X
Amount of each lump sum adjustment
Program to provider	3.01-3.49		2 & 4	9		9
Provider to program	3.50-3.98		2 & 4	9		9

WORKSHEET I-1

Provider based cost	1-9, 11-13, 15-20, 23-27, 29-30	1,2,4,6, & 7	11	-9

WORKSHEET I-2

Number of FTE personnel	1-3, & 5-7	1	6	9(3).99
Total visits	1-3, 5-7, & 9	2	11	9
Productivity Standards	1, 2, & 3	3	4	9
Greater of columns 2 or 4	4	5	11	9
Parent provider overhead allocated to facility (see instructions)	17	1	11	9

WORKSHEET I-3

Adjusted cost per visit	7	1	6	9(3).99
Maximum rate per visit (from your intermediary)	8	1, 2, & 3	6	9(3).99
Rate for program covered visits	9	1, 2, & 3	6	9(3).99
Medicare covered visits excluding mental health services (from your intermediary)	10	1, 2, & 3	11	9

540. Rev. 14

04-06

FORM CMS 2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET I-3

DESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE
Medicare covered visits for mental health services (from your intermediary)	12	1, 2, & 3	11	9
Beneficiary deductible (from your intermediary)	17	2	11	9
Reimbursable bad debt	22	2	11	9
Interim payments	25	2	11	9
Protested amounts	27	2	11	9

WORKSHEET I-4

Ratio of pneumococcal and influenza vaccine staff time to total health care staff time	2	1&2	8	9.9(6)
Medical supplies cost - pneumococcal and influenza vaccine	4	1&2	11	9
Total number of pneumococcal and influenza vaccine injections	11	1&2	11	9
Number of pneumococcal and influenza vaccine injections administered to Medicare beneficiaries	13	1&2	11	9

WORKSHEET I-5

Total interim payments paid to provider	1	2	11	9
Interim payments payable	2	2	11	9
Date of each retroactive lump sum adjustment (MM/DD/YYYY)	3.01-3.98	1	10	X
Adjustment of each retroactive lump sum adjustment:
Program to provider	3.01-3.49	2	11	9
Provider to program	3.50-3.98	2	11	9

Rev. 14 35-541

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET J-1, PART I

DESCRIPTION	LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Net expenses for cost allocation	1-21		0	9		9
Post step down adjustments (including total)	1-22		17	9		-9
Totals (sum of lines 1-21)	22		0-3, 4-15, 17	9		9

WORKSHEET J-1, PART III

Reconciliation	1-21	1A-15A	9	-9
Cost allocation statistics	1-21	1-15 *	9	9

* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column.

WORKSHEET J-2

Part I: Facility charges
In total	2-21	2	9	9
Title V	2-21	4	9	9
Title XVIII	2-21	8 & 10	9	9
Title XIX	2-21	6	9	9
Part II: Charges for rehabilitation services furnished by shared departments
Title V	23-29	4	9	9
Title XVIII	23-29	8 & 10	9	9
Title XIX	23-29	6	9	9

35-542 Rev. 14

04-06

FORM CMS-2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET J-3

DESCRIPTION	LINE(S)		COLUMN(S)		FIELD SIZE	USAGE
Cost of component service	1	1-3		9		9
Cost of health service	1.01	1-3		9		9
PPS payment received	1.02	1-3		9		9
1996 SNF specific payment to cost ratio	1.03	1-3		5		9.999
Line 1.01 times line 1.03	1.04	1-3		9		9
Line 1.02 divided by line 1.04	1.05	1-3		6		999.99
Transitional corridor payment	1.06	1-3		9		9
Primary payment amounts	2	1-3		9		9
Part B deductible billed to program patients	4	2		9		9
Coinsurance billed	7	1-3		9		9
Reimbursable bad debts	9	1-3		9		9
Amounts applicable to prior periods resulting from depreciable asset disposal	11	1-3		9		9
Recovery of excess depreciation	12	1-3		9		9
Sequestration adjustment	14	1-3		9		9
Interim payments for titles V and XIX (where applicable)	16	1, 3		9		9
Protested amounts	18	1-3		9		-9

WORKSHEET J-4

Total interim payments paid to provider	1	2	9	9
Interim payments payable	2	2	9	9
Date of each retroactive lump sum adjustment (MM/DD/YYYY)	3.01-3.98	1	10	X
Amount of each lump sum adjustment
Program to provider	3.01-3.49	2	9	9
Provider to program	3.50-3.98	2	9	9

Rev. 14 35-543

3595 (Cont.)

FORM CMS-2540-96

04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS

WORKSHEET K

	DESCRIPTION	LINE(S)	COLUMN(S)			FIELD SIZE	USAGE
Salaries		3-33		1	11		9
Employee Benefits		3-33		2	11		9
Transportation		1-33		3	11		9
Contracted Services		3-33		4	11		9
Other Costs		1-33		5	11		9
Reclassification		1-33		7	11		-9
Adjustments		1-33		9	11		9

WORKSHEET K-1

Salaries and wages	3-33	1-7	11	9
All other	3-33	8	11	9

WORKSHEET K-2

Employee Benefits	3-33	1-7	11	9
All other	3-33	8	11	9

WORKSHEET K-3

Contracted services/purchased services	3-33	1-7	11	9
All other	3-33	8	11	9

WORKSHEET K-4, PARTS I & II

Part I
Total	34	1-4 & 5	11	9
Cost allocation	6-33	6	11	9
Part II
Reconciliation	6-33	6A	11	-9
All cost allocation statistics	1-33	1-5*	11	9

*See note to Worksheet B-1 for treatment of administrative and general accumulation cost column

WORKSHEET K-5, PART I,

Allocated Hospice A&G	2-28	17	11	-9
Total Hospice Cost	2-28	18	11	-9
Total cost after finding	29	18	11	-9

WORKSHEET K-5, PART II,

All Cost Allocation Statistics

1-28

1-3, 4-15

11

-9

WORKSHEET K-5, PART III

Total Hospice Charges	1-8	5	11	-9
Total	9	6	11	-9

35-544 Rev. 14

04-06

FORM CMS-2540-96

3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3A ‑ WORKSHEETS REQUIRING NO INPUT

Worksheet S, Part I

Worksheet A‑8‑3, Parts II, III, and IV

Worksheet A-8-4, Parts II and III

Worksheet J‑1, Part II

Worksheet H-4, Part I

TABLE 3B ‑ TABLES TO WORKSHEET S-2

Table I: Type of Control

1 = Voluntary Nonprofit, Church

2 = Voluntary Nonprofit, Other

3 = Proprietary, Individual

4 = Proprietary, Corporation

5 = Proprietary, Partnership

6 = Proprietary, Other

7 = Governmental, Federal

8 = Governmental, City-County

9 = Governmental, County

10 = Governmental, State

11 = Governmental, Hospital District

12 = Governmental, City

13 = Governmental, Other

Table II: All-inclusive provider methods (see CMS Pub. 15-I, §2208.2).

Method A = Departmental statistical data

Method D = Comparable SNF data

Method E = Percentage of average cost per diem

TABLE 3C ‑ LINES THAT CANNOT BE SUBSCRIPTED

(BEYOND THOSE PREPRINTED)

	Worksheet	Lines
	S, Part II	1, 3, 7
	S-2	1,2,4, 6, 6.10, 7, 13,14, 16-35, 41-46
	S-3, Part I	1, 3, 4
	S-3, Parts II & III	All
	S-4, Part I	1-8
	S-4, Part II	1-12
	S-5	1-8, 14, 16
	S-6	1-17

Rev. 14

35-545

3595 (Cont.)

FORM CMS 2540-96

04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3C ‑ LINES THAT CANNOT BE SUBSCRIPTED

(BEYOND THOSE PREPRINTED) (CONTINUED)

	Worksheet	Lines
	S-7, Parts I, II, III	All
	S-7, Part IV	1&2, 4&5, 7&8, 10&11, 13, 15-46
	S-8	All
	A	16, 19, 48, 49, 52-54, 75 (lines 17 and 20 may not be used)
	A-6	All
	A-7	All
	A-8 - full cost report A-8 - simplified cost report	Lines 2, through 20, 28 and 32 All except lines 23 and 31
	A-8-1, Part A	All
	A-8-1, Part B	1-8
	A-8-1, Part C	1-9
	A-8-2	All
	A-8-3	All (except lines 5, 6, 12, 13, 28-38, 51, 59, 62, and 64)
	A-8-4	All
	A-8-5	All (except lines 5, 6, 12, 12.01, 13, 13.01, 66-70, 77-81)
	B, Parts I & II	16, 19, 48, 49, 52-54, 65, and 75 (lines 17 and 20 may not be used)
	B, Part III	15.1, 16, 17, 18, 18.1, 19, 21-33, 59, 63 (Lines 17 and 20 may not be used)
	B-1	16, 19, 48, 49, and 52-54 (lines 17 and 20 may not be used)
	B, Part II	15.1, 16, 17, 18, 18.1, 19, 21-33, 59, 63 (Lines 17 and 20 may not be used)
	C	75
	D, Part I	75
	D-1	All
	D-2	2, 4-5, and 17 (lines 3, 7, 11, 18, and 19 may not be used)
	E, Part I	All (except line 30)
	E, Part II	All (except line 22)
	E, Part III	All (except lines 10, 16, 32, and 36)

35-546

Rev. 14

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3C ‑ LINES THAT CANNOT BE SUBSCRIPTED

(BEYOND THOSE PREPRINTED) (CONTINUED)

	Worksheet	Lines
	E, Part V	All
	E-1	1, 2, 3.01-3.04, and 3.50-3.53
	G	All
	G-1	1
	G-2, Part I	1, 3, and 4 (line 2 may not be used)
	G-2, Part II	15
	G-3	2, 7-24, and 32
	H	All
	H-1	All
	H-2	All
	H-3	All
	H-4	10 & 11
	H-5	All
	H-6	1 through 19, 21 through 23
	H-7	1, 2, 3.01-3.04, and 3.50-3.53
	I-1	All
	I-2	All
	I-3	All, except line 25
	I-4	All
	J-1	All
	J-2	All
	J-3	2 through 15, 17, & 18
	J-4	1, 2, 3.01-3.04, and 3.50-3.53
	.

Rev. 14 35-547

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3D - PERMISSIBLE PAYMENT MECHANISMS

P = Prospective payment	O = Other	N = Not applicable

Component	Title V	Title XVIII	Title XIX
Skilled Nursing Facility	P or O	P	P or O
Nursing Facility	P or O	N	P or O
ICF/MR	N	N	O
SNF-Based OLTC	N	N	N
SNF-Based HHA	P or O	P	P or O
SNF-Based Outpatient Rehabilitation Provider	O	O	O
SNF-Based RHC	O	O	O
SNF-Based Hospice	N	N	N

35-548 Rev. 14

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3E - CORRELATION OF SUBSCRIPTINGS AMONG THE WORKSHEETS

WKST A	WKST A-8	WKST A-8-5-PT	WKST A-8-5-RT	WKST A-8-5-OT	WKST A-8-5-SP
24 (RT-Ancillary) 24.01 24.02 24.03 24.04 24.05 24.06 24.07 24.08 24.09	24 (RT-Ancillary) 24.01 24.02 24.03 24.04 24.05 24.06 24.07 24.08 24.09	N/A	77	N/A	N/A
25 (PT- Ancillary) 25.01 25.02 25.03 25.04 25.06 25.07 25.08 25.09	25 (PT- Ancillary) 25.01 25.02 25.03 25.04 25.06 25.07 25.08 25.09	77	N/A	N/A	N/A
26 (OT- Ancillary) 26.01 26.02 26.03 26.04 26.05 26.06 26.07 26.08 26.09	26 (OT- Ancillary) 26.01 26.02 26.03 26.04 26.05 26.06 26.07 26.08 26.09	N/A	N/A	77	N/A
27 (SP- Ancillary) 27.01 27.02 27.03 27.04 27.05 27.06 27.07 27.08 27.09	27 (SP- Ancillary) 27.01 27.02 27.03 27.04 27.05 27.06 27.07 27.08 27.09	N/A	N/A	N/A	77

Rev. 11 35-549

3595 (Cont.) FORM CMS 2540-96 08-01

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 3E - CORRELATION OF SUBSCRIPTINGS AMONG THE WORKSHEETS

WKST A	WKST A-8	WKST A-8-5-PT	WKST A-8-5-RT	WKST A-8-5-OT	WKST A-8-5-SP
50 (CORF - Reimb) 50.01	22.01, 23.01, 24.01, 25.01	67, 73, 78 67.01,73.01, 78.01	67, 73, 78 67.01, 73.01, 78.01	67, 73, 78 67.01, 73.01, 78.01	67, 73, 78 67.01, 73.01, 78.01
50.10(CMHC- Reimb) 50.11	22.10, 23.10, 24.10, 25.10	68, 74, 79 68.10,74.10 79.10	68, 74, 79 68.10, 74.10 79.10	68, 74, 79 68.10, 74.10, 79.10	68, 74, 79 68.10, 74.10, 79.10
50.20 (OPT- Reimb) 50.21	22.20, 23.20, 24.20, 25.20	69, 75, 80 69.20,74.20, 79.20	69, 75, 80, 69.20,74.20, 79.20	69, 75, 80 69.20,74.20, 79.20	69, 75, 80 69.20,74.20, 79.20
50.30 (OOT- Reimb)	22.30, 23.30 24.30, 25.30	N/A	N/A	N/A	N/A
50.40 (OSP- Reimb)	22.40, 23.40, 24.40, 25.40	N/A	N/A	N/A	N/A
39(HHA- Reimb)	22.50, 23.50, 25.50	70, 76, 81, 70.01,76.01, 81.01	N/A	70. 76, 81 70.01, 76.01, 81.01	70, 76, 81 70.01,76.01, 81.01

35-550 Rev. 11

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 4 - NUMBERING CONVENTION FOR MULTIPLE COMPONENTS

This table provides line and column numbering conventions for health care complexes with more than one SNF-based component of the same kind. Table 4 is necessary to ensure that data associated with each component are consistently identified throughout the cost report. For example, if there are four additional components, component II is subline .01, component III is .02, component IV is .03, and component V is .04. For outpatient rehabilitation providers other than CORFs, i.e., CMHCs, OPTs, OOTs, and OSPs, begin at a fixed subline for each type of outpatient rehabilitation provider, and increment that subscript by .01 for each additional outpatient rehabilitation provider of that type.

I. For use in facilities with more than one home health agency

	WKST.	PART	COLUMNS	LINES	SUBLINES
HHA II-V	S	II	1-4	4	1-4
HHA II-V	S-2		1-6	8	1-4
HHA II-V	S-3	I	22-23	5	1-4
HHA II-V	A		1-2, 7	37-47	1-4
H HA II-V	A-8		1-4	22.04, 23.04, 24.04 & 25.04	1-4
HHA II-V	B	I	18	37-47	1-4
HHA II-V	B	II	18	37-47	1-4
HHA II-V	B-1		1-15	37-47	1-4
HHA II-V	D-2		1	6	1-4
HHA II-V	G-2	I	2	8	1-4

II. For use in facilities with more than one comprehensive outpatient rehabilitation facility

	WKST.	PART	COLUMNS	LINES	SUBLINES
CORF II-IX	S	II	1, 3-4	5	1-8
CORF II-IX	S-2		1-6	10	1-8
CORF II-IX	S-3	I	22-23	7	1-8
CORF II-IX	A		1-2, 7	50	1-8
CORF II-IX	A-8		1-4	22.01, 23.01, 24.01 & 25.01	1-8
CORF II-IX	B	I	18	50	1-8

Rev. 12 35-551

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 4 - NUMBERING CONVENTION FOR MULTIPLE COMPONENTS

II. For use in facilities with more than one comprehensive outpatient rehabilitation facility

	WKST.	PART	COLUMNS	LINES	SUBLINES
CORF II-IX	B	II	18	50	1-8
CORF II-IX	B-1		1-15	50	1-8
CORF II-IX	D-2		1	8	1-8
CORF II-IX	G-2	I	2	12	1-8

III. For use in facilities with more than one community mental health center

CMHC I-IX	S	II	1, 3-4	5	10-18
CMHC I-IX	S-2		1-6	10	10-18
CMHC I-IX	S-3	I	22-23	7	10-18
CMHC I-IX	A		1-2, 7	50	10-18
CMHC 1-IX	A-8		1-4	22.02, 23.02, 24.02 & 25.02	10-18
CMHC I-IX	B	I	18	50	10-18
CMHC I-IX	B	II	18	50	10-18
CMHC I-IX	B-1		1-15	50	10-18
CMHC I-IX	D-2		1	8	10-18
CMHC I-IX	G-2	I	2	12	10-18

IV. For use in facilities with more than one outpatient physical therapy facility

	WKST.	PART	COLUMNS	LINES	SUBLINES
OPT I-IX	S	II	1, 3-4	5	20-28
OPT I-IX	S-2		1-6	10	20-28
OPT I-IX	S-3	I	22-23	7	20-28
OPT I-IX	A		1-2, 7	50	20-28
OPT I-IX	A-8		1-4	22.03, 23.03, 24.03 & 25.03	20-28
OPT I-IX	B	I	18	50	20-28

35-552 Rev. 12

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 4 - NUMBERING CONVENTION FOR MULTIPLE COMPONENTS

IV. For use in facilities with more than one outpatient physical therapy facility

	WKST.	PART	COLUMNS	LINES	SUBLINES
OPT I-IX	B	II	18	50	20-28
OPT I-IX	B-1		1-15	50	20-28
OPT I-IX	D-2		1	8	20-28
OPT I-IX	G-2	I	2	12	20-28

V. For use in facilities with more than one outpatient occupational therapy facility

OOT I-IX	S	II	1, 3-4	5	30-38
OOT I-IX	S-2		1-6	10	30-38
OOT I-IX	S-3	I	22-23	7	30-38
OOT I-IX	A		1-2, 7	50	30-38
OOT I-IX	B	I	18	50	30-38
OOT I-IX	B	II	18	50	30-38
OOT I-IX	B-1		1-15	50	30-38
OOT I-IX	D-2		1	8	30-38
OOT I-IX	G-2	I	2	12	30-38

VI. For use in facilities with more than one outpatient speech pathology facility

	WKST.	PART	COLUMNS	LINES	SUBLINES
OSP I-IX	S	II	1, 3-4	5	40-48
OSP I-IX	S-2		1-6	10	40-48
OSP I-IX	S-3	I	22-23	7	40-48
OSP I-IX	A		1-2, 7	50	40-48
OSP I-IX	B	I	18	50	40-48
OSP I-IX	B	II	18	50	40-48
OSP I-IX	B-1		1-15	50	40-48
OSP I-IX	D-2		1	8	40-48
OSP I-IX	G-2	I	2	12	40-48

Rev. 11 35-553

3595 (Cont.) FORM CMS 2540-96 08-01

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 5 - COST CENTER CODING

INSTRUCTIONS FOR PROGRAMMERS

Cost center coding is required because there are thousands of unique cost center names in use by providers. Many of these names are peculiar to the reporting provider and give no hint as to the actual function being reported. By using codes to standardize meanings, practical data analysis becomes possible. The methodology to accomplish this must be rigidly controlled to enhance accuracy.

For any added cost center names (the preprinted cost center labels must be precoded), the preparers must be presented with the allowable choices for that line or range of lines from the lists of standard and nonstandard descriptions. They then select a description that best matches their added label. The code associated with the matching description, including increments due to choosing the same description more than once, is then appended to the user’s label by the software.

Additional guidelines are:

• Do not allow any pre-existing codes for the line to be carried over.

• Do not precode all “Other” lines.

• For cost centers, the order of choice must be standard first, then specific nonstandard, and finally the nonstandard “Other . . ."

• For the nonstandard "Other . . .", prompt the preparer with “Is this the most appropriate choice?," and then offer the chance to answer yes or to select another description.

• Allow the preparers to invoke the cost center coding process again to make corrections.

• For the preparers’ review, provide a separate printed list showing their added cost center names on the left with the chosen standard or nonstandard descriptions and codes on the right.

• On the screen next to the description, display the number of times the description can be selected on a given report, decreasing this number with each usage to show how many remain. The numbers are shown on the cost center tables.

• Do not change standard cost center lines, descriptions, and codes. The acceptable formats for these items are listed on page 35-551 of the Standard Cost Center Descriptions and Codes. The proper line number is the first two digits of the cost center code.

INSTRUCTIONS FOR PREPARERS

Cost center coding standardizes the meaning of cost center labels used by health care providers on the Medicare cost reporting forms. This coding methodology allows you to continue to use labels for cost centers that have meaning within your institution.

The four digit codes that must be associated with each label provide standardized meaning for data analysis. Normally, it is necessary to code only added labels because the preprinted standard labels are automatically coded by CMS approved cost report software.

Additional cost center descriptions are identified. These additional descriptions will hereafter be referred to as the nonstandard labels. Included with the nonstandard descriptions are "Other . . ." designations to provide for situations where no match in meaning can be found. Refer to Worksheet A, lines 15, 33, 36, 51, 56, and 63.

Both the standard and nonstandard cost center descriptions along with their cost center codes are shown on Table 5. The AUSE column on that table indicates the number of times that a given code can be used on one cost report. Compare your added label to the descriptions shown on the standard and nonstandard tables for purposes of selecting a code. Most CMS approved software provides an automated process to present you with the allowable choices for the line/column being coded and automatically associates the code for the selected matching description with your label.

35-554 Rev. 11

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 5 - COST CENTER CODING

Additional Guidelines

Categories

Make a selection from the proper category such as general service description for general service lines, special purpose cost center descriptions for special purpose cost center lines, etc.

Use of a Cost Center Coding Description More Than Once

Often a description from the standard or nonstandard tables applies to more than one of the labels being added or changed by the preparer. In the past, it was necessary to determine which code was to be used and then increment the code number upwards by one for each subsequent use. This was done to provide a unique code for each cost center label. Now, most approved software associate the proper code, including increments as required, once a matching description is selected. Remember to use your label. You are matching to CMS’s description only for coding purposes.

Cost Center Coding and Line Restrictions

Use cost center codes only in designated lines in accordance with the classification of cost center(s), e.g., lines 58 through 63 may only contain cost center codes within the nonreimbursable services cost center category of both standard and nonstandard coding.

Multiple SNF-Based Home Health Agencies

Form CMS 2540-96 provides preprinted labels for one HHA on lines 37-47. If you must report two or more HHAs, lines 37-47 must be subscripted as needed. After your label for the first HHA is entered, the standard descriptions for HHA cost centers is selected. Then enter your label for the second HHA on subscripted lines 37.01, 38.01, etc. The appropriate description is again selected as the correct match. The standard code, e.g., 3700, incremented by one, e.g., 3701, is applied to the second HHA. Additional HHAs are handled in the same manner.

Outpatient Rehabilitation Facilities

Form CMS 2540-96 provides a preprinted labels for one outpatient rehabilitation facility on line 50. Where you must report two or more CORFs, line 50 must be subscripted as needed. After your label for the first CORF is entered, the standard description for the CORF cost center is selected. Then enter your label for the second CORF on subscripted line 50.01. The appropriate description is again selected as the correct match. The standard code, i.e. 5000, incremented by one, i.e., 5001, is applied to the second CORF. Additional CORFs are handled in the same manner.

For SNF-based outpatient rehabilitation facilities other than CORFs, you must subscript line 50 as outlined in Table 4. Select the standard description and cost center code for the appropriate cost center. For example, if you have a SNF-based outpatient physical therapy facility, enter label for the first OPT on line 50.20. Select the standard description for the OPT cost center, with the standard code 5020. Where you must report two or more OPTs, enter the label for the second OPT on line 50.21. Select the appropriate description for the OPT cost center, incrementing the standard code by one, i.e., 5021. Additional OPTs are handled in the same manner.

Rev. 11 35-555

3595 (Cont.) FORM CMS 2540-96 08-01

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 5 - COST CENTER CODING

STANDARD COST CENTER DESCRIPTIONS AND CODES

	CODE	USE
GENERAL SERVICE COST CENTERS
CAP REL COSTS - BLDGS & FIXTURES	0100	(100)
CAP REL COSTS - MOVABLE EQUIPMENT	0200	(100)
EMPLOYEE BENEFITS	0300	(100)
ADMINISTRATIVE & GENERAL	0400	(100)
PLANT OPERATION, MAINT. & REPAIRS	0500	(100)
LAUNDRY & LINEN SERVICE	0600	(100)
HOUSEKEEPING	0700	(100)
DIETARY	0800	(100)
NURSING ADMINISTRATION	0900	(100)
CENTRAL SERVICES & SUPPLY	1000	(100)
PHARMACY	1100	(100)
MEDICAL RECORDS & LIBRARY	1200	(100)
SOCIAL SERVICE	1300	(50)
INTERNS & RESIDENTS (APPRVD PROGRAM)	1400	(100)
INPATIENT ROUTINE SERVICE COST CENTERS
SKILLED NURSING FACILITY	1600	(01)
NURSING FACILITY	1800	(01)
INTERMEDIATE CARE FACILITY/ MENTALLY RETARDED	1810	(01)
OTHER LONG TERM CARE	1900	(01)
ANCILLARY SERVICE COST CENTERS
RADIOLOGY	2100	(100)
LABORATORY	2200	(100)
INTRAVENOUS THERAPY	2300	(10)
OXYGEN (INHALATION) THERAPY	2400	(10)

35-556 Rev.11

02-03 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 5 - COST CENTER CODING

STANDARD COST CENTER DESCRIPTIONS AND CODES (CONTINUED)

	CODE	USE
ANCILLARY SERVICE COST CENTERS (CONTINUED)
PHYSICAL THERAPY	2500	(10)
OCCUPATIONAL THERAPY	2600	(10)
SPEECH PATHOLOGY	2700	(10)
ELECTROCARDIOLOGY	2800	(100)
MEDICAL SUPPLIES CHARGED TO PATIENTS	2900	(100)
DRUGS CHARGED TO PATIENTS	3000	(50)
DENTAL CARE - TITLE XIX ONLY	3100	(100)
SUPPORT SURFACES	3200	(100)
OUTPATIENT SERVICE COST CENTERS
CLINIC	3400	(10)
RURAL HEALTH CLINIC	3500	(10)
OTHER REIMBURSABLE COST CENTERS
ADMINISTRATIVE & GENERAL - HHA	3700	(05)
SKILLED NURSING CARE - HHA	3800	(05)
PHYSICAL THERAPY - HHA	3900	(05)
OCCUPATIONAL THERAPY - HHA	4000	(05)
SPEECH PATHOLOGY - HHA	4100	(05)
MEDICAL SOCIAL SERVICES - HHA	4200	(05)
HOME HEALTH AIDE - HHA	4300	(05)
DME RENTED - HHA	4400	(05)
DME SOLD - HHA	4500	(05)
HOME DELIVERED MEALS - HHA	4600	(05)
OTHER HOME HEALTH SERVICES - HHA	4700	(05)
TELEMEDICINE	4710	(05)

Rev. 12 35-557

3595 (Cont.) FORM CMS 2540-96 02-03

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 5 - COST CENTER CODING

STANDARD COST CENTER DESCRIPTIONS AND CODES (CONTINUED)

	CODE	USE
OTHER REIMBURSABLE COST CENTERS (CONTINUED)
AMBULANCE	4800	(01)
INTERNS AND RESIDENTS (NOT APPROVED)	4900	(01)
CORF	5000	(10)
CMHC	5010	(10)
OPT	5020	(10)
OOT	5030	(10)
OSP	5040	(10)
SPECIAL PURPOSE COST CENTERS
MALPRACTICE PREMIUMS & PAID LOSSES	5200	(01)
INTEREST EXPENSE	5300	(01)
UTILIZATION REVIEW - SNF	5400	(01)
HOSPICE	5500	(09)
NONREIMBURSABLE COST CENTERS
GIFT, FLOWER, COFFEE SHOPS & CANTEEN	5800	(100)
BARBER & BEAUTY SHOP	5900	(100)
PHYSICIANS’ PRIVATE OFFICES	6000	(100)
NONPAID WORKERS	6100	(50)
PATIENTS’ LAUNDRY	6200	(100)

35-558 Rev. 12

08-01 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 5 - COST CENTER CODING

NONSTANDARD COST CENTER DESCRIPTIONS AND CODES

	CODE	USE
GENERAL SERVICE COST CENTERS
Other General Service Cost Centers	1350	(50)
ANCILLARY SERVICE COST CENTERS
Other Ancillary Service Cost Centers	3050	(50)
OUTPATIENT SERVICE COST CENTERS
Other Outpatient Service Cost Centers	3450	(50)
OTHER REIMBURSABLE COST CENTERS
Other Reimbursable Cost Centers	4750	(50)
SPECIAL PURPOSE COST CENTERS
Other Special Purpose Cost Centers	5350	(50)
NONREIMBURSABLE COST CENTERS
Other Nonreimbursable Cost Centers	6150	(50)

Rev. 11 35-559

3595 (Cont.) FORM CMS 2540-96 08-01

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 - EDITS

Medicare cost reports submitted electronically must meet a variety of edits. These include mathematical accuracy edits, certain minimum file requirements, and other data edits. Any vendor software that produces an electronic cost report file for Medicare skilled nursing facilities must automate all of these edits. Failure to properly implement these edits may result in the suspension of a vendor’s system certification until corrective action is taken. The vendor’s software should provide meaningful error messages to notify the skilled nursing facility of the cause of every exception. The edit message generated by the vendor systems must contain the related 4 digit and 1 alpha character, where indicated, reject/edit code specified below. Any file submitted by a provider containing a level I edit will be rejected by the fiscal intermediary, without exception.

The edits are applied at two levels. Level I edits (1000 series reject codes) are those that test the format of the data to identify for correction those error conditions that result in a cost report rejection. These edits also test for the presence of some critical data elements specified in Table 3. Level II edits (2000 series edit codes) identify potential inconsistencies and/or missing data items. Resolve these items and submit appropriate worksheets and/or data supporting the exceptions with the cost report. Failure to submit the appropriate data with your cost report may result in payments being withheld pending resolution of the issue(s).

The vendor requirements (above) and the edits (below) reduce both intermediary processing time and unnecessary rejections. Vendors should develop their programs to prevent their client skilled nursing facilities from generating either a hard copy substitute cost report or electronic cost report file where level I edit conditions exist. Ample warnings should be given to the provider where level II edit conditions are violated.

NOTE: Dates in brackets [ ] at end of edit indicate effective date of that edit for cost reporting periods ending on or after that date.

E dits that affect only a “full” cost report (i.e., not filed under the “simplified” method) are identified with the letter “A” after the edit. Edits that affect only cost reports filed under the “simplified” method are identified with the letter “B” after the edit. Edits with neither an “A” or “B” are applicable to both the full SNF cost report and the “simplified” SNF cost report.

I. Level I Edits (Minimum File Requirements)

Reject Code	Condition
1000	The first digit of every record must be either 1, 2, 3, or 4 (encryption code only).[03/31/1998]
1005	No record may exceed 60 characters. [03/31/1997]
1010	All alpha characters must be in upper case. This is exclusive of the encryption code, type 4 record, record numbers 1, 1.01, and 1.02. [03/31/1998]
1015	For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence. [03/31/1997]
1020	The skilled nursing facility provider number (record #1, positions 17-22) must be valid and numeric. [10/31/1998]
1025	All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format and legitimate. [10/31/1998]

35-560 Rev. 11

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 – EDITS

Reject Code	Condition
1030	The fiscal year begin date (record #1, positions 23-29) must be less than or equal to the fiscal year end date (record #1, positions 30-36). [10/31/1998]
1035	The vendor code (record #1, positions 38-40) must be a valid code. [03/31/1997]
1050	The type 1 record # 1 must be correct and the first record in the file [03/31/1997]
1055	All record identifiers (positions 1-20) must be unique
NOTE:	The FI should attempt to correct this condition in its working copy and continue processing the cost report. If the condition is correctable, notify the provider’s vendor and send a copy of the ECR file to both the vendor and CMS Central Office. CMS Central Office will require a vendor software update to resolve the condition. [03/31/1997]
1060	Only a Y or N is valid for fields which require a Yes/No response. [03/31/97]
1065	Variable column (Worksheet B, Parts I and II and Worksheet B-1) must have a corresponding type 2 record (Worksheet A label) with a matching line number. (A) [03/31/1997] Variable column (Worksheet B, Part III and Worksheet B-1, Part II) must have a corresponding type 2 record (Worksheet A label) with a matching line number. (B)
1070	All line, subline, column, and subcolumn numbers (positions 11-13, 14-15, 16-18, and 19-20, respectively) must be numeric, except as noted below for reconciliation columns. [03/31/1997]
NOTE:	If the administrative and general (A&G) cost center (Worksheet A, line 4) is fragmented into two or more cost centers, then line 4 must be deleted. Fragmented A&G lines must begin with subscripted line 4.01 and continue in sequential order. Line numbers may be skipped, but must be in sequential order, e.g., 4.01, 4.02, 4.04, etc. is permissible. Any cost center with accumulated costs as its statistic must have its Worksheet B-1 reconciliation column numbered the same as its Worksheet A line number followed by an “A” as part of the line number followed by the subline number. [03/31/1997]
1075	Cost center integrity for variable worksheets must be maintained throughout the cost report. For subscripted lines, the relative position must be consistent throughout the cost report. An exception to this rule is subscripts of line 48 on Worksheet D, Part I should be excluded from this edit check. [04/01/2002]
1080	For every line used on Worksheets A, B, C, and D, there must be a corresponding type 2 record. An exception to this requirement is subscripts of line 48 on Worksheet D, Part I. These subscripted lines should be excluded from this edit check. [04/01/2002]
1090	Fields requiring numeric data (charges, costs, FTEs, etc.) may not contain any alpha character. [03/31/1997]
1100	In all cases where the file includes both a total and the parts that comprise that total, each total must equal the sum of its parts. [03/31/1997]

Rev. 14 35-561

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 – EDITS

Reject Code	Condition
1000S	The SNF address, city, State, zip code, and county (Worksheet S-2 lines 1, 2, and 3, columns 1, 2, and 3 respectively) must be present and valid. [12/31/02]
1005S	The cost report ending date (Worksheet S-2, column 2, line 13) must be on or after 3/31/97. [03/31/1997]
1010S	All provider and component numbers displayed on Worksheet S-2, column 2, lines 4, 6-8, and 10-12, must contain six (6) alphanumeric characters. [03/31/1997]
1015S	The cost report period beginning date (Worksheet S-2, column 1, line 13) must precede the cost report ending date (Worksheet S-2, column 2, line 13). [03/31/1997]
1020S	The skilled nursing facility name, provider number, certification date, and Title XVIII payment mechanism (Worksheet S-2, line 4, columns 1, 2, 3, and 5, respectively) must be present and valid. [03/31/1997]
1030S	For each provider name reported (Worksheet S-2, column 1, lines 4, 6, 6.10, 8, and 10-12), there must be corresponding entries made on Worksheet S-2, lines 4, 6, 6.10, 8, and 10-12 for the provider number (column 2), the certification date (column 3), and the payment system for either Titles V, XVIII, or XIX (columns 4, 5, or 6, respectively) indicated with a valid code (P, O, or N). (See Table 3D.) [03/31/1997]
1035S	On Worksheet S-2, there must be a response in every file in column 1, lines 13-18, 22, 28-32, 43, 46, 47, 49, and 52. If line 47 is “Y”, then line 48 must have a response. For provider names reported (Worksheet S-2, column 1, lines 4, 6, 6.10, 7, 8, and 10), there must be corresponding entries made on Worksheet S-2, column 1, lines 33, 36, 37; in column 2, lines 33, 36, 37, 39, and 40; and in column 3, line 35, and 35.10. If any of lines 37, 39, or 40 have been subscripted, there must be a response in the appropriate columns for each subscripted line. [09/30/1998] (A) On Worksheet S-2, there must be a response in every file in column 1, lines 13 & 14, 28-40 46, 47, 49, and 52. If line 47 is “Y”, then line 48 must have a response For provider’s name reported (Worksheet S-2, column 1, line 4,), there must be a corresponding entry made on Worksheet S-2, columns 1 and 2, line 33. (B)
1040S	If Worksheet S-2, column 1, line 47 equals “Y” and column 2, line 47 equals “N” and the provider’s cost reporting period begins other than October 1st, Worksheet S-2, columns 1 and 2 line 48 must be greater than zero. However, if Worksheet S-2, column 2, line 47 equals “Y” this edit should be ignored. [11/30/1999] (A)
1045S	If Worksheet S-2, column 1, line 47 equals “Y” and column 2, line 47 equals “N” and the cost reporting period begins on October 1st, Worksheet S-2, column 1, line 48 must be greater than zero, and no entry should be made in column 2. However, if Worksheet S-2, column 2, line 47 equals “Y” this edit should be ignored. [11/30/1999] (A)
1050S	If Worksheet S-2, lines 50 and 51 equal “N”, then line 52 must also be “N”. (A) Line 52 can only be “Y” when: a) lines 50 and 51 are “Y”, or: b) you are a new provider, and filing the first cost report of that provider, so that lines 50 and 51 are not applicable. [02/28/2001] (B)

35-562 Rev. 14

04-06 Form CMS 2540-96 3595 (Cont.)

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 - EDITS

Reject Code	Condition

1075S	All amounts reported on Worksheet S-3, Part I must not be less than zero. [03/31/1997]
1080S	For Worksheet S-3, Part I, the sum of the inpatient days in columns 3-6 for each of lines 1, 3, and 4 must be equal to or less than the total inpatient days in column 7 for each line. [03/31/1997]
1100S	The amount of hours reported in column 4, lines 1-13 (Worksheet S-3, Part III) must be greater than or equal to zero. [03/31/1997]
1105S	For Worksheet S-3, Part I, the sum of the discharges in columns 8-11 for each of lines 1, 3, and 4 must be equal to or less than the total discharges in column 12 for each line indicated. [03/31/1997]
1110S	Worksheet S-3, Part II, columns 1 and 4, line 23 must be greater than zero. [03/31/1997]
1115S	The amount on Worksheet S-3, Part II, Column 3, line 22 (total wage related costs), must be greater than 7.65 percent and less than 50.0 percent of the amount in column 3, line 16 (total salaries). [12/31/2002]
1120S	For Worksheet S-3, Part II, all values for column 5 lines 1-18, and 23 must equal or exceed $5.15. When there are no salaries reported in column three, then it is okay to have zero amounts in columns 3 and 5. [12/31/2002]
1125S	The amount of total salaries reported in column 1, line 1 (Worksheet S-3, Part II) must equal Worksheet A, Column 1, line 75 [12/31/2002]

Rev. 14 35-563

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 – EDITS

Reject Code	Condition

The following Wage Index edits are to be applied against PPS SNFs only, edit number 1200S, 1205S, and 1220S.

1200S	For Worksheet S-3, Part II, sum of columns 1 and 2 each of lines 2-5, 8-14, 17-21, and subscripts as applicable must be equal to or greater than zero. [01/31/2001]
1205S	The amount of salaries reported for Interns & Residents in approved programs Worksheet S-3, Part II column 1, line 4 must be equal to or greater than the amount on Worksheet A, column 1 line 14 (including subscripts). [09/30/1998]
1220S	Worksheet S-3, Part II, sum of columns 1 & 2, line 19 must be greater than zero. [09/30/1998]
1000A	Worksheet A, columns 1 and 2, line 75 must be greater than zero. [03/31/97]
1015A	On Worksheet A, lines 52 and 53, the sum of column 2 and the corresponding reclassifications and adjustments must equal zero. On line 54, the sum of columns 1 and 2 and the corresponding reclassifications and adjustments must equal zero. [03/31/1997]
1020A	For reclassifications reported on Worksheet A-6, the sum of all increases (columns 4 and 5) must equal the sum of all decreases (columns 8 and 9). [03/31/1997]
1025A	For each line on Worksheet A-6, if there is an entry in column 3, 4, 5, 7, 8, or 9, there must be an entry in column 1. There must be an entry on each line of columns 4 and/or 5 for each entry in column 3 (and vice versa), and there must be an entry on each line of columns 8 and/or 9 for each entry in column 7 (and vice versa). All entries must be valid, for example, no salary adjustments in columns 3 and/or 7, for capital lines 1 & 2 of Worksheet A. [09/30/1998]
1040A	For Worksheet A-8 adjustments on lines 1-7, 9-11, and 13-21, if either columns 2 or 4 has an entry, then columns 1, 2, and 4 must have entries, and if any one of columns 0, 1, 2, or 4 for line 31 (and subscripts of line 31) has an entry, then all columns 0, 1, 2, and 4 must have entries. [03/31/1997] If lines 28-30 have an entry in column 2, then column 1 of that line must have an entry. [03/31/1997]
1045A	This edit was changed to a level two edit April 2003. See edit # 2045A
1050A	On Worksheet A-8-2, column 3 must be equal to or greater than the sum of columns 4 and 5. If column 5 is greater than zero, column 6, and column 7 must be greater than zero. [06/13/02]

35-564 Rev. 14

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 – EDITS

Reject Code	Condition
1055A	Worksheet A-8-3, column 1, line 56 must equal the sum of column 1, lines 58 and 59. [03/31/1997]
1060A	If Worksheet A-8-5, column 5, line 47 is equal to zero, column 5, line 51 must also be equal to zero. Conversely, if Worksheet A-8-5, columns 1-4, line 47 is greater than zero, column 5, line 51 must be greater than column 5, line 47 and equal to or less than 2080 hours for a 12 month cost report, (2240 hours for a 13 month cost report, 2400 hours for a 14 month cost report, or 2560 hours for a 15 month cost report). [10/31/1998]
1000B	On Worksheet B-1, all statistical amounts must be greater than or equal to zero, except for reconciliation columns. [03/31/1997] (A): On Worksheet B-1, Part II, all statistical amounts must be greater than or equal to zero, except for reconciliation columns. [02/01/2001] (B)
1005B	Worksheet B, Part I, column 18, line 75 must be greater than zero. [03/31/1997]
1010B	For each general service cost center with a net expense for cost allocation greater than zero (Worksheet B-1, columns 1 through 15, line 75), the corresponding total cost allocation statistics (Worksheet B-1, column 1, line 1; column 2, line 2; etc.) must also be greater than zero. Exclude from this edit any column, including any reconciliation column, that uses accumulated cost as its basis for allocation. [03/31/1997]
1015B	For any column which uses accumulated cost as its basis of allocation (Worksheet B-1), there may not simultaneously exist on any line an amount both in the reconciliation column and the accumulated cost column, including a negative one. [03/31/1997]
1010C	On Worksheet C, all amounts in column 1 line 75 and column 2 must be greater than or equal to zero. [03/31/1997]
1000D	On Worksheet D, all amounts must be greater than or equal to zero. [03/31/1997]
1020H	For the home health agency, [FYs ending through 9/30/2000], the total Medicare program (Title XVIII) visits reported as the sum of all Worksheets H-5, Part II (sum of columns 5 and 6, lines 1-6, plus Worksheet H-5, Part V, columns 3, 5, and 5.01, lines 26-28) must equal the sum of the visits reported on Worksheet S-4 (column 2, sum of lines 1-6). Do not apply this edit for cost reports beginning on or after 10/01/2000. (A)
1021H	For the home health agency, [FYs which over lap 10/1/2000], the total Medicare program (Title XVIII) visits reported as the sum of all Worksheets H-5, Part II (sum of columns 5 and 6, lines 1-6 which are pre 10/1/2000 visits excluding subscripts, plus Worksheet H-5, Part V, columns 5.01 pre 10/1/2000 visits, lines 26-28) must equal the sum of the visits reported on Worksheet S-4, column 2, sum of lines 1-6. (A)
1022H	For the home health agency, [FYs beginning on or after 10/1/ 2000], the total Medicare program (Title XVIII) visits reported as the sum of all Worksheets H-5, Part II (sum of columns 5 and 6, lines 1-6, must equal the sum of the visits reported on Worksheet S-4, Part III, column 7, sum of lines 1, 3, 5, 7, 9 and 11. (A)

Rev. 14 35-565

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 – EDITS

1023H		For the home health agency, [FYs ending through 9/30/2000], the total Medicare (Title XVIII) unduplicated census count (Worksheet S-4, Part I, column 3, line 9) must be equal to or greater than the sum of the unduplicated census count for all MSAs (Worksheet H-5, Part IV, column 1, line 25). Do not apply this edit for cost reports beginning on or after 10/01/2000. (A)
1024H	For the home health agency, [FYs which over lap 10/1/2000], the total Medicare (Title XVIII) unduplicated census count (Worksheet S-4, Part I, column 3, line 9.01) must be equal to or greater than the sum of the unduplicated census count for all MSAs (Worksheet H-5, Part IV, column 1, line 25). (A)
1030H	For the home health agency, [FYs ending through 9/30/2000], if Medicare visits on Worksheet S-4, column 2, lines 1-6, respectively, are greater than zero, then the corresponding cost on Worksheet H-4, Part I, Column 3, lines 2 through 7, must also be greater than zero. Do not apply this edit for cost reports beginning on or after 10/01/2000. (A)
1000J	Worksheet J-1, Part I, sum of columns 0-3, 4-15, and 17, line 22, must equal the corresponding Worksheet B, column 18, line 50 or appropriate subscript as identifies this provider type. [03/31/1997]

II. Level II Edits (Potential Rejection Errors)

These conditions are usually, but not always, incorrect. These edit errors should be cleared when possible through the cost report. When corrections on the cost report are not feasible, you should provide additional information in schedules, note form, or any other manner as may be required by your fiscal intermediary (FI). Failure to clear these errors in a timely fashion, as determined by your FI, may be grounds for withholding payments.

Edit	Condition
2000	All type 3 records with numeric fields and a positive usage must have values equal to or greater than zero (supporting documentation may be required for negative amounts).
2005	Only elements set forth in Table 3, with subscripts as appropriate, are required in the file.
2010	The cost center code (positions 21-24) (type 2 records) must be a code from Table 5, and each cost center code must be unique.
2015	Standard cost center lines, descriptions, and codes should not be changed. (See Table 5.) This edit applies to the standard line only and not subscripts of that code.
2020	All standard cost center codes must be entered on the designated standard cost center line and subscripts thereof as indicated in Table 5.
2025	Only nonstandard cost center codes within a cost center category may be placed on standard cost center lines of that cost center category.

35-566 Rev. 14

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 - EDITS

Edit	Condition
2030	The following standard cost centers listed below must be reported on the lines indicated and the corresponding cost center codes may appear only on the lines indicated. No other cost center codes may be placed on these lines or subscripts of these lines, unless indicated herein. [03/31/1997] (A)

			Cost Center	Line	Code
			CAP REL COSTS - BLDGS & FIXTURES CAP REL COSTS - MOVABLE EQUIPMENT EMPLOYEE BENEFITS SKILLED NURSING FACILITY NURSING FACILITY INTERMEDIATE CARE FACILITY/MENTALLY RETARDED OTHER LONG TERM CARE ADMINISTRATIVE & GENERAL - HHA SKILLED NURSING CARE - HHA PHYSICAL THERAPY - HHA OCCUPATIONAL THERAPY - HHA SPEECH PATHOLOGY - HHA MEDICAL SOCIAL SERVICES - HHA HOME HEALTH AIDE - HHA DME RENTED - HHA DME SOLD - HHA HOME DELIVERED MEALS - HHA OTHER HOME HEALTH SERVICES - HHA TELEMEDICINE AMBULANCE INTERNS & RESIDENTS (NOT APPRVD) MALPRACTICE PREMIUMS & PAID LOSSES INTEREST EXPENSE UTILIZATION REVIEW - SNF HOSPICE GIFT, FLOWER, COFFEE SHOPS & CANTEEN BARBER & BEAUTY SHOP PHYSICIANS-PRIVATE OFFICES NONPAID WORKERS PATIENTS-LAUNDRY	1 2 3 16 18 18.1 19 37 38 39 40 41 42 43 44 45 46 47 47.1 48 49 52 53 54 55 58 59 60 61 62	0100-0199 0200-0299 0300-0399 1600 1800 1810 1900 3700-3704 3800-3804 3900-3904 4000-4004 4100-4104 4200-4204 4300-4304 4400-4404 4500-4504 4600-4604 4700-4704 4710-4714 4800 4900 5200 5300 5400 5500-5504 5800-5899 5900-5999 6000-6099 6100-6149 6200-6299
2035		Administrative and general cost center code 0400-0499 may appear only on line 4 and subscripts of line 4. [03/31/1997]
2040		All calendar format dates must be edited for 10 character format, e.g., 01/01/1996 (MM/DD/YYYY). [10/31/1998]
2045		All dates must be possible, e.g., no "00", no "30" or "31" of February. [03/31/1997]
2005S		DELETE THIS EDIT: The combined amount due the provider or program (Worksheet S, Part II, line 7, sum of columns 1-4) should not equal zero. [03/31/1997]

Rev. 14 35-567

3595 (Cont.) FORM CMS 2540-96 04-06

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 - EDITS

Edit	Condition
2015S	The SNF certification date (Worksheet S-2, column 3, line 4) should be on or before the cost report beginning date (Worksheet S-2, column 1, line 13). [03/31/1997]
2020S	The length of the cost reporting period should be greater than 27 days and less than 459 days. [03/31/1997]
2045S	Worksheet S-2, line 14 (type of control) must have a value of 1 through 13. [03/31/1997]
2085S	The sum of column 1, lines 2-5, 8-14, 17-21, and 24 (Worksheet S-3, Part II) must be greater than zero. [03/31/1997]
2090S	The sum of column 4, lines 2-5, 8-14, 17-18, and 24 (Worksheet S-3, Part II) must be greater than zero. [03/31/1997]
2100S	Total days for the SNF (Worksheet S-3, Part I, column 7, line 9) should be greater than zero. [03/31/1997]
2105S	If Medicare SNF inpatient days (Worksheet S-3, Part I, column 4, line 1) is greater than zero, then the following fields on Worksheet S-3, Part I, should also be greater than zero. [03/31/1997]
	a. Total skilled nursing facility discharges (column 12, line 9); and
	b. Medicare SNF discharges (column 9, line 9)
2110S	Total SNF inpatient days (Worksheet S-3, Part I, column 7, lines 1 and 3) should be less than or equal to SNF bed days available (Worksheet S-3, Part I, column 2, lines 1 and 3)[03/31/1997].
2115S	If on Worksheet S-2, either of columns 4 or 6 for line 4 equals P or O, then the corresponding columns for line 6 must be blank or equal N and vice versa. This edit flags the existence of SNF and NF simultaneously for title V and/or title XIX services. [03/31/1997]
2125S	Worksheet S-3, Part II, column 1, lines 8 through 14 must equal the sum of all related lines on Worksheet A, column 1. [03/31/1997]
2150S	If Worksheet S-3, Part II (column 4, sum of lines 8 through 14 divided by the sum of line 1 minus the sum of lines 2 through 5) is greater than 5 percent, then Worksheet S-3, Part III, column 1, line 14 must equal the sum of the amounts on Worksheet A, column 1, lines 3 through 15. [03/31/1997]
2155S	If Worksheet S-3, Part II (column 4, sum of lines 8 through 14 divided by the sum of line 1 minus the sum of lines 2 through 5) is equal to or greater than 15 percent, then Worksheet S-3, Part III, columns 1 and 4 for line 14 should be greater than zero. [03/31/1997]

35-568 Rev. 14

04-06 FORM CMS 2540-96 3595 (Cont.)

ELECTRONIC COST REPORTING SPECIFICATIONS FOR FORM CMS 2540-96

TABLE 6 – EDITS

Edit	Condition
2160S	If Worksheet S-3, Part III, column 4, line 14 is greater than zero, then those hours should be at least 20 percent but not more than 60 percent of Worksheet S-3, Part II, column 4, line 1. [03/31/1997]
2165S	Worksheet S-3, Part II, column 5: line 16 must be greater than $5.14, and less than $50.00; line 17 must be greater than $7.00, and less than $75.00; and line 18 must be greater than $5.14, and less than $50.00;. [12/31/2002]
2000A	Worksheet A-6, column 1 (reclassification code) must be alpha characters. [03/31/1997]
2020A	Worksheet A-8-1, Part A, line 1, must contain an "X" in either columns 1 or 2. [03/31/1997]
2035A	For Worksheet A-7, line 7, the sum of columns 1-3 minus column 5 must be greater than zero. [03/31/1997]
	Column headings (Worksheets B-1; B, Parts I and II; and J-1, Part III) are required as indicated below. (A).
2045A	If there are any transactions with related organizations or home offices as defined in CMS Pub. 15-I, chapter 10 (Worksheet A-8-1, Part A, line 1, column 1, is "X"), Worksheet A-8-1, Part B, columns 4 or 5, sum of lines 1-9 must be greater than zero; and Part C, column 1, any one of lines 1-10 must contain any one of alpha characters A through G. However, for each line completed in Part B, at least one line entry must be completed in Part C. Conversely, if Worksheet A-8-1, Part A, line 1, column 2, is "X," Worksheet A-8-1, Parts B and C must not be completed. [03/31/1997]
2000B	At least one cost center description (lines 1-3), at least one statistical basis label (lines 4-5), and one statistical basis code (line 6) must be present for each general service cost center with costs to allocate. This edit applies to all general service cost centers required and/or listed. [03/31/1997]
2005B	The column numbering among these worksheets must be consistent. For example, data in capital related costs - buildings and fixtures is identified as coming from column 1 on all applicable worksheets. [03/31/1997]
2000G	Total assets on Worksheet G (line 33, sum of columns 1-4) must equal total liabilities and fund balances (line 59, sum of columns 1-4). [03/31/1997]
2010G	Net income or loss (Worksheet G-3, column 1, line 32) should not equal zero. [03/31/1997]
NOTE:	CMS reserves the right to require additional edits to correct deficiencies that become evident after processing the data commences and, as needed, to meet user requirements.

Rev. 14 35-569