Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

TRANSMITTAL CHECK SHEET -- PROVIDER REIMBURSEMENT MANUAL - PART 2

CHAPTER 38

Use this check list to record receipt of revision transmittals.

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CHAPTER 38

HOSPICE FACILITY

FORM CMS 1984-99

Section

General 3800 Rounding Standards for Fractional Computations 3801

Definitions 3802

Acronyms and Abbreviations 3803

Recommended Sequence for Completing Form HCFA 1984-99 3804

Sequence of Assembly 3805

Worksheet S - Hospice Cost Report Information Required 3806

Certification 3806.1 Worksheet S-1 - Hospice Identification Data 3807

Part I - Identification Data 3807.1

Part II - Enrollment Data 3807.2

Part III - Census Data 3807.3

Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses 3810

Worksheet A-1 - Compensation Analysis - Salaries and Wages 3811

Worksheet A-2 - Compensation Analysis - Employee benefits (Payroll Related) 3812

Worksheet A-3 - Compensation Analysis - Contracted Services/Purchased Services 3813 Worksheet A-6 - Reclassifications 3816

Worksheet A-7 - Analysis of Changes in Capital Asset Balances 3817

Worksheet A-8 - Adjustments to Expenses 3818

Worksheet A-8-1 - Statement of Costs of Services From Related Organizations and

Home Office Costs 3818.1 Worksheet B - Cost Allocation - General Service Costs and Worksheet B-1 -

Cost Allocation Statistical Basis 3820

Worksheet D-1 - Calculation of Per Diem Cost 3830

Worksheet G - Balance Sheet 3850

Worksheet G-1 - Statement of Changes in Fund Balances 3850.1

Worksheet G-2 - Statement of Patient Revenues and Net Income 3850.2

E XHIBIT 1 - Form CMS-1984-99 3890

E XHIBIT 2 – Electronic Reporting Specifications for Form CMS-1984-99 3895

38-1

Rev. 5