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

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Overview

TABLECONT
TABLE1
TABLE2
TABLE3
T3A_3C
TABLE5
CODES
TABLE6

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Sheet 1: TABLECONT

	03-04				FORM CMS-1984-99				3895
			EXHIBIT 2 - ELECTRONIC REPORTING SPECIFICATIONS FOR
				FORM CMS 1984-99 TABLE OF CONTENTS
			Topic					Page(s)
	Table 1:		Record Specifications					38-203 - 38-211
	Table 2:		Worksheet Indicators					38-212
	Table 3:		List of Data Elements with Worksheet,
			Line, and Column Designations					38-213 -38-217
	Table 3A:		Worksheets Requiring No Input					38-218
	Table 3B:		Tables to Worksheet S-2					38-218
	Table 3C:		Lines Which Cannot Be Subscripted					38-218
	Table 5:		Cost Center Coding					38-219 - 38-222
	Table 6:		Edits, Levels I & II					38-223 -38-228
	Rev. 5								38-201

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Sheet 2: TABLE1

	03-04					FORM CMS-1984-99						3895 (Cont.)
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
	Table 1 specifies the standard record format to be used for electronic 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)
	are included in the type 2 records. Refer to Table 5 for cost center coding. The data, detailed
	in Table 3, is identified as type 3 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 3½" diskettes.
	These disks must be in IBM format. The character set must be ASCII. Providers should seek
	approval from their fiscal intermediaries regarding the method of submission to insure 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 set of type 1 records with a narrative description of their meaning.
	1 2 3 4 5 6
	123456789012345678901234567890123456789012345678901234567890
	1 1 010123200400120043665A99P00520050202004366
	Record #1:		This is a cost report file submitted by Provider 010123 for the period from
			January 1, 2004 (2004001) through Decmber 31, 2004 (2004366). It is filed on the Form
			CMS-1984-99. It is prepared with vendor number A99's PC based system, version
			number 5. Position 38 changes with each new test case and/or reapproval and is alpha.
			Positions 39 and 40 will remain constant for approvals issued after the first test case.
			This file is prepared by the hospice on January 20, 2005 (2005020). The electronic cost
			report specification, dated December 31, 2004 (2004366), is used to prepare this file.
	Rev. 5											38-203
	3895 (Cont.)					FORM CMS-1984-99						03-04
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
						FILE NAMING CONVENTION
	Name each cost report file in the following manner:
		HSNNNNNN.YYL, where
		1. HS (Electronic Cost Report) is constant;
		2. NNNNNN is the 6 digit Medicare hospice 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
		hospices with two or more cost reporting periods ending in the same calendar year.
					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.	Space			1	X	12
	4.	Record Number			1	X	13		Constant "1"
	5.	Spaces			3	X	14-16
	6.	Hospice Provider			6	9	17-22		Field must have 6 numeric characters
		Number
	7.	Fiscal Year							YYYYDDD - Julian date; first day
	Ending Date	Beginning Date			7	9	23-29		covered by this cost report
	8.	Fiscal Year							YYYYDDD - Julian date; last day
		Ending Date			7	9	30-36		covered by this cost report
	9.	MCR Version			1	9	37		Constant "5" (for Form
									CMS 1984-99)
	10.	Vendor Code			3	X	38-40		To be supplied upon approval. Refer
									to page 38-703.
	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).
	38-204											Rev. 5
	08-06					FORM CMS-1984-99						3895 (Cont.)
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
					RECORD NAME: Type 1 Records - Record Number 1 (Continued)
					Size	Usage	Loc.			Remarks
	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 ending on
									or after 2006181 (6/30/2006). Prior
									approval 2004366 (12/31/2004).
					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 - Reserved for future use.
									#3 - Vendor information; optional
									record for use by vendors. Left
									justified in positions 21-60.
									#4 - The time that the cost report is
									created. This is represented in
									military time as alpha numeric. Use
									position 21-26. Example 2:30PM
									is expressed as 14:30.
									#5 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.
	Rev. 7											38-205
	3895 (Cont.)					FORM CMS-1984-99						08-06
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
					RECORD NAME: Type 2 Records for Labels
					Size	Usage	Loc.			Remarks
	1.	Record Type			1	9	1		Constant "2"
	2.	Worksheet 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
	b. Col. Headings	Basis & Code			10	X	21-30		Alphanumeric, left justified
	The type 2 records contain text which appears on the pre-printed cost report. Of these, there are
	three groups: (1) Worksheet A cost center names (labels); (2) column headings for stepdown 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.
	38-206											Rev. 7
	02-05					FORM CMS-1984-99						3895 (Cont.)
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
					RECORD NAME: Type 2 Records for Labels (Continued)
	Column headings for the General Service cost centers on Worksheets B-1and B are supplied once,
	consisting of one to three records. The statistical basis shown on worksheet B-1 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 recorded as line 6 and only for capital cost centers, columns 1-4
	and subscripts as applicable. The statistical code agree with the statistical basis indicated on line 4
	and 5, i.e., code 1 = square footage, code 2 = dollar value, and code 3 = all others. Refer to Table 2
	for the special worksheet identifier to be used with column headings and statistical basis and to
	Table 3 for line and column references.
	Use the following type 2 cost center descriptions for all Worksheet A standard cost center lines.
	Line	Description					Line	Description
	1	CAPITAL REL COSTS-BLDG & FIXT					24	HOME HEALTH AIDE AND HOMEMAKER
	2	CAPITAL REL COSTS-MOVABLE EQUIP					25	OTHER VISITING SERVICES
	3	PLANT OPERATION AND MAINTENANCE					30	DRUGS, BIOLOGICAL AND INFUSION
	4	TRANSPORTATION-STAFF					31	DURABLE MEDICAL EQUIPMENT/OXYGEN
	5	VOLUNTEER SERVICE COORDINATION					32	PATIENT TRANSPORTATION
	6	ADMINISTRATIVE AND GENERAL					33	IMAGING SERVICES
	10	INPATIENT- GENERAL CARE					34	LABS AND DIAGNOSTICS
	11	INPATIENT- RESPITE CARE					35	MED SUPPLIES CHARGED TO PATIENTS
	15	PHYSICIAN SERVICES					36	OUTPATIENT SERVICES (INCL E/R DEPT.)
	16	NURSING CARE					37	RADIATION THERAPY
	17	PHYSICAL THERAPY					38	CHEMOTHERAPY
	18	OCCUPATIONAL THERAPY					39	OTHER HOSPICE SERVICE COST CENTER
	19	SPEECH/LANGUAGE PATHOLOGY					50	BEREAVEMENT PROGRAM COSTS
	20	MEDICAL SOCIAL SERVICES					51	VOLUNTEER PROGRAM COSTS
	21	SPIRITUAL COUNSELING					52	FUNDRAISING
	22	DIETARY COUNSELING					53	OTHER NONREIMBURSABLE COSTS
	23	COUNSELING-OTHER
	Type 2 records for Worksheet B-1, columns 1-6, lines 1-2 and line 6 (for columns 1-4
	only (capital cost center columns)) are listed below. The numbers running vertical to line 1
	descriptions are the general service cost center line designations.
						LINE
		1		2		3		4		5		6
	1	CAPITAL		BLDGS &		FIXTURES		SQUARE		FEET		1
	2	CAPITAL		MOVABLE		EQUIPMENT		DOLLAR		VALUE		2
	3	PLANT		OPER. &		MAINT.		SQUARE		FEET		1
	4	TRANS-		PORTAT-		ION		MILEAGE				3
	5	VOLUNT.		SERVICES		COORDI.		HOURS OF		SERVICE		3
	6	ADMINIS-		TRATIVE &		GENERAL		ACCUM.		COSTS		3
	Rev. 6											38-207
	3895 (Cont.)					FORM CMS-1984-99						02-05
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
				TABLE 1 - RECORD SPECIFICATIONS
	Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline,
	column, and subcolumn number fields (positions 11-20). Spaces are preferred. (See
	first two lines of the example.)* Refer to Table 6 for additional cost center code requirements.
	Examples:
		Worksheet A line labels with embedded cost center codes:
	*	2A000000 1 0100CAP REL COSTS-BLDS & FIXT		0100CAPITAL REL COSTS-BLDG & FIXT
	*	2A000000 101 0101CAPITAL REL COSTS-WEST WING
		2A000000 2 0200CAP REL COSTS-MVBLE EQUIP		0200CAPITAL REL COSTS-MOVABLE EQUIP
		2A000000 6 0600ADMINISTRATIVE AND GENERAL
		2A000000 10 1000INPATIENT-GENERAL CARE
		2A000000 11 1100INPATIEN-RESPITE CARE
		Examples of column headings for Worksheets B-1 and B, statistical bases used in cost
		allocation on Worksheet B-1, and statistical coded used for worksheet B-1 (line 6)
		are displayed below.
		2B10000* 1 1 CAP
		2B10000* 2 1 BLDGS &
		2B10000* 3 1 FIXTURES
		2B10000* 4 1 SQUARE
		2B10000* 5 1 FEET
		2B10000* 6 1 1
	38-208											Rev. 6
	03-04					FORM CMS-1984-99						3895 (Cont.)
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
					RECORD NAME: Type 3 Records for Nonlabel Data
					Size	Usage	Loc.			Remarks
	1.	Record Type			1	9	1		Constant "3"
	2.	Worksheet Indicator			7	X	2-8		Numeric. 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).
		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,
									unless the field is defined as negative
									on the form. 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.
	Rev. 5											38-209
	3895 (Cont.)					FORM CMS-1984-99						03-04
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
	A sample of type 3 records and a number line for reference are below.
				1 1	3
		123456789		5 8	6
		3A000000	4	1	32961
		3A000000	21	1	1336393
		3A000000	21	1 1	185599
		3A000000	52	1 1	17750
		3A000000	1	2	1014775
		3A000000	1	1 2	1767922
		3A000000	2	2	14596
		3A000000	21	2	768441
		3A000000	21	1 2	2746235
		3A000000	52	1 2	4982
	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, columns 3, and 7
		Worksheet A-8, column 4
		Worksheet A-8-1, Part A, column 1
	38-210											Rev. 5
	08-06					FORM CMS-1984-99						3895 (Cont.)
			ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
					TABLE 1 - RECORD SPECIFICATIONS
	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
		3A600010	13	0		TO SPREAD INTEREST EXPENSE
		3A600010	13	1		G
	*	3A600010	13	3				1.00
		3A600010	13	4				221409
	*	3A600010	13	7				52.00
		3A600010	13	8				225321
		3A600010	14	0		BETWEEN CAPITAL-RELATED COST
		3A600010	14	1		G
	*	3A600010	14	3				4.01
		3A600010	14	4				3912
		3A600010	15	0		BUILDING & FIXTURES AND
		3A600010	16	0		ADMINISTRATIVE AND GENERAL
				RECORD NAME: TYPE "3" RECORDS
			1	1		2
		123456789	3	8		1
		3A800000	8	1 1		MISCELANEOUS ADJUSTMENT
		3A800000	8	1 2		A
		3A800000	8	1 3				-250935
	*	3A800000	8	1 4				61.00
		3A810000	1	3		CAT SCANS
		3A810000	1	4				13352
		3A810000	1	5				11122
				RECORD NAME: TYPE 4 RECORDS - File Encryption
		This type 4 record consist 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 or
		compact disk to insure the integrity of the file.
	Rev. 7											38-211

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Sheet 3: TABLE2

3895 (Cont.)			FORM CMS-1984-99						08-06
	ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		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 characters in positions 2-8 of the record identifier. The
first two characters of the worksheet indicator (positions 2 and 3 of the record identifier) always show
the worksheet. The third character of the worksheet indicator (position 4 of the record identifier)
is used in several ways. It may be used as part of the worksheet, e.g., A81. The fourth character
of the worksheet indicator (position 5 of the record identifier) represents the type of provider, by
using the keys below. Except for Worksheet A-6 (to handle multiple worksheets), the fifth and sixth
characters of the worksheet indicator position 6 and 7 of the record identifier) identify worksheets
Federal program (18 = title XVIII, 05 = Title V, or 19 =Title XIX) or worksheets required for the
facility (00 = Universal). The seventh character of the worksheet indicator (position 8 of the record
identifier) represent the worksheet part.
		Worksheets Which Apply to the Hospice Cost Report
						Worksheet
		Worksheet				Indicator
		S-1 (a)				S100000
		A				A000000
		A-1				A100000
		A-2				A200000
		A-3				A300000
		A-6 (b)				A600010
		A-7				A700000
		A-8				A800000
		A-8-1, Part A				A81000A
		A-8-1, Part B				A81000B
		B-1 (For use in column headings)				B10000*
		B				B000000
		B-1				B100000
		D				D000000
		G				G000000
		G-1				G100000
		G-2, Part I				G200001
		G-2, Part II				G200002
(a)	Worksheets 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 still identifies each worksheet and
	part as they appear on the printed cost report. This affects Worksheet S-1.
(b)	Multiple Worksheets for Reclassification and Adjustments Before and After Stepdown
	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. For reports
	which do not need additional worksheets, the default is 01. For reports which d 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.
38-212									Rev. 7

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Sheet 4: TABLE3

		08-06			FORM CMS-1984-99				3895 (Cont.)
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
					INTRODUCTION
		This table identifies those data elements necessary to calculate a hospice cost report. It also identifies
		some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 7) are
		needed to verify the mathematical accuracy of the raw data elements and to isolate differences between
		the file submitted by the hospital 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
		adjustment 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 or less than 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.
		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 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. any other non cost center lines, all subscripted lines should be in
		sequence and consecutively numbered beginning with subscripted subline "01". Automated systems
		should reorder these numbers where the provider skips or deletes 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 which are specified in Table 3 with a usage of "-9".
		Italic script within this table denotes adjustments which are not displayed in the print image or hard copy
		of the cost report, but are contained in the ECR file.
		Rev. 7							38-213
		3895 (Cont.)			FORM CMS-1984-99				08-06
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
								FIELD
				DESCRIPTION		LINE(S)	COLUMN(S)	SIZE	USAGE
					WORKSHEET S-1
		Part I
			Name of the hospice			1	1	36	X
			Address			1	2	36	X
			City			1	3	36	X
			State			1	4	2	X
			Zip Code			1	5	10	X
			County			2	1	36	X
			Date hospice began operation (mm/dd/yyyy)			3	1	10	X
			Certification date (mm/dd/yyyy) for Title XVIII			4	1	10	X
			Certification date (mm/dd/yyy) for Title XIX			4	2	10	X
			Cost reporting period beginning date (mm/dd/yyyy)			5	1	10	X
			Cost reporting period ending date (mm/dd/yyyy)			5	2	10	X
			Provider number (xxxxxx)			6	1	6	X
			National Provider Identifier			6.01	1	10	X
			Type of control (See Table 3B.)			7	1	2	9
		Part II - Enrollment Days
		Continuous Home Care				8	1-5	11	9
		Routine Home Care				9	1-5	11	9
		Inpatient Respite Care				10	1-5	11	9
		General Inpatient Care				11	1-5	11	9
		Total Hospice days				12	1-6	11	9
		Part III - Census Data
		Number of Patients Receiving Hospice Care				13	1-6	11	9
		Unduplicated Continuous Medicare Hours				14	1 & 3	11	9(8).99
		Average Length of Stay (line5/line 6)				15	1-6	11	9(8).99
		Unduplicated Census Count				16	1-6	11	9
		If the hospice componentized (or fragmented) it’s administrative
		and general service cost, indicate whether option one or
		or two is being utilized. (See instructions)				17	1	1	9
		Are there any related organization or home office costs as defined
		in CMS Pub. 15-I, chapter 10?				18	1	1	X
		If yes, enter home office chain number, if applicable.				18	2	6	X
					WORKSHEET A
		Transportation				1-6,10-11, 15-25,
						30-39, 50-53	3	11	9
		Other costs				1-6,10-11, 15-25,
						30-39, 50-53	5	11	9
		Reclassifications				1-6,10-11, 15-25,
						30-39, 50-53	7	11	-9
		Adjustments				1-6,10-11, 15-25,
						30-39, 50-53	9	11	-9
		Net expense for allocation				1-6,10-11, 15-25,
						30-39, 50-53	10	11	-9
		Total				100	1-10	11	-9
					WORKSHEETS A-1, A-2, & A-3
		Salaries, benefits & Contract Services				3-6,10-11, 15-25,
						30-39, 50-53	1-8	11	-9
						3-6,10-11, 15-25,
		Total				30-39, 50-53	9	11	9
		38-214							Rev. 7
		08-06			FORM CMS-1984-99				3895 (Cont.)
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
								FIELD
				DESCRIPTION		LINE(S)	COLUMN(S)	SIZE	USAGE
					WORKSHEET A-6
		For each expense reclassification:
			Explanation			1-35	0	36	X
			Increases:
				Adjustment letter(s)		1-35	1	2	X
				Worksheet A line number		1-35	3	6	9(3).99
				Reclassification salary amount		1-35	4	11	9
				Reclassification other amount		1-35	5	11	9
			Decreases:
				Worksheet A line number		1-35	7	6	9(3).99
				Reclassification salary amount		1-35	8	11	9
				Reclassification other amount		1-35	9	11	9
			Total			100	4, 5, 8 & 9	11	9
					WORKSHEET A-7
		For land, land improvements, buildings and fixtures, building
		improvements, fixed and movable equipment, and in total:
		Analysis of changes in capital asset balances
				Beginning balance		1-9	1	11	9
				Purchases		1-9	2	11	9
				Donations		1-9	3	11	9
				Disposals and retirements		1-9	5	11	9
					WORKSHEET A-8
		Description of adjustment				8	0	36	X
		Basis (A or B) *				1-2, 4-10,	1	1	X
		Amount *				1-10	2	11	-9
		Worksheet A line number +				1-2, 4-10	4	6	9(3).99
		Total				11	2	11	-9
		* These include subscripts of lines 1-2 and 4-10 requiring records for columns 1 and 2. These subscripts should occur
		based on Worksheet A layout.
		+ Do not include preprinted lines, i.e. lines 9-10.
					WORKSHEET A-8-1
		Part A - For costs incurred and adjustments required as a
		result of transactions with related organization(s):
				Worksheet A line number		1-4	1	6	9(3).99
				Expense item(s)		1-4	3	36	X
				Amount allowable in reimbursable cost		1-4	4	11	9
				Amount included in Worksheet A		1-4	5	11	9
				Total		5	4-5	11	-9
		Part B - For each related organization:
				Type of interrelationship (A through G)		1-5	1	1	X
				If type is G, description of relationship must be
				included.		1-5	0	36	X
				Name of individual or partnership with interest
				in provider and related organization		1-5	2	36	X
				Percent of ownership of provider		1-5	3	6	9(3).99
				Name of related organization		1-5	4	36	X
				Percent of ownership of related organization		1-5	5	6	9(3).99
				Type of business		1-5	6	15	X
		Rev. 7							38-215
		3895 (Cont.)			FORM CMS-1984-99				08-06
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
								FIELD
				DESCRIPTION		LINE(S)	COLUMN(S)	SIZE	USAGE
					WORKSHEETS B-1 HEADINGS*
		Column heading (cost center name)				1-3*	1-6	10	X
		Statistical basis				4, 5*	1-6	10	X
					WORKSHEET B
		Total adjustments after cost finding				100	6	11	-9
		Costs after cost finding and post stepdown
		adjustments by department				10-11,
						15-25, 30-39,
						50-53	7	11	-9
		Total costs after cost finding and post stepdown adjustments				100	7	11	9
		*	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 which 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-1
		For each cost allocation using accumulated costs as the
		statistic, include a record containing an X.				0	6	1	X
		All cost allocation statistics				1-6, 10-11,
						15-25, 30-39,
						50-53	1-6*	11	9
		Reconciliation				1-6, 10-11,
						15-25, 30-39,
						50-53	6A	11	-9
		Total cost to be Allocated				100	1-6	11	9
		*	In each column using accumulated costs as the statistical basis for allocating costs, identify each cost center which is
			to receive no allocation with a negative 1 (-1) placed in the accumulated cost column. Providers 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 column simultaneously on the same line. For those cost centers which
			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 6 is fragmented, line 6 must be deleted and subscripts of line 6 must be used.
		+	Include any column which uses accumulated cost as it basis for allocation.
					WORKSHEET D
		Total cost (Worksheet B, line 100, col 7, less line 53, col. 7)				1	4	11	-9
		Total Unduplicated Days (Worksheet S-1, line 12, col. 6)				2	4	11	9
		Average cost per diem (line 1 divided by line 2)				3	4	11	9(8).99
		Unduplicated Medicare Days (Worksheet S-1, line 12, col.1)				4	1	11	9
		Average Medicare cost (line 3 times line 4)				5	1	11	9
		Unduplicated Medicaid Days (Worksheet S-1, line 12, col. 2)				6	2	11	9
		Average Medicaid cost (line 3 times line 6)				7	2	11	9
		Unduplicated SNF days (Worksheet S-1, line 12, col. 3)				8	1	11	9
		Average SNF cost (line 3 times line 8)				9	1	11	9
		Unduplicated NF days (Worksheet S-1, line 12, col. 4)				10	2	11	9
		Average NF cost (line 3 times line 10)				11	2	11	9
		Other Unduplicated days (Worksheet S-1, line 12, col. 5)				12	3	11	9
		Average NF cost (line 3 times line 12)				13	3	11	9
		38-216							Rev. 7
		08-06			FORM CMS-1984-99				3895 (Cont.)
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
								FIELD
				DESCRIPTION		LINE(S)	COLUMN(S)	SIZE	USAGE
					WORKSHEET G
		For the hospice:
		Text as needed for blank lines				48	0	36	X
		Balance sheet accounts				1-10, 12-26, 28-31,
						34-41, 43-48, 51	1	11	-9
		For hospices or hospices using fund accounting:
			Specific purpose fund account balances			1-10, 12-26, 28-31,
						34-38,40-41, 43-48,
						52	2	11	-9
			Endowment fund account balances			1-10, 12-26, 28-31,
						34-38,40-41, 43-48,
						53-55	3	11	-9
			Plant fund account balances			1-10, 12-26, 28-31,
						34-38,40-41, 43-48,
						56-57	4	11	-9
		Total Assets				33	1-4	11	-9
		Total Liabilities and Fund Balance				59	1-4	11	-9
		NOTE: Accumulated Depreciation lines will always be positive numbers unless otherwise specified.
					WORKSHEET G-1
		For hospices using fund accounting:
		Text as needed for blank lines				4-9, 12-17	0	36	X
			Beginning fund balances			1	1-4	11	-9
			Additions and reductions to
			beginning fund balances			4-9, 12-17	1-4	11	-9
					WORKSHEET G-2
		Part I:
		Skilled nursing facility based				1	1	11	9
		Nursing facility based				2	1	11	9
		Home care				3	1	11	9
		Other (see instructions)				4	1	11	9
		State Medicaid room and board				5	1	11	9
		Total general inpatient revenue				6	1	11	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	11	9
		Decreases to operating expenses reported on Worksheet A				9-13	1	11	9
		Total operating expenses				15	2	11	9
		Net income/Loss				16	2	11	-9
		Rev. 7							38-217

---

Sheet 5: T3A_3C

	3895(Cont.)			FORM CMS 1984-99				08-06
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
			TABLE 3A - WORKSHEETS REQUIRING NO INPUT
	WORKSHEET D
				TABLE 3B - TABLES TO WORKSHEET S-1
		TABLE I: Type of Control
		1 =	Voluntary Nonprofit, Church			8 =	Governmental, City-County
		2 =	Voluntary Nonprofit, Other			9 =	Governmental, County
		3 =	Proprietary, Individual			10 =	Governmental, State
		4 =	Proprietary, Corporation			11 =	Governmental, Hospital District
		5 =	Proprietary, Partnership			12 =	Governmental, City
		6 =	Proprietary, Other			13 =	Governmental, Other
		7 =	Governmental, Federal
			TABLE 3C - LINES WHICH CANNOT BE SUBSCRIPTED
				(BEYOND THOSE PREPRINTED)
	Worksheet S-1, lines 1-18
	Worksheet A-6
	Worksheet A-7
	Worksheet A-8, lines 1-7, and 9-11
	Worksheet A-8-1, Part A, lines 1-3
	Worksheet A-8-1, Part B, lines 1-4
	Worksheet D
	Worksheet G
	Worksheet G-1
	Worksheet G-2, Part I, lines 1-3, and 5
	Worksheet G-2, Part II, lines 1-6, 8-12. 14-16
	38-218							Rev. 7

---

Sheet 6: TABLE5

	03-04								3895 (Cont.)
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
				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 preparer
	must be presented with the allowable choices for that line or range of lines from the lists of standard
	and nonstandard descriptions. They will 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, will then be appended to the user's label by the software.
	Additional guidelines are:
	o	Any pre-existing codes for the line must not be allowed to carry over.
	o	All "Other . . ." lines must not be precoded.
	o	The order of choice is standard first, followed by specific nonstandard, and, lastly, the nonstandard
		"Other . . ." cost centers.
	o	When the nonstandard "Other . . ." is chosen, the preparer must be prompted with "Is this the most
		appropriate choice?" and offered a chance to answer yes or to select another description.
	o	The cost center coding process must be able to be invoked again for purposes of making corrections.
	o	A separate list showing the preparer's added cost center names on the left with the chosen standard
		or nonstandard description and code on the right must be printed for review.
	o	The number of times a description can be selected on a given report must be displayed on the screen
		next to the description and this number must decrease with each usage to show the remaining numbers
		available. The numbers are shown on the standard and nonstandard cost center tables.
	o	Standard cost center lines, descriptions, and codes are not to be changed. The acceptable format for
		these are displayed in the STANDARD COST CENTER DESCRIPTIONS AND CODES listed on
		pages 38-222. The proper line number is the first two digits of the cost center code.
		All "Other" nonstandard lines should be changed to the appropriate cost center name.
	Rev. 5								38-219
	3895 (Cont.)			FORM CMS 1984-99					03-04
	ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-92	ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
				TABLE 5 - COST CENTER CODING
			INSTRUCTIONS FOR PREPARERS
	Coding of Cost Center Labels
	Cost center coding is a methodology for standardizing the meaning of cost center labels as used by
	hospices on the Medicare cost report. The use of this coding methodology allows providers to
	continue to use their labels for cost centers that have meaning within the individual institution.
	The four digit codes that are required to be associated with each label provide standardized
	meaning for data analysis. Normally, it is only necessary to code any added labels because the
	preprinted STANDARD labels are automatically coded by CMS approved cost report software.
	Additional cost center descriptions have been identified through analysis of provider labels. The
	meanings of these additional descriptions were sufficiently different when compared to the Standard
	labels to warrant their use. These additional descriptions are hereafter 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 25, 39, and 53. Both the standard
	and nonstandard cost center descriptions along with their cost center codes are shown on Table 5.
	The "USE" column on that table indicates the number of times that a given code can be used on one
	cost report. You are required to compare your added label to the descriptions shown on the standard
	and nonstandard table 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 associate the code for the selected matching description with your label.
			Additional Guidelines
	Categories
	You must make your selection from the proper category such as general service description for general
	service lines, ancillary descriptions for ancillary cost center lines, etc.
	38-220								Rev. 5
	08-06			FORM CMS 1984-99					3895 (Cont.)
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
				TABLE 5 - COST CENTER CODING
	Use of 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 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
	Cost center codes may only be used in designated lines in accordance with the classification of the cost
	center(s), i.e., lines 1 through 6 may only contain cost center codes within the general service cost center
	category of both standard and nonstandard coding. For example, in the general service cost center
	category for Operation of Plant cost, line 3 and subscripts thereof should only contain cost center codes
	of 0300-0349 and nonstandard cost center codes. This logic must hold true for all other cost center
	categories, i.e., inpatient care services, visiting services, and hospice nonreimbursable services cost centers.
	Rev. 7								38-221

---

Sheet 7: CODES

	3895 (Cont.)			FORM CMS-1984-99				08-06
		ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99
		TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
			CODE	USE			CODE	USE
	GENERAL SERVICE COST CENTERS					OTHER HOSPICE SERVICE COST CENTERS
	Capital Rel Costs-Bldg & Fixt		0100	(50)		Drugs, Biological and Infusion	3000	(30)
	Capital Rel Costs-Movable Equip		0200	(50)		Durable Medical Equipment/Oxygen	3100	(30)
	Plant Operation and Maintenance		0300	(50)		Patient Transportation	3200	(30)
	Transportation-Staff		0400	(50)		Imaging Services	3300	(30)
	Volunteer Service Coordination		0500	(20)		Labs. And Diagnostics	3400	(30)
	Administrative and General		0600	(20)		Med Supplies Charged to Patients	3500	(30)
						Outpatient Services (incl E/R Dept.)	3600	(30)
	INPATIENT CARE SERVICE					Radiation Therapy	3700	(30)
						Chemotherapy	3800	(30)
	Inpatient- General Care		1000	(20)
	Inpatient- Respite Care		1100	(20)
						HOSPICE NONREIMBURSABLE COST CENTERS
	VISITING SERVICES
						Bereavement Program Costs	5000	(20)
	Physician Services		1500	(20)		Volunteer Program Costs	5100	(20)
	Nursing Care		1600	(20)		Fundraising	5200	(20)
	Physical Therapy		1700	(20)
	Occupational Therapy		1800	(20)
	Speech/language Pathology		1900	(20)
	Medical Social Services		2000	(20)
	Spiritual Counseling		2100	(20)
	Dietary Counseling		2200	(20)
	Counseling-Other		2300	(20)
	Home Health Aide and Homemaker		2400	(20)
		TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
	GENERAL SERVICE COST CENTERS
	A&G - Shared Costs		0621	(01)
	A&G - Reimbursable Costs		0622	(01)
	A&G - Nonreimbursable Costs		0623	(01)
	VISITING SERVICES
	Other Visiting Services		2500	(50)
	OTHER HOSPICE SERVICE COST CENTERS
	Other Hospice Service Cost Center		3900	(50)
	NONREIMBURSABLE COST CENTERS
	Other Nonreimbursable Costs		5300	(50)
	38-222							Rev. 7

---

Sheet 8: TABLE6

08-06

FORM CMS-1984-99

3895 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99

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 which

produces an electronic cost report file for Medicare hospices 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

hospice 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. Notification

must be made to CMS for any exceptions.

The edits are applied at two levels. Level I edits (1000 series reject codes) are those which test the

format of the data to identify for correction of those error conditions which will 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.

These items should be resolved at the provider site and appropriate worksheets and/or data submitted

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 (FI) processing time

and unnecessary rejections. Vendors should develop their programs to prevent their client hospices

from generating an electronic cost report file where Level I edits conditions exist. Ample warnings

should be given 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. Dates followed by a "b" are for cost reporting periods beginning

on or after and the date followed by an "s" are for services rendered on or after the specified

date. [12/31/2004]

I. Level I Edits (Minimum File Requirements)

Edit

Condition

1000

The first digit of every record must be either 1, 2, 3, or 4 (encryption code only). [12/31/2004]

1005

No record may exceed 60 characters. [12/31/2004]

1010

All alpha characters must be in upper case. This is exclusive of the vendor information,

type 1 record, record number 3 and the encryption code, type 4 record, record numbers

1, 1.01, and 1.02. [12/31/2004]

1015

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

that sequence. [12/31/2004]

1020

The hospice provider number (record #1, positions 17-22) must be valid and numeric. [12/31/2004]

1025

All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format and

a possible date. [12/31/2004]

Rev. 7

38-223

3895 (Cont.)

FORM CMS-1984-99

08-06

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99

TABLE 6 - EDITS

Edit

Condition

1030

The fiscal year beginning date (record #1, positions 23-29) must be greater than 28 days and the

fiscal year ending date (record #1, positions 30-36) cannot exceed 457 days. [12/31/2004]

1035

The vendor code (record #1, positions 38-40) must be a valid code. [12/31/2004]

1050

The type 1 record #1 must be correct and the first record in the file. [12/31/2004]

1055

All record identifiers (positions 1-20) must be unique. [12/31/2004]

NOTE: FIs attempt to correct if all record identifiers are not unique in their working copy and

continue processing the cost report. If the condition is correctable, they notify

the provider's vendor and send copy of ECR file both to the vendor and CMS

Central Office. CMS Central Office requires a vendor software update to

resolve condition. [12/31/2004]

1060

Only a Y or N are valid for fields which require a yes/no response. [12/31/2004]

1065

Variable columns (Worksheet B, and Worksheet B-1) must have a corresponding type 2

record (Worksheet A label) with a matching line number. [12/31/2004]

1070

All line, subline, column, and subcolumn numbers (positions 11-13, 14-15, 16-18, and 19-20,

respectively) must be numeric, except for any cost center with accumulated cost as its

statistics which 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. [12/31/2004]

1075

Cost center integrity must be maintained throughout the cost report. For subscripted lines,

the relative position must be consistent throughout the cost report. [12/31/2004]

1080

For every line used on Worksheets A, A-1, A-2, A-3 and B, there must be a corresponding

type 2 record. [12/31/2004]

1090

Fields requiring numeric data (days, charges, discharges, costs, etc.) may not contain any alpha

character. [12/31/2004]

1100

In all cases where the file includes both a total and the parts which comprise that total,

each total must equal the sum of its parts. [12/31/2004]

1005S

The cost report ending date must be on or after December 31, 2004. [12/31/2004]

1010S

The hospice name must be present on worksheet S-1 line 1 column 1. [12/31/2004}

1020S

The hospice name, address, county, certification date, and provider number (Worksheet S-1,

lines 1, 2, 4 and 6, columns 1-5 as appropriate) must be present and valid. [12/31/2004]

1030S

All amounts reported on Worksheet S-1, must not be less than zero. [12/31/2004]

38-224

Rev. 7

02-05

FORM CMS-1984-99

3895 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99

TABLE 6 - EDITS

Edit

Condition

1040S

The hospice certification date (Worksheet S-1 line 4, column 1) must be present and

possible. The date has to be before the cost report ending date and after 1/1/1966. [12/31/2004]

1000A

Worksheet A, columns 1 and 2, line 100 must be greater than zero. [12/31/2004]

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). [12/31/2004]

1025A

Worksheet A-6, column 1 must be present for each line with a column 3, 4, 5, 7, 8, or 9 entry.

There must be an entry on each line of columns 4 or 5 for each entry in column 3 and vice versa

and an entry on each line of columns 8 or 9 for each entry in column 7 and vice versa. All entries must

be valid; for example, no salary adjustments on columns 3 and/or 7, lines 1-2 for capital [12/31/2004]

1040A

For Worksheet A-8 adjustments on lines 1-2, or 4-8, if either columns 1, 2, or

4 has an entry, then all three columns for that line must have entries and if any one of

columns 0, 1, 2, or 4 for line 8 and subscripts thereof has an entry, then all four

columns for that line must have entries. [12/31/2004]

1045A

If there are any transactions with related organizations or home offices as defined in CMS

Pub. 15-I, chapter 10 (Worksheet S-1, column 1, line 18 is "Y"), Worksheet A-8-1, Part A,

columns 4 or 5 (amounts in columns 4 or 5 must have a parallel line number in column 1

and vise versa), line 5 must be greater than zero; and Part B, column 1, any one of lines 1-5

must contain any one of alpha characters A thru G. Conversely, if Worksheet S-1, column 1,

line 18 is "N", Worksheet A-8-1 should not be present. [12/31/2004]

1000B

On Worksheet B-1, all statistical amounts must be greater than zero, except for

reconciliation columns. [12/31/2004]

1005B

Worksheet B, column 7, line 100 must be greater than zero. [12/31/2004]

1010B

For each general service cost center with a net expense for cost allocation greater than zero

(Worksheet B, columns 1 through 6, line 100), 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 which uses accumulated cost as its basis for allocation

and any reconciliation column. [12/31/2004]

1015B

For any column which uses accumulated cost as its bases of allocation (Worksheet B-1),

there may not exist on any statistical line an amount both in the reconciliation column

and the accumulated cost column, including a negative one, simultaneously. [12/31/2004]

Rev. 6

38-225

3895 (Cont.)

FORM CMS-1984-99

02-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99

TABLE 6 - EDITS

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,

provide additional information in schedules, note form, or any other manner as may be

required by your fiscal intermediary. Failure to clear these errors in a timely fashion,

as determined by your FI, may be grounds for withholding of 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). [12/31/2004]

2005

Only elements set forth in Table 3, with subscripts as appropriate, are required in the

file. [12/31/2004]

2010

The cost center code (position 21-24) (type 2 records) must be a code from Table 5, Cost

Center Coding, and each cost center code must be unique. [12/31/2004]

2015

Standard cost center lines, descriptions, and codes should not be changed. (See Table 5 for

standard descriptions and codes.) This edit applies to the standard line only and not subscripts

of that code. [12/31/2004]

2020

All standard cost center codes must be entered on the designated standard cost center

line and subscripts thereof as indicated in Table 5. [12/31/2004]

2030

The following standard cost centers listed below must be reported on the lines as indicated

and the corresponding cost center codes may only appear on the lines as indicated.

No other cost center codes may be placed on these lines or subscripts of these lines.

[12/31/2004]

Cost Center

Line

Code

Cap. Rel. Costs - Bldg. & Fixt.

1

0100-0149

Cap. Rel. Costs - Moveable Equip.

2

0200-0249

Plant Operation and Maintenance

3

0300-0349

Transportation-Staff

4

0400-0449

Volunteer Services

5

0500-0519

Inpatient -General Care

10

1000-1019

Inpatient-Respite Care

11

1100-1119

Physician Services

15

1500-1519

Nursing Care

16

1600-1619

Physical Therapy

17

1700-1719

Occupational therapy

18

1800-1819

Speech/Language Pathology

19

1900-1919

Medical Social Services

20

2000-2019

Spiritual Counseling

21

2100-2119

Dietary Counseling

22

2200-2219

Home Health Aide and Homemaker

24

2400-2419

38-226

Rev. 6

02-05

FORM CMS-1984-99

3895 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99

TABLE 6 - EDITS

Edit

Condition

Drugs and Biological Infusion Therapy

30

3000-3029

Durable Medical Equipment/Oxygen

31

3100-3129

Patient Transportation

32

3200-3229

Imaging Services

33

3300-3329

Labs and Diagnostics

34

3400-3429

Med. Supplied charged to patients

35

3500-3529

Outpatient Services(incl E/R Dept.)

36

3600-3629

Radiation Therapy

37

3700-3729

Chemotherapy

38

3800-3829

Bereavement Program Cost

50

5000-5019

Volunteer Program Cost

51

5100-5119

Fundraising

52

5200-5219

2035

Administrative and general cost center codes 0600 and 0621-0623 (standard and nonstandard)

may only appear on line 6 and subscripts of line 6. Other nonstandard descriptions

and codes may also appear on subscripts of line 6, but must be within the general

services cost center category. [12/31/2004]

2040

All calendar format dates must be edited for 10 character format, e.g., 01/01/1996

(MM/DD/YYYY). [12/31/2004]

2045

All dates must be possible, e.g., no "00", no "30" or "31" of February. [12/31/2004]

2015S

The hospice certification date (Worksheet S-1, column 1 and 2, line 4) should be on or before

the cost report beginning date (Worksheet S-1, column 1, line 3). [12/31/2004]

2045S

Worksheet S-1, line 7 (type of control) must have a value of 1 through 13. (See Table 3B.)

[12/31/2004]

2100S

The following statistics from Worksheet S-1, Part II should be greater than or equal to zero:

a.

Number of unduplicated days for the hospice (columns 1-5, lines 8-12) [12/31/2004];

b.

Number of patients receiving hospice care (columns 1-5, line 13) [12/31/2004];

c.

Total number of unduplicated continuous care hours billable to Medicare

(columns 1 and 3, line 14). [12/31/2004]

d.

Average length of stay within a hospice (columns 1-5, line 15).[12/31/2004]

e.

Unduplicated Census Count (columns 1-5, line 16).[12/31/2004]

Rev. 6

38-227

3895 (Cont.)

FORM CMS-1984-99

02-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 1984-99

TABLE 6 - EDITS

Edit

Condition

2000A

Worksheet A-6, column 1 (reclassification code) must be one or two alpha characters. [12/31/2004]

Column headings (Worksheets B-1, and B) are required as indicated for edit 2000B and 2005B:

2000B

a.

At least one cost center description (lines 1-3), at least one statistical bases label

(lines 4-5), and one statistical bases code (line 6) (capital cost center lines only) must

be present for each general service cost center with cost greater than zero (Worksheet

B-1, columns 1 through 6, line 100). Exclude any reconciliation columns from this

edit. [12/31/2004]

2005B

b.

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. [12/31/2004]

2000G

Total assets on Worksheet G line 33 must equal total liabilities and fund balance. [12/31/2004]

2010G

Net income or loss (Worksheet G-2, Part II, column 1, line 16) should not equal zero. [12/31/2004]

38-228

Rev. 6