Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24 (CMS-222)

01-05

FORM CMS-222-92

2990

EXHIBIT 1- Form CMS-222-92

The following is a listing of the Form CMS –222-92 worksheets and the page number location.

Worksheets Page(s)

Wkst. S, Part I 29-303

Wkst. S, Parts I (Cont.) & II 29-304

Wkst. S, Part III 29-304.1

Wkst. A, Page 1 29-305

Wkst. A, Page 2 29-306

Wkst. A-1 29-307

Wkst. A-2 29-308

Wkst. B, Parts I & II 29-309

Wkst. C, Part I 29-310

Wkst. C, Part II 29-311

Supp. Wkst. A-2-1, Parts I-III 29-312

Supp. Wkst. B-1 29-313

Rev. 7

29-301

01-05 FORM CMS 222-92 2995

EXHIBIT 2-ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE OF CONTENTS

	Topic	Page(s)
T able 1:	Record Specifications	29-503 - 29-509
T able 2:	Worksheet Indicators	29-510 - 29-511
T able 3:	List of Data Elements With Worksheet, Line, and Column Designations	29-512 - 29-518
T able 3A:	Worksheets Requiring No Input	29-518
T able 3B:	Lines That Cannot Be Subscripted	29-518
T able 3C:	Table to Worksheet S	29-519
T able 3D:	Table to Worksheet S	29-519
T able 4:	Reserved for future use
T able 5:	Cost Center Coding	29-520 - 34-524
T able 6:	Edits:
	Level I Edits	29-525 - 29-527
	Level II Edits	29-528 - 29-529

Rev. 7 29-501

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 1 - RECORD SPECIFICATIONS

T able 1 specifies the standard record format to be used for electronic cost reporting. Each electronic cost report submission (file) has three types of records. The first group (type one records) contains information for identifying, processing, and resolving problems. The text used throughout the cost report for variable line labels (e.g., Worksheet A) is included in the type two 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.

T he medium for transferring cost reports submitted electronically to fiscal intermediaries is 3½" diskette. These disks must be in IBM format. The character set must be ASCII. You must seek approval from your fiscal intermediary regarding alternate methods of submission to ensure that the method of transmission is acceptable.

T he 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.

B elow is an example of a set of type 1 records with a narrative description of their meaning.

 1  2  3 4 5  6

1 23456789012345678901234567890123456789012345678901234567890

1 1 213975200400120043664A99P00120050312004366

R ecord #1: This is a cost report file submitted by Provider 213975 for the period from January 1, 2004 (2004001) through December 31, 2004 (2004366). It is filed on FORM CMS-222-92. It is prepared with vendor number A99'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 remain constant for approvals issued after the first test case. This file is prepared by the independent rural health clinic facility on January 31, 2005 (2005031). The electronic cost report specification dated December 31, 2004 (2004366) is used to prepare this file.

F ILE NAMING CONVENTION

N ame each cost report file in the following manner:

R FNNNNNN.YYL, where

1 . RF (Independent Rural Health Clinic or Federally Qualified Health Center Electronic Cost Report) is constant;

2 . NNNNNN is the 6 digit Medicare independent rural health clinic or federally qualified health center 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 independent RHC/FQHC facility with two or more cost reporting periods ending in the same calendar year.

Rev. 7 29-503

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 1 - RECORD SPECIFICATIONS

R ECORD 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 .	RHC/FQHC 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 "4" (for FORM CMS-222-92)
10.	Vendor Code	3	X	38-40	To be supplied upon approval. Refer to page 32-503.
1 1.	Vendor Equipment	1	X	41	P = PC; M = Main Frame
1 2.	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).
1 3.	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 2004366 (12/31/2004).

29-504 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 1 - RECORD SPECIFICATIONS

R ECORD 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	#2-99 - Reserved for future use.
4 .	Spaces	7	X	14-20	Spaces (optional)
5 .	ID Information	40	X	21-60	Left justified to position 21 except for records 5 & 6 (if applicable) which are right justified to position 36.

R ECORD 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

T he type 2 records contain both the text that appears on the pre‑printed cost report and any labels added by the preparer. Of these, there are three groups: (1) Worksheet A cost center names (labels); and (2) other text appearing in various places throughout the cost report.

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. 7 29-505

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 1 - RECORD SPECIFICATIONS

T he following type 2 cost center descriptions are to be used for all Worksheet A standard cost center lines.

L ine 1 2 3 4 5 6 7 8 13 14 17 18 19 20 26 27 28 29 3 0 3 1 3 2 3 3 3 8 3 9 4 0 4 1 4 2 4 3 4 4 4 5 5 1 5 2 5 3

Description PHYSICIAN PHYSICIAN ASSISTANT NURSE PRACTITIONER VISITNG NURSE OTHER NURSE CLINICAL PSYCHOLOGIST CLINICAL SOCIAL WORKER LABORATORY TECHNICIAN PHYSICIAN SERVICES UNDER AGREEMENT PHYSICIAN SUPERV UNDER AGREEMENT MEDICAL SUPPLIES TRANSPORTATION (HEALTH CARE STAFF) DEPRECIATION-MEDICAL EQUIPMENT PROFESSIONAL LIABILITY INSURANCE RENT INSURANCE INTEREST ON MORTAGE OR LOANS UTILITIES DEPRECIATION-BUILDING AND FIXTURES DEPRECIATION-EQUIPMENT HOUSEKEEPING AND MAINTENANCE PROPERTY TAX OFFICE SALARIES DEPRECIATION-OFFICE EQUIPMENT OFFICE SUPPLIES LEGAL ACCOUNTING INSURANCE TELEPHONE FRINGE BENEFITS AND PAYROLL TAXES PHARMACY DENTAL OPTOMETRY

29-506 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 1 - RECORD SPECIFICATIONS

E xamples 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). However, spaces are preferred. Refer to Table 5 and 6 for additional cost center code requirements.

E xamples:

W orksheet A line labels with embedded cost center codes:

2A000000 1 0100PHYSICIAN

2 A000000 2 0200PHYSICIAN ASSISTANT

2 A000000 8 0800LABORATORY TECHNICIAN

2 A000000 17 1700MEDICAL SUPPLIES

2 A000000 19 1900DEPRECIATION-MEDICAL EQUIPMENT

2 A000000 26 2600RENT

Rev. 7 29-507

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 1 - RECORD SPECIFICATIONS

R ECORD 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).
	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.

A sample of type 3 records are below.

3 A000000 5 1 20502

3 A000000 8 1 46347

3 A000000 17 2 469

29-508 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 1 - RECORD SPECIFICATIONS

T he 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.

W orksheet A-1, columns 3 and 6

W orksheet A-2, column 4

W orksheet A-2-1, Part II, column 1

E xamples of records (*) with a Worksheet A line number as data are below.

3 A100010 1 0 NON-RHC PHYSICIAN COMPENSATION

3 A100010 1 1 AA

* 3A100010 1 3 58.00

3 A100010 1 4 121656

* 3A100010 1 6 1.00

3 A100010 1 7 121656

3 A200000 7 1 B

3 A200000 7 2 -1993

* 3A200000 7 4 26.00

3 A210002 1 1 17.00

3 A210002 1 3 LATEX GLOVES

3 A210002 1 4 325

* 3A210002 1 5 280

R ECORD NAME: Type 4 Records - File Encryption

T his 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.

Rev. 7 29-509

2995(Cont.)

FORM CMS 222-92

01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 2 - WORKSHEET INDICATORS

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

T he 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 to identify Supplemental worksheet A-2-1. For Worksheet A-1, if there is a need for extra lines on multiple worksheets, the fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record identifier) identify the page number. The seventh digit of the worksheet indicator (position 8 of the record identifier) represents the worksheet or worksheet part.

W orksheets That Apply to the Rural Health Clinic/Federally Qualified Health Center Cost Report

	Worksheet	Worksheet Indicator
	S, Part I	S000001
	S, Part III	S000013	(a)
	A	A000000
	A-1	A100010	(a)
	A-2	A200000
	B, Part I	B000001	(b)
	C, Part I	C000001	(b)
	A-2-1, Part 1	A210001
	A-2-1, Part 2	A210002
	A-2-1, Part 3	A210003
	B-1	B100000

29-510 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 2 - WORKSHEET INDICATORS

F OOTNOTES:

( a) Multiple Worksheets for Reclassifications and Consolidated Cost Reports

T he 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 S, Part III and A-1. For reports that do not need additional worksheets, the default is 01. For reports that do need additional worksheets, the first page is numbered 01. The number for each additional page of the worksheet is incremented by 1.

( b) Worksheets With Multiple Parts Using Identical Worksheet Indicator

A lthough some worksheets have multiple parts, the lines are numbered sequentially. In these instances, the same 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 Worksheets B and C.

Rev. 7 29-511

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

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

T his table identifies those data elements necessary to calculate a independent renal dialysis cost report. It also identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 8) are needed to verify the mathematical accuracy of the raw data elements and to isolate differences between the file submitted by the independent renal dialysis facility 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.

T able 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.

C onsistency 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.

T able 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" (with a space preceding the 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 should be in sequence and consecutively numbered beginning with subscripted line number 01. Automated systems should reorder these numbers where providers skip or delete a line in the series.

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

A ll 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 reported as positive values.

29-512 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

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

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

W ORKSHEET S, PART I

	N ame	1		1	36	X
	S treet	1.01		1	36	X
	P .O. Box	1.01		2	9	X
	C ity	1.02		1	36	X
	S tate	1.02		2	2	X
	Z ip Code	1.02		3	10	X
	C ounty	1.03		1	36	X
	P rovider Number (999999)	2		1	6	9
	D esignation (R for Rural or U for Urban)	3		1	1	X
	C ost reporting period beginning date (MM/DD/YYYY)	4		1	10	X
	C ost reporting period ending date (MM/DD/YYYY)	4		2	10	X
	T ype of control (See Table 3C)	5		1	2	9
	T ype of Provider	5		3	1	X
	D ate Certified (MM/DD/YYYY)	5		4	10	X
	S ource of Federal Funds (See Table 3D)	6		1	1	9
	G rant Award Number	6		3	20	X
	D ate of Grant (MM/DD/YYYY)	6		4	10	X
	N ame of Physicians Furnishing Services
	N ame of Physician	7.01-7.30		1	36	X
	B illing Number	7.01-7.30		2	36	X
	S upervisor Physician
	N ame	8.01-8.30		1	36	X
	H ours of Supervision For Reporting Period	8.01-8.30		2	6	9
	D oes the facility operate as other than a RHC or FQHC? Enter “Y” for yes or “N” for no.	9		1	1	X
	I f yes, specify what type of operation , (i.e. physicians office, independent laboratory).	10		1	36	X
	I dentify days and hours of operation (from/to) by listing the time the facility operates as an RHC or FQHC next to the applicable day. *
	S unday	11.01		1,2	4	9
	M onday	11.02		1,2	4	9
	T uesday	11.03		1,2	4	9
	W ednesday	11.04		1,2	4	9
	T hursday	11.05		1,2	4	9
	F riday	11.06		1,2	4	9
	S aturday	11.07		1,2	4	9
Rev. 7			29-513

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

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

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

W ORKSHEET S, PART I (Continued)

I dentify days and hours (from/to) by listing the time the facility operates as other than an RHC or FQHC next to the applicable day . *
S unday	12.01	1,2	4	9
M onday	12.02	1,2	4	9
T uesday	12.03	1,2	4	9
W ednesday	12.04	1,2	4	9
T hursday	12.05	1,2	4	9
F riday	12.06	1,2	4	9
S aturday	12.07	1,2	4	9
I f this is a low or no Medicare utilization cost report, enter “L” for low or “N” for no Medicare utilization (L/N).	13	1	1	X
I s this facility filing a consolidated cost report? Enter “Y” for yes or “N” for no.	14	1	1	X
I f “Y” for question 14, then enter the number of additional providers filing under the consolidated cost report option (excluding the main provider).	14	2	2	9

W ORKSHEET S, PART III

N ame	1	1	36	X
S treet	2	1	36	X
P .O. Box	2	2	9	X
C ity	3	1	36	X
S tate	3	2	2	X
Z ip Code	3	3	10	X
C ounty	4	1	36	X
P rovider Number (xxxxxx)	5	1	6	X
D esignation (R for Rural or U for Urban)	6	1	1	X
D ate Certified (MM/DD/YYYY)	6	2	10	X
N ame of Physicians Furnishing Services
N ame of Physician	7.01-7.30	1	36	X
B illing Number	7.01-7.30	2	36	X
S upervisor Physician
N ame	8.01-8.30	1	36	X
H ours of Supervision For Reporting Period	8.01-8.30	2	6	X
D oes the facility operate as other than a RHC or FQHC? Enter “Y” for yes or “N” for no.	9	1	1	X

29-514 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

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

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

W ORKSHEET S, PART III (Continued)

I f yes, specify what type of operation , (i.e. physicians office, independent laboratory).	10	1	36	X
I dentify days and hours (from/to) by listing the time the facility operates as an RHC or FQHC next to the applicable day. *
S unday	11.01	1,2	4	9
M onday	11.02	1,2	4	9
T uesday	11.03	1,2	4	9
W ednesday	11.04	1,2	4	9
T hursday	11.05	1,2	4	9
F riday	11.06	1,2	4	9
S aturday	11.07	1,2	4	9
I dentify days and hours (from/to) by listing the time the facility operates as other than an RHC or FQHC next to the applicable day. *
S unday	12.01	1,2	4	9
M onday	12.02	1,2	4	9
T uesday	12.03	1,2	4	9
W ednesday	12.04	1,2	4	9
T hursday	12.05	1,2	4	9
F riday	12.06	1,2	4	9
S aturday	12.07	1,2	4	9

* Enter the time based on a 24 hour clock. For example 8:30am is 0830 and 5:00pm is 1700.

W ORKSHEET A

P hysicians salaries by department	1-11,13-15,17-23,26-36,38-48,51-56,58-60	1	9	-9
T otal compensation	62	1	9	9
O ther costs by department	1-11,13-15,17-23,26-36,38-48,51-56,58-60	2	9	-9
T otal other costs	62	2	9	9
N et expenses by department	1-11,13-15,17-23,26-36,38-48,51-56,58-60	7	9	-9
T otal expenses	62	7	9	9

Rev. 7 29-515

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

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

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

WORKSHEET A-1

F or each expense reclassification:
Explanation	1-35	0	36	X
Reclassification identification code	1-35	1	2	X
Increases:
Worksheet A line number	1-35	3	6	9(3).99
Reclassification amount	1-35	4	9	9
Decreases:
Worksheet A line number	1-35	6	6	9(3).99
Reclassification amount	1-35	7	9	9
Total increases and decreases	36	3,7	9	9

W ORKSHEET A-2

D escription of adjustment	11	0	36	X
B asis (A or B)	1,4,5,7-11	1	1	X
A mount	1-5,7-11,	2	9	-9
W orksheet A line number	1-5,7-11	4	6	9(3).99

S UPPLEMENTAL WORKSHEET A-2-1

P art I - Are there any related organization costs included on Worksheet A? (Y/N)	1	1	1	X
P art II - For costs incurred and adjustments required as a result of transactions with related organization(s):
Worksheet A line number	1-4	1	5	9(3).99
Expense item(s)	1-4	3	36	X
Amount included in Worksheet A	1-4	4	9	-9
Amount allowable in reimbursable cost	1-4	5	9	-9
P art III - For each related organization:
Type of interrelationship (A through G)	1-4	1	1	X

29-516 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

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

D ESCRIPTION	LINE(S)	COLUMN(S)	FIELD SIZE	USAGE

SUPPLEMENTAL WORKSHEET A-2-1 (Continued)

If type is G, specify description of relationship	1-4	0	36	X
Name of related individual or organization	1-4	2	36	X
Percentage of ownership	1-4	3	6	9 (3).99
Name of related individual or organization	1-4	4	36	X
Percentage of ownership of provider	1-4	5	6	9(3).99
Type of business	1-4	6	15	X

W ORKSHEET B-PART I

P osition by department:
N umber of Full Time Equivalent Personnel	1-3,5-7	1	6	9(3).99
T otal Visits	1-3,5-7,9	2	11	9
P roductivity Standard (see instructions)	1-3	3	11	9
G reater of columns 2 or 4	4	5	11	9

W ORKSHEET C-PART I

M aximum Rate Per Visit

8

1,2,2.01

6

9(3).99

W ORKSHEET C-PART II

M edicare Covered Visits Excluding Mental Health Services	11	1,2,2.01	11	9
M edicare Covered Visits For Mental Health Services	13	1,2,2.01	11	9
B eneficiary Deductibles	17	1,2,2.01	11	9
P ayments to RHC/FQHC during Reporting Period	22	3	11	9
T otal Reimbursable Bad Debts, Net of Recoveries	24	3	11	9
T otal Gross Reimbursable Bad Debts for Dual Eligible Beneficiaries	24.01	3	11	9

Rev. 7 29-517

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

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

S UPPLEMENTAL WORKSHEET B-1

R atio of Pneomococcal and Influenza Vaccine Staff Time to Total Health Care Staff Time	2	1,2	8	9.9(6)
M edicare supplies cost-Pneumococcal and Influenza Vaccine (From Your Records)	4	1,2	11	9
T otal Number of Pneumococcal and Influenza injections (From Provider Records)	11	1,2	11	9
N umber of Pneumococcal and Influenza Vaccine Injections Administered to Medicare Beneficiaries allowable cost	13	1,2	11	9

T ABLE 3A ‑ WORKSHEETS REQUIRING NO INPUT

Worksheet B, Part II

T ABLE 3B ‑ LINES THAT CANNOT BE SUBSCRIPTED

( BEYOND THOSE PREPRINTED)

	Worksheet	Lines
	S, Part I	1-6,9,10,13,14
	S, Part III	1-6,9,10
	A	1-8,13-14,16-23,24-33,37-42,44-45,49-53,57,61,62
	A-1	ALL
	A-2	1-10
	A-2-1, Part I	1
	A-2-1, Part II	1-3,5
	A-2-1, Part III	1-3
	B-Part I	1-9
	B-Part II	10-16
	C, Part I	1-9
	C, Part II	10-25
	B-1	1-16

29-518 Rev. 7

0 1-05

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 3C -TABLE TO WORKSHEET S

T ype of Control

1 = Voluntary Nonprofit, Corporation

2 = Voluntary Nonprofit, Other

3 = Proprietary, Individual

4 = Proprietary, Corporation

5 = Proprietary, Partnership

6 = Proprietary, Other

7 = Government, Federal

8 = Government, State

9 = Government, County

10 = Government, City

11 = Government, Other

T ype of Provider

1= RHC

2= FQHC

TABLE 3D-TABLE TO WORKSHEET S

S ource of Federal Funds

1 = Community Health Center(Section 330 (d), Public Health Service Act)

2 = Migrant Health Center (Section 329 (d), Public Health Service Act)

3 = Health Services for the Homeless (Section 340 (d), Public Health Service Act)

4 = Appalachian Regional Commission

5 = Look-Alikes

6 = Other

Rev. 7 29-519

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 5 - COST CENTER CODING

I NSTRUCTIONS FOR PROGRAMMERS

C ost 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. Using codes to standardize meanings makes practical data analysis possible. The method to accomplish this must be rigidly controlled to assure accuracy.

F or any added cost center names (the preprinted cost center labels must be precoded), prepares 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, will then be appended to the user’s label by the software.

A dditional guidelines are:

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

• D o not precode all Other lines.

• F or cost centers, the order of choice must be standard first, then specific nonstandard, and finally the nonstandard AOther . . ."

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

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

• F or 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.

• O n 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.

• D o not change standard cost center lines, descriptions and codes. The acceptable formats for these items are listed on page 29-521 of the Standard Cost Center Descriptions and Codes. The proper line number is the first two digits of the cost center code.

I NSTRUCTIONS FOR PREPARERS

C oding of Cost Center Labels

C ost center coding standardized the meaning of cost center labels used by health care providers on the Medicare cost reporting forms. The use of this coding methodology allows providers to continue to use their labels for cost centers that have meaning within the individual institution.

T he four digit codes that are required to 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.

A dditional cost center descriptions have been identified. These additional descriptions are hereafter referred to as the nonstandard labels. Included with the some nonstandard descriptions is an "Other . . ." designation to provide for situations where no match in meaning can be found. Refer to Worksheet A, line 9 or 21.

29-520 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 5 - COST CENTER CODING

B oth 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 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.

A dditional Guidelines

C ategories

M ake 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.

U se of a Cost Center Coding Description More Than Once

O ften 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.

C ost Center Coding and Line Restrictions

U se cost center codes only in designated lines in accordance with the classification of cost center(s), e.g., lines 58 through 60 may only contain cost center codes within the nonreimbursable services cost center category of both standard and nonstandard coding.

Rev. 7 29-521

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 5 - COST CENTER CODING

S TANDARD COST CENTER DESCRIPTIONS AND CODES

	CODE	USE
F ACILITY HEALTH CARE STAFF COSTS
P hysician	0100	(01)
P hysician Assistant	0200	(01)
N urse Practitioner	0300	(01)
V isiting Nurse	0400	(01)
O ther Nurse	0500	(01)
C linical Psychologist	0600	(01)
C linical Social Worker	0700	(01)
L aboratory Technician	0800	(01)
COSTS UNDER AGREEMENT
P hysician Services Under Agreement	1300	(01)
P hysician Supervision Under Agreement	1400	(01)
OTHER HEALTH CARE COSTS
M edical Supplies	1700	(01)
T ransportation (Health Care Staff)	1800	(01)
D epreciation-Medical Equipment	1900	(01)
P rofessional Liability Insurance	2000	(01)
FACILITY OVERHEAD-FACILITY COST
R ent	2600	(01)
I nsurance	2700	(01)
I nterest on Mortgage or Loans	2800	(01)
U tilities	2900	(01)
D epreciation-Building and Fixtures	3000	(01)
D epreciation-Equipment	3100	(01)
Housekeeping and Maintenance	3200	(01)
Property Tax	3300	(01)

29-522 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 5 - COST CENTER CODING-CONTIUED

S TANDARD COST CENTER DESCRIPTIONS AND CODES (Continued)

	CODE	USE
F ACILITY OVERHEAD-ADMINISTRATIVE COSTS
O ffice Salaries	3800	(01)
D epreciation-Office Equipment	3900	(01)
O ffice Supplies	4000	(01)
L egal	4100	(01)
A ccounting	4200	(01)
I nsurance	4300	(10)
T elephone	4400	(01)
F ringe Benefits and Payroll Taxes	4500	(01)
COSTS OTHER THAN RHC/FQHC SERVICES
P harmacy	5100	(01)
D ental	5200	(01)
O ptometry	5300	(01)

N ONSTANDARD COST CENTER DESCRIPTIONS AND CODES

	CODE	USE
FACILITY HEALTH CARE STAFF COSTS
O ther Facility Health Care Staff Costs	9000	(10)
O ther Facility Health Care Staff Costs	1000	(10)
O ther Facility Health Care Staff Costs	1100	(10)
COSTS UNDER AGREEMENT
O ther Costs Under Arrangement	1500	(10)
OTHER HEALTH CARE COSTS
O ther Health Care Costs	2100	(10)
O ther Health Care Costs	2200	(10)
O ther Health Care Costs	2300	(10)

Rev. 7 29-523

2995 (Cont.) FORM CMS 222-92 01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92

TABLE 5 - COST CENTER CODING-CONTIUED

N ONSTANDARD COST CENTER DESCRIPTIONS AND CODES (Continued)

	CODE	USE
F ACILITY OVERHEAD-FACILITY COSTS
O ther Facility Overhead-Facility Costs	3400	(10)
O ther Facility Overhead-Facility Costs	3500	(10)
O ther Facility Overhead-Facility Costs	3600	(10)
F ACILITY OVERHEAD-ADMINISTRATIVE COSTS
O ther Facility Overhead-Administrative Costs	4600	(10)
O ther Facility Overhead-Administrative Costs	4700	(10)
O ther Facility Overhead-Administrative Costs	4800	(10)
COSTS OTHER THAN RHC/FQHC SERVICES
O ther Than RHC/FQHC Service Costs	5400	(10)
O ther Than RHC/FQHC Service Costs	5500	(10)
O ther Than RHC/FQHC Service Costs	5600	(10)
NON-REIMBURSABLE COSTS
O ther Non-reimbursable Costs	5800	(10)
O ther Non-reimbursable Costs	5900	(10)
O ther Non-reimbursable Costs	6000	(10)

29-524 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 6 - EDITS

M edicare cost reports submitted electronically must be subjected to various edits, which are divided into two categories: Level I and level II 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 RHC/FQHCs 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 RHC/FQHC 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 containing a level I edit will be rejected by your fiscal intermediary without exception.

L evel I edits (1000 series reject codes) test that the file conforms to processing specifications, identifying error conditions that would 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 that may have exceptions and should not automatically cause a cost report rejection. 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).

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

N OTE: Dates in brackets [ ] at the end of an edit indicate the 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 the specified date. Dates followed by an “s” are for services rendered on or after the specified date unless otherwise noted. [12/31/2004]

I . Level I Edits (Minimum File Requirements)

R eject Code	Condition
1 000	The first digit of every record must be either 1, 2, 3, or 4 (encryption code only). [12/31/2004]
1 005	No record may exceed 60 characters. [12/31/2004]
1 010	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. [12/31/2004]
1 015	For micro systems, the end of record indicator must be a carriage return and line feed, in that sequence. [12/31/2004]
1 020	The independent RHC/FQHC facility provider number (record #1, positions 17-22) must be valid and numeric (issued by the applicable certifying agency and falls within the specified range). [12/31/2004]
1 025	All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format and legitimate. [12/31/2004]
1 030	The fiscal year beginning date (record #1, positions 23-29) must be less than the fiscal year ending date (record #1, positions 30-36). [12/31/2004]

Rev. 7 29-525

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 6 – EDITS

R eject Code	Condition
1 035	The vendor code (record #1, positions 38-40) must be a valid code. [12/31/2004]
1 050	The type 1 record #1 must be correct and the first record in the file. [12/31/2004]
1 055	All record identifiers (positions 1-20) must be unique. [12/31/2004]
1 060	Only a Y or N is valid for fields which require a Yes/No response. [12/31/2004]
1 075	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]
1 080	For every line used on Worksheet A, there must be a corresponding type 2 record. [12/31/2004]
1 090	Fields requiring numeric data (charges, treatments, costs, FTEs, etc.) may not contain any alpha character. [12/31/2004]
1 100	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. [12/31/2004]
1 005S	The cost report ending date (Worksheet S, Part I, column 2, line 4) must be on or after December 31, 2004. [12/31/2004]
1 015S	The cost report period beginning date (Worksheet S, Part I, column 1, line 4) must precede the cost report ending date (Worksheet S, Part I, column 2, line 4). [12/31/2004]
1 020S	The independent RHC/FQHC facility name, address, provider number, and certification date (Worksheet S, line 1, column 1; line 1.01, column 1; line 1.02, columns 1, 2, and 3; line 1.03, column 1; line 2, column 1; and line 5, column 4, respectively) must be present and valid. [12/31/2004]
1 025S	If the response to Worksheet S, Part I, line14, column 1 is “Y”, then the facility name, address, provider number, designation, and certification date (Worksheet S, Part III, line 1, column 1; line 2, column 1; line 3, columns 1, 2, and 3; line 4, column 1; line 5, column 1; and line 6, columns 1 and 2, respectively) must be present and valid. [12/31/2004]
1 000A	All amounts reported on Worksheet A, columns 1-2, line 62, must be greater than or equal to zero. [12/31/2004]
1 020A	For reclassifications reported on Worksheet A-1 the sum of all increases (column 4) must equal the sum of all decreases (column 7). [12/31/2004]
1 025A	For each line on Worksheet A-1, if there is an entry in columns 3, 4, 6, or 7, there must be an entry in column 1. There must be an entry on each line of column 4 for each entry in column 3 (and vice versa), and there must be an entry on each line of column 7 for each entry in column 6 (and vice versa). [12/31/2004]
1040A	For Worksheet A-2 adjustments on lines1-5, and 7-10, if either columns 2 or 4 has an entry, then both columns 2 and 4 must have entries, and if any one of columns 0, 1, 2, or 4 for line 11 and subscripts thereof has an entry, then all columns 0, 1, 2, and 4 must have entries. Only valid line numbers may be used in column 4. [12/31/2004]

29-526 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 6 – EDITS

R eject Code	Condition
1 045A	If there are any transactions with related organizations as defined in CMS Pub. 15-I, chapter 10 (Worksheet A-2-1, Part I, column 1, line 1 is "Y"), Worksheet A-2-1, Part II, columns 4 or 5, sum of lines 1-4 must be greater than zero; and Part C, column 1, any one of lines 1-4 must contain any one of alpha characters A through G. Conversely, if Worksheet A-2-1, Part I, column 1, line 1 is "N", Worksheet A-2-1, Parts II and III must not be completed. [12/31/2004]
1 050A	If the following amounts on Worksheet A are greater than zero, then the corresponding FTEs and total visits on worksheet B, Part I must also be greater than zero and vise versa: Worksheet A, column 7, Worksheet B, Part I, columns 1& 2, Line: Line: 1 1 2 2 3 3 4 5 6 6 7 7 [12/31/2004]
1 055A	If the amount on Worksheet A, column 7, line 13 (Physician Services Under Agreement) is greater than zero, then the corresponding total visits on worksheet B, Part I, column 2, line 9 must also be greater than zero and vise versa. [12/31/2004]
1 000B	Total visits on Worksheet B, Part I (sum of column 2, lines 1-3, 5-7, & 9), must be greater than or equal to the sum of the total Medicare covered visits on lines 11 &13, columns 1, 2, & 2.01. [12/31/2004]

Rev. 7

29-527

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 6 – EDITS

I I. Level II Edits (Potential Rejection Errors)

T hese 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 (FI). Failure to clear these errors in a timely fashion, as determined by your FI, may be grounds for withholding payments.

E dit	Condition
2 000	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]
2 005	Only elements set forth in Table 3, with subscripts as appropriate, are required in the file. [12/31/2004]
2 010	The cost center codes (positions 21-24) (type 2 records) must be a code from Table 5, and each cost center code must be unique. [12/31/2004]
2 015	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. [12/31/2004]
2 020	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]
2 025	Only nonstandard cost center codes within a cost center category may be placed on standard cost center lines of that cost center category. [12/31/2004]
2 030	The 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, unless indicated herein. [12/31/2004]

		Cost Center		Line			Code
	Physician		1		0100
	Physician Assistant		2		0200
	Nurse Practitioner		3		0300
	Visiting Nurse		4		0400
	Other Nurse		5		0500
	Clinical Psychologist		6		0600
	Clinical Social Worker		7		0700
	Laboratory Technician		8		0800
	Physicians Services Under Agreement		13		1300
	Physicians Supervision Under Agreement		14		1400
	Medical Supplies		17		1700
	Transportation (Health Care Staff)		18		1800

29-528 Rev. 7

01-05 FORM CMS 222-92 2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92

TABLE 6 – EDITS

E dit

Condition

	Cost Center	Line	Code
	Depreciation	19	1900
	Professional Liability Insurance	20	2000
	Rent	26	2600
	Interest on Mortgage or Loans	28	2800
	Utilities	29	2900
	Depreciation-Building & Fixtures	30	3000
	Depreciation-Equipment	31	3100
	Housekeeping & Maintenance	32	3200
	Property Tax	33	3300
	Office Salaries	38	3800
	Depreciation-Office Equipment	39	3900
	Office Supplies	40	4000
	Legal	41	4100
	Accounting	42	4200
	Insurance (Specify)	43	4300
	Telephone	44	4400
	Fringe Benefits & Payroll Taxes	45	4500
	Pharmacy	51	5100
	Dental	52	5200
	Optometry	53	5300

2 040	All calendar format dates must be edited for 10 character format, e.g., 01/01/1996 (MM/DD/YYYY). [12/31/2004]
2 045	All dates must be possible, e.g., no "00", no "30", or "31" of February. [12/31/2004]
2 020S	The length of the cost reporting period should be greater than 27 days and less than 459 days. [12/31/2004]
2 020A	Worksheet A-2-1, Part I, must contain a "Y" or "N" response. [12/31/2004]
N OTE:	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. 7

29-529