| DRAFT |
|
|
|
FORM CMS-2552-10 |
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|
4090 (Cont.) |
4090 (Cont.) |
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|
FORM CMS-2552-10 |
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DRAFT |
DRAFT |
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FORM CMS-2552-10 |
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|
4090 (Cont.) |
| COST ALLOCATION - GENERAL SERVICE COSTS |
|
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|
PROVIDER NO.: |
PERIOD: |
|
WORKSHEET B, |
|
COST ALLOCATION - GENERAL SERVICE COSTS |
|
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|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
COST ALLOCATION - GENERAL SERVICE COSTS |
|
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|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
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FROM _________ |
|
PART I |
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FROM _________ |
|
PART I |
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FROM _________ |
|
PART I |
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_ |
TO ____________ |
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_ |
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TO ____________ |
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_ |
|
TO ____________ |
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NET EXPENSES |
CAPITAL |
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INTERN & |
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FOR COST |
RELATED COSTS |
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NON- |
|
INTERNS & |
INTERNS & |
|
|
RESIDENT |
|
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|
|
ALLOCATION |
|
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|
ADMINIS- |
MAIN- |
|
|
|
|
LAUNDRY |
|
|
|
MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
|
|
|
|
OTHER |
PHYSICIAN |
|
RESIDENTS |
RESIDENTS |
PARAMEDICAL |
|
COST & POST |
|
|
|
COST CENTER DESCRIPTIONS |
(from Wskt |
BLDGS. & |
MOVABLE |
EMPLOYEE |
SUBTOTAL |
TRATIVE & |
TENANCE & |
OPERATION |
|
|
COST CENTER DESCRIPTIONS |
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
COST CENTER DESCRIPTIONS |
GENERAL |
ANES- |
NURSING |
SALARY AND |
PROGRAM |
EDUCATION |
|
STEPDOWN |
|
|
|
|
A col. 7) |
FIXTURES |
EQUIPMENT |
BENEFITS |
(cols. 0-4) |
GENERAL |
REPAIRS |
OF PLANT |
|
|
|
SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
|
|
|
SERVICE |
THETISTS |
SCHOOL |
FRINGES |
COSTS |
(SPECIFY) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
|
|
|
0 |
1 |
2 |
4 |
4A |
5 |
6 |
7 |
|
|
|
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
|
|
|
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
|
|
GENERAL SERVICE COST CENTERS |
|
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GENERAL SERVICE COST CENTERS |
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GENERAL SERVICE COST CENTERS |
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| 1 |
Capital Related Costs-Buildings and Fixtures |
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|
1 |
1 |
Capital Related Costs-Buildings and Fixtures |
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|
1 |
1 |
Capital Related Costs-Buildings and Fixtures |
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|
1 |
| 2 |
Capital Related Costs-Movable Equipment |
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2 |
2 |
Capital Related Costs-Movable Equipment |
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2 |
2 |
Capital Related Costs-Movable Equipment |
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2 |
| 4 |
Employee Benefits |
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4 |
4 |
Employee Benefits |
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4 |
4 |
Employee Benefits |
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4 |
| 5 |
Administrative and General |
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5 |
5 |
Administrative and General |
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5 |
5 |
Administrative and General |
|
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|
5 |
| 6 |
Maintenance and Repairs |
|
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|
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|
|
6 |
6 |
Maintenance and Repairs |
|
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|
|
|
|
|
|
|
6 |
6 |
Maintenance and Repairs |
|
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6 |
| 7 |
Operation of Plant |
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7 |
7 |
Operation of Plant |
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7 |
7 |
Operation of Plant |
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|
7 |
| 8 |
Laundry and Linen Service |
|
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|
8 |
8 |
Laundry and Linen Service |
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8 |
8 |
Laundry and Linen Service |
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|
8 |
| 9 |
Housekeeping |
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9 |
9 |
Housekeeping |
|
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9 |
9 |
Housekeeping |
|
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9 |
| 10 |
Dietary |
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10 |
10 |
Dietary |
|
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|
10 |
10 |
Dietary |
|
|
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|
|
|
|
10 |
| 11 |
Cafeteria |
|
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11 |
11 |
Cafeteria |
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11 |
11 |
Cafeteria |
|
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|
11 |
| 12 |
Maintenance of Personnel |
|
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|
|
12 |
12 |
Maintenance of Personnel |
|
|
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|
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|
|
|
|
12 |
12 |
Maintenance of Personnel |
|
|
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|
12 |
| 13 |
Nursing Administration |
|
|
|
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|
|
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|
13 |
13 |
Nursing Administration |
|
|
|
|
|
|
|
|
|
|
13 |
13 |
Nursing Administration |
|
|
|
|
|
|
|
|
|
13 |
| 14 |
Central Services and Supply |
|
|
|
|
|
|
|
|
14 |
14 |
Central Services and Supply |
|
|
|
|
|
|
|
|
|
|
14 |
14 |
Central Services and Supply |
|
|
|
|
|
|
|
|
|
14 |
| 15 |
Pharmacy |
|
|
|
|
|
|
|
|
15 |
15 |
Pharmacy |
|
|
|
|
|
|
|
|
|
|
15 |
15 |
Pharmacy |
|
|
|
|
|
|
|
|
|
15 |
| 16 |
Medical Records & Medical Records Library |
|
|
|
|
|
|
|
|
16 |
16 |
Medical Records & Medical Records Library |
|
|
|
|
|
|
|
|
|
|
16 |
16 |
Medical Records & Medical Records Library |
|
|
|
|
|
|
|
|
|
16 |
| 17 |
Social Service |
|
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|
|
17 |
17 |
Social Service |
|
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|
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17 |
17 |
Social Service |
|
|
|
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|
|
|
17 |
| 18 |
Other General Service (specify) |
|
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|
|
|
|
|
18 |
18 |
Other General Service (specify) |
|
|
|
|
|
|
|
|
|
|
18 |
18 |
Other General Service (specify) |
|
|
|
|
|
|
|
|
|
18 |
| 19 |
Nonphysician Anesthetists |
|
|
|
|
|
|
|
|
19 |
19 |
Nonphysician Anesthetists |
|
|
|
|
|
|
|
|
|
|
19 |
19 |
Nonphysician Anesthetists |
|
|
|
|
|
|
|
|
|
19 |
| 20 |
Nursing School |
|
|
|
|
|
|
|
|
20 |
20 |
Nursing School |
|
|
|
|
|
|
|
|
|
|
20 |
20 |
Nursing School |
|
|
|
|
|
|
|
|
|
20 |
| 21 |
Intern & Res. Service-Salary & Fringes (Approved) |
|
|
|
|
|
|
|
|
21 |
21 |
Intern & Res. Service-Salary & Fringes (Approved) |
|
|
|
|
|
|
|
|
|
|
21 |
21 |
Intern & Res. Service-Salary & Fringes (Approved) |
|
|
|
|
|
|
|
|
|
21 |
| 22 |
Intern & Res. Other Program Costs (Approved) |
|
|
|
|
|
|
|
|
22 |
22 |
Intern & Res. Other Program Costs (Approved) |
|
|
|
|
|
|
|
|
|
|
22 |
22 |
Intern & Res. Other Program Costs (Approved) |
|
|
|
|
|
|
|
|
|
22 |
| 23 |
Paramedical Education Program (specify) |
|
|
|
|
|
|
|
|
23 |
23 |
Paramedical Education Program (specify) |
|
|
|
|
|
|
|
|
|
|
23 |
23 |
Paramedical Education Program (specify) |
|
|
|
|
|
|
|
|
|
23 |
|
INPATIENT ROUTINE SERVICE COST CENTERS |
|
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|
INPATIENT ROUTINE SERVICE COST CENTERS |
|
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|
|
INPATIENT ROUTINE SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
| 30 |
Adults and Pediatrics (General Routine Care) |
|
|
|
|
|
|
|
|
30 |
30 |
Adults and Pediatrics (General Routine Care) |
|
|
|
|
|
|
|
|
|
|
30 |
30 |
Adults and Pediatrics (General Routine Care) |
|
|
|
|
|
|
|
|
|
30 |
| 31 |
Intensive Care Unit |
|
|
|
|
|
|
|
|
31 |
31 |
Intensive Care Unit |
|
|
|
|
|
|
|
|
|
|
31 |
31 |
Intensive Care Unit |
|
|
|
|
|
|
|
|
|
31 |
| 32 |
Coronary Care Unit |
|
|
|
|
|
|
|
|
32 |
32 |
Coronary Care Unit |
|
|
|
|
|
|
|
|
|
|
32 |
32 |
Coronary Care Unit |
|
|
|
|
|
|
|
|
|
32 |
| 33 |
Burn Intensive Care Unit |
|
|
|
|
|
|
|
|
33 |
33 |
Burn Intensive Care Unit |
|
|
|
|
|
|
|
|
|
|
33 |
33 |
Burn Intensive Care Unit |
|
|
|
|
|
|
|
|
|
33 |
| 34 |
Surgical Intensive Care Unit |
|
|
|
|
|
|
|
|
34 |
34 |
Surgical Intensive Care Unit |
|
|
|
|
|
|
|
|
|
|
34 |
34 |
Surgical Intensive Care Unit |
|
|
|
|
|
|
|
|
|
34 |
| 35 |
Other Special Care Unit (specify) |
|
|
|
|
|
|
|
|
35 |
35 |
Other Special Care Unit (specify) |
|
|
|
|
|
|
|
|
|
|
35 |
35 |
Other Special Care Unit (specify) |
|
|
|
|
|
|
|
|
|
35 |
| 40 |
Subprovider IPF |
|
|
|
|
|
|
|
|
40 |
40 |
Subprovider IPF |
|
|
|
|
|
|
|
|
|
|
40 |
40 |
Subprovider IPF |
|
|
|
|
|
|
|
|
|
40 |
| 41 |
Subprovider IRF |
|
|
|
|
|
|
|
|
41 |
41 |
Subprovider IRF |
|
|
|
|
|
|
|
|
|
|
41 |
41 |
Subprovider IRF |
|
|
|
|
|
|
|
|
|
41 |
| 42 |
Subprovider (specify) |
|
|
|
|
|
|
|
|
42 |
42 |
Subprovider (specify) |
|
|
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|
|
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|
|
42 |
42 |
Subprovider (specify) |
|
|
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|
42 |
| 43 |
Nursery |
|
|
|
|
|
|
|
|
43 |
43 |
Nursery |
|
|
|
|
|
|
|
|
|
|
43 |
43 |
Nursery |
|
|
|
|
|
|
|
|
|
43 |
| 44 |
Skilled Nursing Facility |
|
|
|
|
|
|
|
|
44 |
44 |
Skilled Nursing Facility |
|
|
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|
|
|
|
|
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|
44 |
44 |
Skilled Nursing Facility |
|
|
|
|
|
|
|
|
|
44 |
| 45 |
Nursing Facility |
|
|
|
|
|
|
|
|
45 |
45 |
Nursing Facility |
|
|
|
|
|
|
|
|
|
|
45 |
45 |
Nursing Facility |
|
|
|
|
|
|
|
|
|
45 |
| 46 |
Other Long Term Care |
|
|
|
|
|
|
|
|
46 |
46 |
Other Long Term Care |
|
|
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|
|
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|
46 |
46 |
Other Long Term Care |
|
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|
46 |
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|
|
| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
|
|
|
|
|
|
|
|
|
|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
|
|
|
|
|
|
|
|
|
|
|
|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
|
|
|
|
|
|
|
|
|
|
|
| Rev. 1 |
|
|
|
|
|
|
|
|
|
40-535 |
40-538 |
|
|
|
|
|
|
|
|
|
|
|
Rev. 1 |
Rev. 1 |
|
|
|
|
|
|
|
|
|
|
40-541 |
| 4090 (Cont.) |
|
|
|
FORM CMS-2552-10 |
|
|
|
|
|
DRAFT |
DRAFT |
|
|
|
FORM CMS-2552-10 |
|
|
|
|
|
|
|
4090 (Cont.) |
4090 (Cont.) |
|
|
|
FORM CMS-2552-10 |
|
|
|
|
|
|
DRAFT |
| COST ALLOCATION - GENERAL SERVICE COSTS |
|
|
|
|
|
|
PERIOD: |
|
WORKSHEET B, |
|
COST ALLOCATION - GENERAL SERVICE COSTS |
|
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
COST ALLOCATION - GENERAL SERVICE COSTS |
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
|
|
|
|
|
|
|
FROM _________ |
|
PART I |
|
|
|
|
|
|
|
|
|
|
FROM _________ |
|
PART I |
|
|
|
|
|
|
|
|
|
FROM _________ |
|
PART I |
|
|
|
|
|
|
|
|
TO ____________ |
|
|
|
|
|
|
|
|
|
|
_ |
|
TO ____________ |
|
|
|
|
|
|
|
|
|
_ |
|
TO ____________ |
|
|
|
|
|
NET EXPENSES |
CAPITAL |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INTERN & |
|
|
|
|
FOR COST |
RELATED COSTS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
NON- |
|
INTERNS & |
INTERNS & |
|
|
RESIDENT |
|
|
|
|
ALLOCATION |
|
|
|
|
ADMINIS- |
MAIN- |
|
|
|
|
LAUNDRY |
|
|
|
MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
|
|
|
|
OTHER |
PHYSICIAN |
|
RESIDENTS |
RESIDENTS |
PARAMEDICAL |
|
COST & POST |
|
|
|
COST CENTER DESCRIPTIONS |
(from Wskt |
BLDGS. & |
MOVABLE |
EMPLOYEE |
SUBTOTAL |
TRATIVE & |
TENANCE & |
OPERATION |
|
|
COST CENTER DESCRIPTIONS |
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
COST CENTER DESCRIPTIONS |
GENERAL |
ANES- |
NURSING |
SALARY AND |
PROGRAM |
EDUCATION |
|
STEPDOWN |
|
|
|
|
A col. 7) |
FIXTURES |
EQUIPMENT |
BENEFITS |
(cols. 0-4) |
GENERAL |
REPAIRS |
OF PLANT |
|
|
|
SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
|
|
|
SERVICE |
THETISTS |
SCHOOL |
FRINGES |
COSTS |
(SPECIFY) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
|
|
|
0 |
1 |
2 |
4 |
4A |
5 |
6 |
7 |
|
|
|
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
|
|
|
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
|
|
ANCILLARY SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
ANCILLARY SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
|
|
ANCILLARY SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
| 50 |
Operating Room |
|
|
|
|
|
|
|
|
50 |
50 |
Operating Room |
|
|
|
|
|
|
|
|
|
|
50 |
50 |
Operating Room |
|
|
|
|
|
|
|
|
|
50 |
| 51 |
Recovery Room |
|
|
|
|
|
|
|
|
51 |
51 |
Recovery Room |
|
|
|
|
|
|
|
|
|
|
51 |
51 |
Recovery Room |
|
|
|
|
|
|
|
|
|
51 |
| 52 |
Labor Room and Delivery Room |
|
|
|
|
|
|
|
|
52 |
52 |
Labor Room and Delivery Room |
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|
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|
|
|
52 |
52 |
Labor Room and Delivery Room |
|
|
|
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|
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|
|
52 |
| 53 |
Anesthesiology |
|
|
|
|
|
|
|
|
53 |
53 |
Anesthesiology |
|
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|
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|
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|
53 |
53 |
Anesthesiology |
|
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|
53 |
| 54 |
Radiology-Diagnostic |
|
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|
54 |
54 |
Radiology-Diagnostic |
|
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|
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|
54 |
54 |
Radiology-Diagnostic |
|
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|
|
|
54 |
| 55 |
Radiology-Therapeutic |
|
|
|
|
|
|
|
|
55 |
55 |
Radiology-Therapeutic |
|
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|
|
|
55 |
55 |
Radiology-Therapeutic |
|
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|
|
|
|
|
55 |
| 56 |
Radioisotope |
|
|
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|
|
|
|
56 |
56 |
Radioisotope |
|
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|
|
56 |
56 |
Radioisotope |
|
|
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|
|
|
56 |
| 57 |
Computed Tomography (CT) Scan |
|
|
|
|
|
|
|
|
57 |
57 |
Computed Tomography (CT) Scan |
|
|
|
|
|
|
|
|
|
|
57 |
57 |
Computed Tomography (CT) Scan |
|
|
|
|
|
|
|
|
|
57 |
| 58 |
Magnetic Resonance Imaging (MRI) |
|
|
|
|
|
|
|
|
58 |
58 |
Magnetic Resonance Imaging (MRI) |
|
|
|
|
|
|
|
|
|
|
58 |
58 |
Magnetic Resonance Imaging (MRI) |
|
|
|
|
|
|
|
|
|
58 |
| 59 |
Cardiac Catheterization |
|
|
|
|
|
|
|
|
59 |
60 |
Cardiac Catheterization |
|
|
|
|
|
|
|
|
|
|
59 |
60 |
Cardiac Catheterization |
|
|
|
|
|
|
|
|
|
60 |
| 60 |
Laboratory |
|
|
|
|
|
|
|
|
60 |
61 |
Laboratory |
|
|
|
|
|
|
|
|
|
|
60 |
61 |
Laboratory |
|
|
|
|
|
|
|
|
|
60 |
| 61 |
PBP Clinical Laboratory Services-Program Only |
|
|
|
|
|
|
|
|
61 |
62 |
PBP Clinical Laboratory Services-Program Only |
|
|
|
|
|
|
|
|
|
|
61 |
62 |
PBP Clinical Laboratory Services-Program Only |
|
|
|
|
|
|
|
|
|
61 |
| 62 |
Whole Blood & Packed Red Blood Cells |
|
|
|
|
|
|
|
|
62 |
63 |
Whole Blood & Packed Red Blood Cells |
|
|
|
|
|
|
|
|
|
|
62 |
63 |
Whole Blood & Packed Red Blood Cells |
|
|
|
|
|
|
|
|
|
62 |
| 63 |
Blood Storing, Processing, & Trans. |
|
|
|
|
|
|
|
|
63 |
64 |
Blood Storing, Processing, & Trans. |
|
|
|
|
|
|
|
|
|
|
63 |
64 |
Blood Storing, Processing, & Trans. |
|
|
|
|
|
|
|
|
|
63 |
| 64 |
Intravenous Therapy |
|
|
|
|
|
|
|
|
64 |
65 |
Intravenous Therapy |
|
|
|
|
|
|
|
|
|
|
64 |
65 |
Intravenous Therapy |
|
|
|
|
|
|
|
|
|
64 |
| 65 |
Respiratory Therapy |
|
|
|
|
|
|
|
|
65 |
66 |
Respiratory Therapy |
|
|
|
|
|
|
|
|
|
|
65 |
66 |
Respiratory Therapy |
|
|
|
|
|
|
|
|
|
65 |
| 66 |
Physical Therapy |
|
|
|
|
|
|
|
|
66 |
67 |
Physical Therapy |
|
|
|
|
|
|
|
|
|
|
66 |
67 |
Physical Therapy |
|
|
|
|
|
|
|
|
|
66 |
| 67 |
Occupational Therapy |
|
|
|
|
|
|
|
|
67 |
68 |
Occupational Therapy |
|
|
|
|
|
|
|
|
|
|
67 |
68 |
Occupational Therapy |
|
|
|
|
|
|
|
|
|
67 |
| 68 |
Speech Pathology |
|
|
|
|
|
|
|
|
68 |
69 |
Speech Pathology |
|
|
|
|
|
|
|
|
|
|
68 |
69 |
Speech Pathology |
|
|
|
|
|
|
|
|
|
68 |
| 69 |
Electrocardiology |
|
|
|
|
|
|
|
|
69 |
70 |
Electrocardiology |
|
|
|
|
|
|
|
|
|
|
69 |
70 |
Electrocardiology |
|
|
|
|
|
|
|
|
|
69 |
| 70 |
Electroencephalography |
|
|
|
|
|
|
|
|
70 |
71 |
Electroencephalography |
|
|
|
|
|
|
|
|
|
|
70 |
71 |
Electroencephalography |
|
|
|
|
|
|
|
|
|
70 |
| 71 |
Medical Supplies Charged to Patients |
|
|
|
|
|
|
|
|
71 |
72 |
Medical Supplies Charged to Patients |
|
|
|
|
|
|
|
|
|
|
71 |
72 |
Medical Supplies Charged to Patients |
|
|
|
|
|
|
|
|
|
71 |
| 72 |
Implantable Devices Charged to Patients |
|
|
|
|
|
|
|
|
72 |
73 |
Implantable Devices Charged to Patients |
|
|
|
|
|
|
|
|
|
|
72 |
73 |
Implantable Devices Charged to Patients |
|
|
|
|
|
|
|
|
|
72 |
| 73 |
Drugs Charged to Patients |
|
|
|
|
|
|
|
|
73 |
74 |
Drugs Charged to Patients |
|
|
|
|
|
|
|
|
|
|
73 |
74 |
Drugs Charged to Patients |
|
|
|
|
|
|
|
|
|
73 |
| 74 |
Renal Dialysis |
|
|
|
|
|
|
|
|
74 |
75 |
Renal Dialysis |
|
|
|
|
|
|
|
|
|
|
74 |
75 |
Renal Dialysis |
|
|
|
|
|
|
|
|
|
74 |
| 75 |
ASC (Non-Distinct Part) |
|
|
|
|
|
|
|
|
75 |
76 |
ASC (Non-Distinct Part) |
|
|
|
|
|
|
|
|
|
|
75 |
76 |
ASC (Non-Distinct Part) |
|
|
|
|
|
|
|
|
|
75 |
| 76 |
Other Ancillary (specify) |
|
|
|
|
|
|
|
|
76 |
77 |
Other Ancillary (specify) |
|
|
|
|
|
|
|
|
|
|
76 |
77 |
Other Ancillary (specify) |
|
|
|
|
|
|
|
|
|
76 |
|
OUTPATIENT SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
OUTPATIENT SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
|
|
OUTPATIENT SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
| 88 |
Rural Health Clinic (RHC) |
|
|
|
|
|
|
|
|
88 |
88 |
Rural Health Clinic (RHC) |
|
|
|
|
|
|
|
|
|
|
88 |
88 |
Rural Health Clinic (RHC) |
|
|
|
|
|
|
|
|
|
88 |
| 89 |
Federally Qualified Health Center (FQHC) |
|
|
|
|
|
|
|
|
89 |
89 |
Federally Qualified Health Center (FQHC) |
|
|
|
|
|
|
|
|
|
|
89 |
89 |
Federally Qualified Health Center (FQHC) |
|
|
|
|
|
|
|
|
|
89 |
| 90 |
Clinic |
|
|
|
|
|
|
|
|
90 |
90 |
Clinic |
|
|
|
|
|
|
|
|
|
|
90 |
90 |
Clinic |
|
|
|
|
|
|
|
|
|
90 |
| 91 |
Emergency |
|
|
|
|
|
|
|
|
91 |
91 |
Emergency |
|
|
|
|
|
|
|
|
|
|
91 |
91 |
Emergency |
|
|
|
|
|
|
|
|
|
91 |
| 92 |
Observation Beds |
|
|
|
|
|
|
|
|
92 |
92 |
Observation Beds |
|
|
|
|
|
|
|
|
|
|
92 |
92 |
Observation Beds |
|
|
|
|
|
|
|
|
|
92 |
| 93 |
Other Outpatient Service (specify) |
|
|
|
|
|
|
|
|
93 |
93 |
Other Outpatient Service (specify) |
|
|
|
|
|
|
|
|
|
|
93 |
93 |
Other Outpatient Service (specify) |
|
|
|
|
|
|
|
|
|
93 |
|
|
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
|
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|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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| 40-536 |
|
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|
|
Rev. 1 |
Rev. 1 |
|
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|
40-539 |
40-542 |
|
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|
|
Rev. 1 |
| DRAFT |
|
|
|
FORM CMS-2552-10 |
|
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|
|
4090 (Cont.) |
4090 (Cont.) |
|
|
|
FORM CMS-2552-10 |
|
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|
|
DRAFT |
DRAFT |
|
|
|
FORM CMS-2552-10 |
|
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|
|
|
4090 (Cont.) |
| COST ALLOCATION - GENERAL SERVICE COSTS |
|
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|
|
|
|
PERIOD: |
|
WORKSHEET B, |
|
COST ALLOCATION - GENERAL SERVICE COSTS |
|
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
COST ALLOCATION - GENERAL SERVICE COSTS |
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
|
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|
|
FROM _________ |
|
PART I |
|
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FROM _________ |
|
PART I |
|
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FROM _________ |
|
PART I |
|
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TO ____________ |
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_ |
|
TO ____________ |
|
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_ |
|
TO ____________ |
|
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|
|
NET EXPENSES |
CAPITAL |
|
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INTERN & |
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FOR COST |
RELATED COSTS |
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NON- |
|
INTERNS & |
INTERNS & |
|
|
RESIDENT |
|
|
|
|
ALLOCATION |
|
|
|
|
ADMINIS- |
MAIN- |
|
|
|
|
LAUNDRY |
|
|
|
MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
|
|
|
|
OTHER |
PHYSICIAN |
|
RESIDENTS |
RESIDENTS |
PARAMEDICAL |
|
COST & POST |
|
|
|
COST CENTER DESCRIPTIONS |
(from Wskt |
BLDGS. & |
MOVABLE |
EMPLOYEE |
SUBTOTAL |
TRATIVE & |
TENANCE & |
OPERATION |
|
|
COST CENTER DESCRIPTIONS |
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
COST CENTER DESCRIPTIONS |
GENERAL |
ANES- |
NURSING |
SALARY AND |
PROGRAM |
EDUCATION |
|
STEPDOWN |
|
|
|
|
A col. 7) |
FIXTURES |
EQUIPMENT |
BENEFITS |
(cols. 0-4) |
GENERAL |
REPAIRS |
OF PLANT |
|
|
|
SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
|
|
|
SERVICE |
THETISTS |
SCHOOL |
FRINGES |
COSTS |
(SPECIFY) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
|
|
|
0 |
1 |
2 |
4 |
4A |
5 |
6 |
7 |
|
|
|
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
|
|
|
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
|
|
OTHER REIMBURSABLE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
OTHER REIMBURSABLE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
|
|
OTHER REIMBURSABLE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
| 94 |
Home Program Dialysis |
|
|
|
|
|
|
|
|
94 |
94 |
Home Program Dialysis |
|
|
|
|
|
|
|
|
|
|
94 |
94 |
Home Program Dialysis |
|
|
|
|
|
|
|
|
|
94 |
| 95 |
Ambulance Services |
|
|
|
|
|
|
|
|
95 |
95 |
Ambulance Services |
|
|
|
|
|
|
|
|
|
|
95 |
95 |
Ambulance Services |
|
|
|
|
|
|
|
|
|
95 |
| 96 |
Durable Medical Equipment-Rented |
|
|
|
|
|
|
|
|
96 |
96 |
Durable Medical Equipment-Rented |
|
|
|
|
|
|
|
|
|
|
96 |
96 |
Durable Medical Equipment-Rented |
|
|
|
|
|
|
|
|
|
96 |
| 97 |
Durable Medical Equipment-Sold |
|
|
|
|
|
|
|
|
97 |
97 |
Durable Medical Equipment-Sold |
|
|
|
|
|
|
|
|
|
|
97 |
97 |
Durable Medical Equipment-Sold |
|
|
|
|
|
|
|
|
|
97 |
| 98 |
Other Reimbursable (specify) |
|
|
|
|
|
|
|
|
98 |
98 |
Other Reimbursable (specify) |
|
|
|
|
|
|
|
|
|
|
98 |
98 |
Other Reimbursable (specify) |
|
|
|
|
|
|
|
|
|
98 |
| 99 |
Outpatient Rehabilitation Provider (specify) |
|
|
|
|
|
|
|
|
99 |
99 |
Outpatient Rehabilitation Provider (specify) |
|
|
|
|
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|
|
|
|
|
99 |
99 |
Outpatient Rehabilitation Provider (specify) |
|
|
|
|
|
|
|
|
|
99 |
| 100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
|
|
|
|
|
|
|
|
100 |
100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
|
|
|
|
|
|
|
|
|
|
100 |
100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
|
|
|
|
|
|
|
|
|
100 |
| 101 |
Home Health Agency |
|
|
|
|
|
|
|
|
101 |
101 |
Home Health Agency |
|
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|
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|
101 |
101 |
Home Health Agency |
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|
|
|
|
|
101 |
|
SPECIAL PURPOSE COST CENTERS |
|
|
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|
|
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|
|
|
SPECIAL PURPOSE COST CENTERS |
|
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|
|
SPECIAL PURPOSE COST CENTERS |
|
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|
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|
|
| 105 |
Kidney Acquisition |
|
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|
|
|
|
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|
105 |
105 |
Kidney Acquisition |
|
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|
105 |
105 |
Kidney Acquisition |
|
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|
|
|
|
|
|
|
105 |
| 106 |
Heart Acquisition |
|
|
|
|
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|
|
106 |
106 |
Heart Acquisition |
|
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|
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|
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|
106 |
106 |
Heart Acquisition |
|
|
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|
106 |
| 107 |
Liver Acquisition |
|
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|
107 |
107 |
Liver Acquisition |
|
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|
107 |
107 |
Liver Acquisition |
|
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|
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|
107 |
| 108 |
Lung Acquisition |
|
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|
108 |
108 |
Lung Acquisition |
|
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108 |
108 |
Lung Acquisition |
|
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|
108 |
| 109 |
Pancreas Acquisition |
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109 |
109 |
Pancreas Acquisition |
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109 |
109 |
Pancreas Acquisition |
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|
109 |
| 110 |
Intestinal Acquisition |
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110 |
110 |
Intestinal Acquisition |
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110 |
110 |
Intestinal Acquisition |
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|
110 |
| 111 |
Islet Acquisition |
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111 |
111 |
Islet Acquisition |
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111 |
111 |
Islet Acquisition |
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111 |
| 112 |
Other Organ Acquisition (specify) |
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112 |
112 |
Other Organ Acquisition (specify) |
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112 |
112 |
Other Organ Acquisition (specify) |
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|
112 |
| 115 |
Ambulatory Surgical Center (Distinct Part) |
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|
115 |
115 |
Ambulatory Surgical Center (Distinct Part) |
|
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|
115 |
115 |
Ambulatory Surgical Center (Distinct Part) |
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|
115 |
| 116 |
Hospice |
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116 |
116 |
Hospice |
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116 |
116 |
Hospice |
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|
116 |
| 117 |
Other Special Purpose (specify) |
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|
117 |
117 |
Other Special Purpose (specify) |
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|
117 |
117 |
Other Special Purpose (specify) |
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|
117 |
| 118 |
SUBTOTALS (sum of lines 1-117) |
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118 |
118 |
SUBTOTALS (sum of lines 1-117) |
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118 |
118 |
SUBTOTALS (sum of lines 1-117) |
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|
118 |
|
NONREIMBURSABLE COST CENTERS |
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|
|
NONREIMBURSABLE COST CENTERS |
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|
NONREIMBURSABLE COST CENTERS |
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| 190 |
Gift, Flower, Coffee Shop, & Canteen |
|
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|
190 |
190 |
Gift, Flower, Coffee Shop, & Canteen |
|
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|
190 |
190 |
Gift, Flower, Coffee Shop, & Canteen |
|
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|
|
190 |
| 191 |
Research |
|
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|
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|
191 |
191 |
Research |
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191 |
191 |
Research |
|
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|
|
|
|
191 |
| 192 |
Physicians' Private Offices |
|
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|
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|
192 |
192 |
Physicians' Private Offices |
|
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|
192 |
192 |
Physicians' Private Offices |
|
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|
|
192 |
| 193 |
Nonpaid Workers |
|
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|
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|
193 |
193 |
Nonpaid Workers |
|
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|
193 |
193 |
Nonpaid Workers |
|
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|
|
193 |
| 194 |
Other Nonreimbursable (specify) |
|
|
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|
|
|
194 |
194 |
Other Nonreimbursable (specify) |
|
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|
194 |
194 |
Other Nonreimbursable (specify) |
|
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|
194 |
| 200 |
Cross Foot Adjustments |
|
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|
200 |
200 |
Cross Foot Adjustments |
|
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|
200 |
200 |
Cross Foot Adjustments |
|
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|
200 |
| 201 |
Negative Cost Centers |
|
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|
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|
|
|
201 |
201 |
Negative Cost Centers |
|
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|
201 |
201 |
Negative Cost Centers |
|
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|
201 |
| 202 |
TOTAL (sum lines 118-201) |
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|
202 |
202 |
TOTAL (sum lines 118-201) |
|
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|
202 |
202 |
TOTAL (sum lines 118-201) |
|
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|
202 |
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0 |
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
|
|
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|
|
|
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|
|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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|
|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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| Rev. 1 |
|
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|
40-537 |
40-540 |
|
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|
|
Rev. 1 |
Rev. 1 |
|
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|
|
40-543 |
| 4090 (Cont.) |
|
|
|
|
FORM CMS-2552-10 |
|
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|
|
|
DRAFT |
DRAFT |
|
|
|
FORM CMS-2552-10 |
|
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|
|
4090 (Cont.) |
4090 (Cont.) |
|
|
|
FORM CMS-2552-10 |
|
|
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|
|
|
DRAFT |
| ALLOCATION OF CAPITAL RELATED COSTS |
|
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
ALLOCATION OF CAPITAL RELATED COSTS |
|
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|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
ALLOCATION OF CAPITAL RELATED COSTS |
|
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|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
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|
|
FROM _________ |
|
PART II |
|
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|
FROM _________ |
|
PART II |
|
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FROM _________ |
|
PART II |
|
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_ |
|
TO ____________ |
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_ |
|
TO ____________ |
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_ |
|
TO ____________ |
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DIRECTLY |
CAPITAL |
|
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INTERN & |
|
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|
ASSIGNED |
RELATED COSTS |
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NON- |
|
INTERNS & |
INTERNS & |
|
|
RESIDENT |
|
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|
|
|
|
NEW CAPITAL |
|
|
SUBTOTAL |
|
ADMINIS- |
MAIN- |
|
|
|
|
LAUNDRY |
|
|
|
MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
|
|
|
|
OTHER |
PHYSICIAN |
|
RESIDENTS |
RESIDENTS |
PARAMEDICAL |
|
COST & POST |
|
|
|
COST CENTER DESCRIPTIONS |
|
|
RELATED |
BLDGS. & |
MOVABLE |
(sum of |
EMPLOYEE |
TRATIVE & |
TENANCE & |
OPERATION |
|
|
COST CENTER DESCRIPTIONS |
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
COST CENTER DESCRIPTIONS |
GENERAL |
ANES- |
NURSING |
SALARY AND |
PROGRAM |
EDUCATION |
|
STEPDOWN |
|
|
|
|
|
|
COSTS |
FIXTURES |
EQUIPMENT |
(cols. 0-2) |
BENEFITS |
GENERAL |
REPAIRS |
OF PLANT |
|
|
|
SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
|
|
|
SERVICE |
THETISTS |
SCHOOL |
FRINGES |
COSTS |
(SPECIFY) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
|
|
|
|
|
0 |
1 |
2 |
2A |
4 |
5 |
6 |
7 |
|
|
|
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
|
|
|
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
|
|
GENERAL SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
|
|
GENERAL SERVICE COST CENTERS |
|
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|
|
GENERAL SERVICE COST CENTERS |
|
|
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|
|
|
|
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|
|
| 1 |
Capital Related Costs-Buildings and Fixtures |
|
|
|
|
|
|
|
|
|
|
1 |
1 |
Capital Related Costs-Buildings and Fixtures |
|
|
|
|
|
|
|
|
|
|
1 |
1 |
Capital Related Costs-Buildings and Fixtures |
|
|
|
|
|
|
|
|
|
1 |
| 2 |
Capital Related Costs-Movable Equipment |
|
|
|
|
|
|
|
|
|
|
2 |
2 |
Capital Related Costs-Movable Equipment |
|
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|
2 |
2 |
Capital Related Costs-Movable Equipment |
|
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|
2 |
| 4 |
Employee Benefits |
|
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|
4 |
4 |
Employee Benefits |
|
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|
4 |
4 |
Employee Benefits |
|
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|
4 |
| 5 |
Administrative and General |
|
|
|
|
|
|
|
|
|
|
5 |
5 |
Administrative and General |
|
|
|
|
|
|
|
|
|
|
5 |
5 |
Administrative and General |
|
|
|
|
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|
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|
|
5 |
| 6 |
Maintenance and Repairs |
|
|
|
|
|
|
|
|
|
|
6 |
6 |
Maintenance and Repairs |
|
|
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|
|
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|
6 |
6 |
Maintenance and Repairs |
|
|
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|
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|
6 |
| 7 |
Operation of Plant |
|
|
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|
|
|
|
|
|
|
7 |
7 |
Operation of Plant |
|
|
|
|
|
|
|
|
|
|
7 |
7 |
Operation of Plant |
|
|
|
|
|
|
|
|
|
7 |
| 8 |
Laundry and Linen Service |
|
|
|
|
|
|
|
|
|
|
8 |
8 |
Laundry and Linen Service |
|
|
|
|
|
|
|
|
|
|
8 |
8 |
Laundry and Linen Service |
|
|
|
|
|
|
|
|
|
8 |
| 9 |
Housekeeping |
|
|
|
|
|
|
|
|
|
|
9 |
9 |
Housekeeping |
|
|
|
|
|
|
|
|
|
|
9 |
9 |
Housekeeping |
|
|
|
|
|
|
|
|
|
9 |
| 10 |
Dietary |
|
|
|
|
|
|
|
|
|
|
10 |
10 |
Dietary |
|
|
|
|
|
|
|
|
|
|
10 |
10 |
Dietary |
|
|
|
|
|
|
|
|
|
10 |
| 11 |
Cafeteria |
|
|
|
|
|
|
|
|
|
|
11 |
11 |
Cafeteria |
|
|
|
|
|
|
|
|
|
|
11 |
11 |
Cafeteria |
|
|
|
|
|
|
|
|
|
11 |
| 12 |
Maintenance of Personnel |
|
|
|
|
|
|
|
|
|
|
12 |
12 |
Maintenance of Personnel |
|
|
|
|
|
|
|
|
|
|
12 |
12 |
Maintenance of Personnel |
|
|
|
|
|
|
|
|
|
12 |
| 13 |
Nursing Administration |
|
|
|
|
|
|
|
|
|
|
13 |
13 |
Nursing Administration |
|
|
|
|
|
|
|
|
|
|
13 |
13 |
Nursing Administration |
|
|
|
|
|
|
|
|
|
13 |
| 14 |
Central Services and Supply |
|
|
|
|
|
|
|
|
|
|
14 |
14 |
Central Services and Supply |
|
|
|
|
|
|
|
|
|
|
14 |
14 |
Central Services and Supply |
|
|
|
|
|
|
|
|
|
14 |
| 15 |
Pharmacy |
|
|
|
|
|
|
|
|
|
|
15 |
15 |
Pharmacy |
|
|
|
|
|
|
|
|
|
|
15 |
15 |
Pharmacy |
|
|
|
|
|
|
|
|
|
15 |
| 16 |
Medical Records & Medical Records Library |
|
|
|
|
|
|
|
|
|
|
16 |
16 |
Medical Records & Medical Records Library |
|
|
|
|
|
|
|
|
|
|
16 |
16 |
Medical Records & Medical Records Library |
|
|
|
|
|
|
|
|
|
16 |
| 17 |
Social Service |
|
|
|
|
|
|
|
|
|
|
17 |
17 |
Social Service |
|
|
|
|
|
|
|
|
|
|
17 |
17 |
Social Service |
|
|
|
|
|
|
|
|
|
17 |
| 18 |
Other General Service (specify) |
|
|
|
|
|
|
|
|
|
|
18 |
18 |
Other General Service (specify) |
|
|
|
|
|
|
|
|
|
|
18 |
18 |
Other General Service (specify) |
|
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|
18 |
| 19 |
Nonphysician Anesthetists |
|
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19 |
19 |
Nonphysician Anesthetists |
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19 |
19 |
Nonphysician Anesthetists |
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19 |
| 20 |
Nursing School |
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20 |
20 |
Nursing School |
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20 |
20 |
Nursing School |
|
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20 |
| 21 |
Intern & Res. Service-Salary & Fringes (Approved) |
|
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21 |
21 |
Intern & Res. Service-Salary & Fringes (Approved) |
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21 |
21 |
Intern & Res. Service-Salary & Fringes (Approved) |
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21 |
| 22 |
Intern & Res. Other Program Costs (Approved) |
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22 |
22 |
Intern & Res. Other Program Costs (Approved) |
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22 |
22 |
Intern & Res. Other Program Costs (Approved) |
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22 |
| 23 |
Paramedical Education Program (specify) |
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23 |
23 |
Paramedical Education Program (specify) |
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23 |
23 |
Paramedical Education Program (specify) |
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23 |
|
INPATIENT ROUTINE SERVICE COST CENTERS |
|
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|
INPATIENT ROUTINE SERVICE COST CENTERS |
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|
INPATIENT ROUTINE SERVICE COST CENTERS |
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| 30 |
Adults and Pediatrics (General Routine Care) |
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30 |
30 |
Adults and Pediatrics (General Routine Care) |
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30 |
30 |
Adults and Pediatrics (General Routine Care) |
|
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30 |
| 31 |
Intensive Care Unit |
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31 |
31 |
Intensive Care Unit |
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31 |
31 |
Intensive Care Unit |
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31 |
| 32 |
Coronary Care Unit |
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32 |
32 |
Coronary Care Unit |
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32 |
32 |
Coronary Care Unit |
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32 |
| 33 |
Burn Intensive Care Unit |
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33 |
33 |
Burn Intensive Care Unit |
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33 |
33 |
Burn Intensive Care Unit |
|
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33 |
| 34 |
Surgical Intensive Care Unit |
|
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34 |
34 |
Surgical Intensive Care Unit |
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34 |
34 |
Surgical Intensive Care Unit |
|
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34 |
| 35 |
Other Special Care Unit (specify) |
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35 |
35 |
Other Special Care Unit (specify) |
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35 |
35 |
Other Special Care Unit (specify) |
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35 |
| 40 |
Subprovider IPF |
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40 |
40 |
Subprovider IPF |
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40 |
40 |
Subprovider IPF |
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40 |
| 41 |
Subprovider IRF |
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41 |
41 |
Subprovider IRF |
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41 |
41 |
Subprovider IRF |
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41 |
| 42 |
Subprovider (specify) |
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42 |
42 |
Subprovider (specify) |
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42 |
42 |
Subprovider (specify) |
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42 |
| 43 |
Nursery |
|
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43 |
43 |
Nursery |
|
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43 |
43 |
Nursery |
|
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|
43 |
| 44 |
Skilled Nursing Facility |
|
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44 |
44 |
Skilled Nursing Facility |
|
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44 |
44 |
Skilled Nursing Facility |
|
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|
44 |
| 45 |
Nursing Facility |
|
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|
45 |
45 |
Nursing Facility |
|
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45 |
45 |
Nursing Facility |
|
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|
45 |
| 46 |
Other Long Term Care |
|
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46 |
46 |
Other Long Term Care |
|
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46 |
46 |
Other Long Term Care |
|
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46 |
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|
|
| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
|
|
|
|
|
|
|
|
|
|
|
|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
|
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|
|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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| 40-544 |
|
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|
|
Rev. 1 |
Rev. 1 |
|
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|
|
40-547 |
40-550 |
|
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|
|
Rev. 1 |
| DRAFT |
|
|
|
|
FORM CMS-2552-10 |
|
|
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|
|
|
4090 (Cont.) |
4090 (Cont.) |
|
|
|
FORM CMS-2552-10 |
|
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|
|
|
|
|
DRAFT |
DRAFT |
|
|
|
FORM CMS-2552-10 |
|
|
|
|
|
|
4090 (Cont.) |
| ALLOCATION OF CAPITAL RELATED COSTS |
|
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
ALLOCATION OF CAPITAL RELATED COSTS |
|
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
ALLOCATION OF CAPITAL RELATED COSTS |
|
|
|
|
|
PROVIDER NO.: |
|
PERIOD: |
|
WORKSHEET B, |
|
|
|
|
|
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|
|
FROM _________ |
|
PART II |
|
|
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|
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|
|
FROM _________ |
|
PART II |
|
|
|
|
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|
|
FROM _________ |
|
PART II |
|
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|
_ |
|
TO ____________ |
|
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_ |
|
TO ____________ |
|
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_ |
|
TO ____________ |
|
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|
|
DIRECTLY |
CAPITAL |
|
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|
|
INTERN & |
|
|
|
|
|
|
ASSIGNED |
RELATED COSTS |
|
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|
|
NON- |
|
INTERNS & |
INTERNS & |
|
|
RESIDENT |
|
|
|
|
|
|
NEW CAPITAL |
|
|
SUBTOTAL |
|
ADMINIS- |
MAIN- |
|
|
|
|
LAUNDRY |
|
|
|
MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
|
|
|
|
OTHER |
PHYSICIAN |
|
RESIDENTS |
RESIDENTS |
PARAMEDICAL |
|
COST & POST |
|
|
|
COST CENTER DESCRIPTIONS |
|
|
RELATED |
BLDGS. & |
MOVABLE |
(sum of |
EMPLOYEE |
TRATIVE & |
TENANCE & |
OPERATION |
|
|
COST CENTER DESCRIPTIONS |
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
COST CENTER DESCRIPTIONS |
GENERAL |
ANES- |
NURSING |
SALARY AND |
PROGRAM |
EDUCATION |
|
STEPDOWN |
|
|
|
|
|
|
COSTS |
FIXTURES |
EQUIPMENT |
(cols. 0-2) |
BENEFITS |
GENERAL |
REPAIRS |
OF PLANT |
|
|
|
SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
|
|
|
SERVICE |
THETISTS |
SCHOOL |
FRINGES |
COSTS |
(SPECIFY) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
|
|
|
|
|
0 |
1 |
2 |
2A |
4 |
5 |
6 |
7 |
|
|
|
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
|
|
|
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
|
|
ANCILLARY SERVICE COST CENTERS |
|
|
|
|
|
|
|
|
|
|
|
|
ANCILLARY SERVICE COST CENTERS |
|
|
|
|
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|
|
|
|
ANCILLARY SERVICE COST CENTERS |
|
|
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|
|
| 50 |
Operating Room |
|
|
|
|
|
|
|
|
|
|
50 |
50 |
Operating Room |
|
|
|
|
|
|
|
|
|
|
50 |
50 |
Operating Room |
|
|
|
|
|
|
|
|
|
50 |
| 51 |
Recovery Room |
|
|
|
|
|
|
|
|
|
|
51 |
51 |
Recovery Room |
|
|
|
|
|
|
|
|
|
|
51 |
51 |
Recovery Room |
|
|
|
|
|
|
|
|
|
51 |
| 52 |
Labor Room and Delivery Room |
|
|
|
|
|
|
|
|
|
|
52 |
52 |
Labor Room and Delivery Room |
|
|
|
|
|
|
|
|
|
|
52 |
52 |
Labor Room and Delivery Room |
|
|
|
|
|
|
|
|
|
52 |
| 53 |
Anesthesiology |
|
|
|
|
|
|
|
|
|
|
53 |
53 |
Anesthesiology |
|
|
|
|
|
|
|
|
|
|
53 |
53 |
Anesthesiology |
|
|
|
|
|
|
|
|
|
53 |
| 54 |
Radiology-Diagnostic |
|
|
|
|
|
|
|
|
|
|
54 |
54 |
Radiology-Diagnostic |
|
|
|
|
|
|
|
|
|
|
54 |
54 |
Radiology-Diagnostic |
|
|
|
|
|
|
|
|
|
54 |
| 55 |
Radiology-Therapeutic |
|
|
|
|
|
|
|
|
|
|
55 |
55 |
Radiology-Therapeutic |
|
|
|
|
|
|
|
|
|
|
55 |
55 |
Radiology-Therapeutic |
|
|
|
|
|
|
|
|
|
55 |
| 56 |
Radioisotope |
|
|
|
|
|
|
|
|
|
|
56 |
56 |
Radioisotope |
|
|
|
|
|
|
|
|
|
|
56 |
56 |
Radioisotope |
|
|
|
|
|
|
|
|
|
56 |
| 57 |
Computed Tomography (CT) Scan |
|
|
|
|
|
|
|
|
|
|
57 |
57 |
Computed Tomography (CT) Scan |
|
|
|
|
|
|
|
|
|
|
57 |
57 |
Computed Tomography (CT) Scan |
|
|
|
|
|
|
|
|
|
57 |
| 58 |
Magnetic Resonance Imaging (MRI) |
|
|
|
|
|
|
|
|
|
|
58 |
58 |
Magnetic Resonance Imaging (MRI) |
|
|
|
|
|
|
|
|
|
|
58 |
58 |
Magnetic Resonance Imaging (MRI) |
|
|
|
|
|
|
|
|
|
58 |
| 59 |
Cardiac Catheterization |
|
|
|
|
|
|
|
|
|
|
59 |
59 |
Cardiac Catheterization |
|
|
|
|
|
|
|
|
|
|
59 |
59 |
Cardiac Catheterization |
|
|
|
|
|
|
|
|
|
59 |
| 60 |
Laboratory |
|
|
|
|
|
|
|
|
|
|
60 |
60 |
Laboratory |
|
|
|
|
|
|
|
|
|
|
60 |
60 |
Laboratory |
|
|
|
|
|
|
|
|
|
60 |
| 61 |
PBP Clinical Laboratory Services-Program Only |
|
|
|
|
|
|
|
|
|
|
61 |
61 |
PBP Clinical Laboratory Services-Program Only |
|
|
|
|
|
|
|
|
|
|
61 |
61 |
PBP Clinical Laboratory Services-Program Only |
|
|
|
|
|
|
|
|
|
61 |
| 62 |
Whole Blood & Packed Red Blood Cells |
|
|
|
|
|
|
|
|
|
|
62 |
62 |
Whole Blood & Packed Red Blood Cells |
|
|
|
|
|
|
|
|
|
|
62 |
62 |
Whole Blood & Packed Red Blood Cells |
|
|
|
|
|
|
|
|
|
62 |
| 63 |
Blood Storing, Processing, & Trans. |
|
|
|
|
|
|
|
|
|
|
63 |
63 |
Blood Storing, Processing, & Trans. |
|
|
|
|
|
|
|
|
|
|
63 |
63 |
Blood Storing, Processing, & Trans. |
|
|
|
|
|
|
|
|
|
63 |
| 64 |
Intravenous Therapy |
|
|
|
|
|
|
|
|
|
|
64 |
64 |
Intravenous Therapy |
|
|
|
|
|
|
|
|
|
|
64 |
64 |
Intravenous Therapy |
|
|
|
|
|
|
|
|
|
64 |
| 65 |
Respiratory Therapy |
|
|
|
|
|
|
|
|
|
|
65 |
65 |
Respiratory Therapy |
|
|
|
|
|
|
|
|
|
|
65 |
65 |
Respiratory Therapy |
|
|
|
|
|
|
|
|
|
65 |
| 66 |
Physical Therapy |
|
|
|
|
|
|
|
|
|
|
66 |
66 |
Physical Therapy |
|
|
|
|
|
|
|
|
|
|
66 |
66 |
Physical Therapy |
|
|
|
|
|
|
|
|
|
66 |
| 67 |
Occupational Therapy |
|
|
|
|
|
|
|
|
|
|
67 |
67 |
Occupational Therapy |
|
|
|
|
|
|
|
|
|
|
67 |
67 |
Occupational Therapy |
|
|
|
|
|
|
|
|
|
67 |
| 68 |
Speech Pathology |
|
|
|
|
|
|
|
|
|
|
68 |
68 |
Speech Pathology |
|
|
|
|
|
|
|
|
|
|
68 |
68 |
Speech Pathology |
|
|
|
|
|
|
|
|
|
68 |
| 69 |
Electrocardiology |
|
|
|
|
|
|
|
|
|
|
69 |
69 |
Electrocardiology |
|
|
|
|
|
|
|
|
|
|
69 |
69 |
Electrocardiology |
|
|
|
|
|
|
|
|
|
69 |
| 70 |
Electroencephalography |
|
|
|
|
|
|
|
|
|
|
70 |
70 |
Electroencephalography |
|
|
|
|
|
|
|
|
|
|
70 |
70 |
Electroencephalography |
|
|
|
|
|
|
|
|
|
70 |
| 71 |
Medical Supplies Charged to Patients |
|
|
|
|
|
|
|
|
|
|
71 |
71 |
Medical Supplies Charged to Patients |
|
|
|
|
|
|
|
|
|
|
71 |
71 |
Medical Supplies Charged to Patients |
|
|
|
|
|
|
|
|
|
71 |
| 72 |
Implantable Devices Charged to Patients |
|
|
|
|
|
|
|
|
|
|
72 |
72 |
Implantable Devices Charged to Patients |
|
|
|
|
|
|
|
|
|
|
72 |
72 |
Implantable Devices Charged to Patients |
|
|
|
|
|
|
|
|
|
72 |
| 73 |
Drugs Charged to Patients |
|
|
|
|
|
|
|
|
|
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73 |
73 |
Drugs Charged to Patients |
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73 |
73 |
Drugs Charged to Patients |
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73 |
| 74 |
Renal Dialysis |
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74 |
74 |
Renal Dialysis |
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74 |
74 |
Renal Dialysis |
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74 |
| 75 |
ASC (Non-Distinct Part) |
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75 |
75 |
ASC (Non-Distinct Part) |
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75 |
75 |
ASC (Non-Distinct Part) |
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75 |
| 76 |
Other Ancillary (specify) |
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76 |
76 |
Other Ancillary (specify) |
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76 |
76 |
Other Ancillary (specify) |
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76 |
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OUTPATIENT SERVICE COST CENTERS |
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OUTPATIENT SERVICE COST CENTERS |
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OUTPATIENT SERVICE COST CENTERS |
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| 88 |
Rural Health Clinic (RHC) |
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88 |
88 |
Rural Health Clinic (RHC) |
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88 |
88 |
Rural Health Clinic (RHC) |
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88 |
| 89 |
Federally Qualified Health Center (FQHC) |
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89 |
89 |
Federally Qualified Health Center (FQHC) |
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89 |
89 |
Federally Qualified Health Center (FQHC) |
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89 |
| 90 |
Clinic |
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90 |
90 |
Clinic |
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90 |
90 |
Clinic |
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90 |
| 91 |
Emergency |
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91 |
91 |
Emergency |
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91 |
91 |
Emergency |
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91 |
| 92 |
Observation Beds |
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92 |
92 |
Observation Beds |
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92 |
92 |
Observation Beds |
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92 |
| 93 |
Other Outpatient Service (specify) |
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93 |
93 |
Other Outpatient Service (specify) |
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93 |
93 |
Other Outpatient Service (specify) |
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93 |
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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| Rev. 1 |
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40-545 |
40-548 |
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Rev. 1 |
Rev. 1 |
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40-551 |
| 4090 (Cont.) |
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FORM CMS-2552-10 |
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DRAFT |
DRAFT |
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FORM CMS-2552-10 |
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4090 (Cont.) |
4090 (Cont.) |
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FORM CMS-2552-10 |
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DRAFT |
| ALLOCATION OF CAPITAL RELATED COSTS |
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PROVIDER NO.: |
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PERIOD: |
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WORKSHEET B, |
|
ALLOCATION OF CAPITAL RELATED COSTS |
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PROVIDER NO.: |
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PERIOD: |
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WORKSHEET B, |
|
ALLOCATION OF CAPITAL RELATED COSTS |
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PROVIDER NO.: |
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PERIOD: |
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WORKSHEET B, |
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FROM _________ |
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PART II |
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FROM _________ |
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PART II |
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FROM _________ |
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PART II |
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_ |
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TO ____________ |
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_ |
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TO ____________ |
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_ |
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TO ____________ |
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DIRECTLY |
CAPITAL |
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INTERN & |
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ASSIGNED |
RELATED COSTS |
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NON- |
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INTERNS & |
INTERNS & |
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RESIDENT |
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NEW CAPITAL |
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SUBTOTAL |
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ADMINIS- |
MAIN- |
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LAUNDRY |
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MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
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OTHER |
PHYSICIAN |
|
RESIDENTS |
RESIDENTS |
PARAMEDICAL |
|
COST & POST |
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|
COST CENTER DESCRIPTIONS |
|
|
RELATED |
BLDGS. & |
MOVABLE |
(sum of |
EMPLOYEE |
TRATIVE & |
TENANCE & |
OPERATION |
|
|
COST CENTER DESCRIPTIONS |
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
COST CENTER DESCRIPTIONS |
GENERAL |
ANES- |
NURSING |
SALARY AND |
PROGRAM |
EDUCATION |
|
STEPDOWN |
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|
COSTS |
FIXTURES |
EQUIPMENT |
(cols. 0-2) |
BENEFITS |
GENERAL |
REPAIRS |
OF PLANT |
|
|
|
SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
|
|
|
SERVICE |
THETISTS |
SCHOOL |
FRINGES |
COSTS |
(SPECIFY) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
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|
|
|
|
0 |
1 |
2 |
2A |
4 |
5 |
6 |
7 |
|
|
|
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
|
|
|
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
|
|
OTHER REIMBURSABLE COST CENTERS |
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OTHER REIMBURSABLE COST CENTERS |
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OTHER REIMBURSABLE COST CENTERS |
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| 94 |
Home Program Dialysis |
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94 |
94 |
Home Program Dialysis |
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94 |
94 |
Home Program Dialysis |
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94 |
| 95 |
Ambulance Services |
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95 |
95 |
Ambulance Services |
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95 |
95 |
Ambulance Services |
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95 |
| 96 |
Durable Medical Equipment-Rented |
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96 |
96 |
Durable Medical Equipment-Rented |
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96 |
96 |
Durable Medical Equipment-Rented |
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96 |
| 97 |
Durable Medical Equipment-Sold |
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97 |
97 |
Durable Medical Equipment-Sold |
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|
97 |
97 |
Durable Medical Equipment-Sold |
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|
97 |
| 98 |
Other Reimbursable (specify) |
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98 |
98 |
Other Reimbursable (specify) |
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98 |
98 |
Other Reimbursable (specify) |
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98 |
| 99 |
Outpatient Rehabilitation Provider (specify) |
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99 |
99 |
Outpatient Rehabilitation Provider (specify) |
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99 |
99 |
Outpatient Rehabilitation Provider (specify) |
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99 |
| 100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
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100 |
100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
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100 |
100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
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100 |
| 101 |
Home Health Agency |
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101 |
101 |
Home Health Agency |
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101 |
101 |
Home Health Agency |
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101 |
|
SPECIAL PURPOSE COST CENTERS |
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SPECIAL PURPOSE COST CENTERS |
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SPECIAL PURPOSE COST CENTERS |
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| 105 |
Kidney Acquisition |
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105 |
105 |
Kidney Acquisition |
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105 |
105 |
Kidney Acquisition |
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105 |
| 106 |
Heart Acquisition |
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106 |
106 |
Heart Acquisition |
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106 |
106 |
Heart Acquisition |
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106 |
| 107 |
Liver Acquisition |
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107 |
107 |
Liver Acquisition |
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107 |
107 |
Liver Acquisition |
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|
107 |
| 108 |
Lung Acquisition |
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108 |
108 |
Lung Acquisition |
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108 |
108 |
Lung Acquisition |
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|
108 |
| 109 |
Pancreas Acquisition |
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|
109 |
109 |
Pancreas Acquisition |
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109 |
109 |
Pancreas Acquisition |
|
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|
109 |
| 110 |
Intestinal Acquisition |
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|
110 |
110 |
Intestinal Acquisition |
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110 |
110 |
Intestinal Acquisition |
|
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|
110 |
| 111 |
Islet Acquisition |
|
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111 |
111 |
Islet Acquisition |
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111 |
111 |
Islet Acquisition |
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|
111 |
| 112 |
Other Organ Acquisition (specify) |
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112 |
112 |
Other Organ Acquisition (specify) |
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112 |
112 |
Other Organ Acquisition (specify) |
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|
112 |
| 115 |
Ambulatory Surgical Center (Distinct Part) |
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|
115 |
115 |
Ambulatory Surgical Center (Distinct Part) |
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|
115 |
115 |
Ambulatory Surgical Center (Distinct Part) |
|
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|
115 |
| 116 |
Hospice |
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116 |
116 |
Hospice |
|
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|
116 |
116 |
Hospice |
|
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|
|
|
116 |
| 117 |
Other Special Purpose (specify) |
|
|
|
|
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|
|
|
|
|
117 |
117 |
Other Special Purpose (specify) |
|
|
|
|
|
|
|
|
|
|
117 |
117 |
Other Special Purpose (specify) |
|
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|
|
117 |
| 118 |
SUBTOTALS (sum of lines 1-117) |
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|
118 |
118 |
SUBTOTALS (sum of lines 1-117) |
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|
|
|
118 |
118 |
SUBTOTALS (sum of lines 1-117) |
|
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|
|
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|
|
118 |
|
NONREIMBURSABLE COST CENTERS |
|
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|
|
NONREIMBURSABLE COST CENTERS |
|
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|
|
NONREIMBURSABLE COST CENTERS |
|
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|
| 190 |
Gift, Flower, Coffee Shop, & Canteen |
|
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|
|
190 |
190 |
Gift, Flower, Coffee Shop, & Canteen |
|
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|
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|
|
|
|
190 |
190 |
Gift, Flower, Coffee Shop, & Canteen |
|
|
|
|
|
|
|
|
|
190 |
| 191 |
Research |
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|
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|
191 |
191 |
Research |
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|
|
|
191 |
191 |
Research |
|
|
|
|
|
|
|
|
|
191 |
| 192 |
Physicians' Private Offices |
|
|
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|
|
192 |
192 |
Physicians' Private Offices |
|
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|
192 |
192 |
Physicians' Private Offices |
|
|
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|
|
|
|
|
192 |
| 193 |
Nonpaid Workers |
|
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|
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|
|
|
193 |
193 |
Nonpaid Workers |
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|
|
|
|
193 |
193 |
Nonpaid Workers |
|
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|
|
|
|
|
|
193 |
| 194 |
Other Nonreimbursable (specify) |
|
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|
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|
|
|
194 |
194 |
Other Nonreimbursable (specify) |
|
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|
194 |
194 |
Other Nonreimbursable (specify) |
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|
194 |
| 200 |
Cross Foot Adjustments |
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|
200 |
200 |
Cross Foot Adjustments |
|
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|
200 |
200 |
Cross Foot Adjustments |
|
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|
200 |
| 201 |
Negative Cost Centers |
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|
201 |
201 |
Negative Cost Centers |
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|
201 |
201 |
Negative Cost Centers |
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|
201 |
| 202 |
TOTAL (sum lines 118-201) |
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|
202 |
202 |
TOTAL (sum lines 118-201) |
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|
202 |
202 |
TOTAL (sum lines 118-201) |
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202 |
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4021) |
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| 40-546 |
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Rev. 1 |
Rev. 1 |
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40-549 |
40-552 |
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Rev. 1 |
| DRAFT |
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FORM CMS-2552-10 |
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4090 (Cont.) |
4090 (Cont.) |
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FORM CMS-2552-10 |
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DRAFT |
DRAFT |
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FORM CMS-2552-10 |
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4090 (Cont.) |
| COST ALLOCATION - STATISTICAL BASIS |
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PROVIDER NO: |
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PERIOD: |
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WORKSHEET B-1 |
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COST ALLOCATION - STATISTICAL BASIS |
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PROVIDER NO: |
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PERIOD: |
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WORKSHEET B-1 |
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COST ALLOCATION - STATISTICAL BASIS |
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PROVIDER NO: |
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PERIOD: |
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WORKSHEET B-1 |
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FROM ____________ |
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FROM ____________ |
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FROM ____________ |
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_ |
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TO _______________ |
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_ |
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TO _______________ |
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_ |
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TO _______________ |
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CAPITAL RELATED COST |
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ADMINIS- |
MAIN- |
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LAUNDRY |
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MAIN- |
NURSING |
CENTRAL |
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MEDICAL |
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NON- |
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INTERNS & RESIDENTS |
PARA- |
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INTERN & |
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BLDGS. & |
MOVABLE |
EMPLOYEE |
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TRATIVE & |
TENANCE & |
OPERATION |
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& LINEN |
HOUSE- |
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TENANCE OF |
ADMINIS- |
SERVICES & |
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RECORDS & |
SOCIAL |
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OTHER |
PHYSICIAN |
NURSING |
SALARY AND |
PROGRAM |
MEDICAL |
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RESIDENT |
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FIXTURES |
EQUIPMENT |
BENEFITS |
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GENERAL |
REPAIRS |
OF PLANT |
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SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
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GENERAL |
ANES- |
SCHOOL |
FRINGES |
COSTS |
EDUCATION |
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COST & POST |
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COST CENTER DESCRIPTIONS |
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(SQUARE |
(DOLLAR |
(GROSS |
RECONCIL- |
(ACCUM. |
(SQUARE |
(SQUARE |
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|
COST CENTER DESCRIPTIONS |
(POUNDS OF |
(HOURS OF |
(MEALS |
(MEALS |
(NUMBER |
(DIRECT |
(COSTED |
(COSTED |
(TIME |
(TIME |
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COST CENTER DESCRIPTIONS |
SERVICE |
THETISTS |
(ASSIGNED |
(ASSIGNED |
(ASSIGNED |
(ASSIGNED |
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STEPDOWN |
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FEET) |
VALUE) |
SALARIES) |
IATION |
COST) |
FEET) |
FEET) |
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LAUNDRY) |
SERVICE) |
SERVED) |
SERVED) |
HOUSED) |
NURS. HRS) |
REQUIS.) |
REQUIS.) |
SPENT) |
SPENT) |
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(SPECIFY) |
(ASGND TIME) |
TIME) |
TIME) |
TIME) |
TIME) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
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1 |
2 |
4 |
5A |
5 |
6 |
7 |
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8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
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18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
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GENERAL SERVICE COST CENTERS |
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GENERAL SERVICE COST CENTERS |
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GENERAL SERVICE COST CENTERS |
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| 1 |
Capital Related Costs-Buildings and Fixtures |
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1 |
1 |
Capital Related Costs-Buildings and Fixtures |
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1 |
1 |
Capital Related Costs-Buildings and Fixtures |
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1 |
| 2 |
Capital Related Costs-Movable Equipment |
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2 |
2 |
Capital Related Costs-Movable Equipment |
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2 |
2 |
Capital Related Costs-Movable Equipment |
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2 |
| 4 |
Employee Benefits |
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4 |
4 |
Employee Benefits |
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4 |
4 |
Employee Benefits |
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4 |
| 5 |
Administrative and General |
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5 |
5 |
Administrative and General |
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5 |
5 |
Administrative and General |
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5 |
| 6 |
Maintenance and Repairs |
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6 |
6 |
Maintenance and Repairs |
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6 |
6 |
Maintenance and Repairs |
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6 |
| 7 |
Operation of Plant |
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7 |
7 |
Operation of Plant |
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7 |
7 |
Operation of Plant |
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7 |
| 8 |
Laundry and Linen Service |
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8 |
8 |
Laundry and Linen Service |
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8 |
8 |
Laundry and Linen Service |
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8 |
| 9 |
Housekeeping |
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9 |
9 |
Housekeeping |
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9 |
9 |
Housekeeping |
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9 |
| 10 |
Dietary |
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10 |
10 |
Dietary |
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10 |
10 |
Dietary |
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10 |
| 11 |
Cafeteria |
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11 |
11 |
Cafeteria |
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11 |
11 |
Cafeteria |
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11 |
| 12 |
Maintenance of Personnel |
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12 |
12 |
Maintenance of Personnel |
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12 |
12 |
Maintenance of Personnel |
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12 |
| 13 |
Nursing Administration |
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13 |
13 |
Nursing Administration |
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13 |
13 |
Nursing Administration |
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13 |
| 14 |
Central Services and Supply |
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14 |
14 |
Central Services and Supply |
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14 |
14 |
Central Services and Supply |
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14 |
| 15 |
Pharmacy |
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15 |
15 |
Pharmacy |
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15 |
15 |
Pharmacy |
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15 |
| 16 |
Medical Records & Medical Records Library |
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16 |
16 |
Medical Records & Medical Records Library |
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16 |
16 |
Medical Records & Medical Records Library |
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16 |
| 17 |
Social Service |
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17 |
17 |
Social Service |
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17 |
17 |
Social Service |
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17 |
| 18 |
Other General Service (specify) |
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18 |
18 |
Other General Service (specify) |
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18 |
18 |
Other General Service (specify) |
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18 |
| 19 |
Nonphysician Anesthetists |
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19 |
19 |
Nonphysician Anesthetists |
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19 |
19 |
Nonphysician Anesthetists |
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19 |
| 20 |
Nursing School |
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20 |
20 |
Nursing School |
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20 |
20 |
Nursing School |
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20 |
| 21 |
Intern & Res. Service-Salary & Fringes (Approved) |
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21 |
21 |
Intern & Res. Service-Salary & Fringes (Approved) |
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21 |
21 |
Intern & Res. Service-Salary & Fringes (Approved) |
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21 |
| 22 |
Intern & Res. Other Program Costs (Approved) |
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22 |
22 |
Intern & Res. Other Program Costs (Approved) |
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22 |
22 |
Intern & Res. Other Program Costs (Approved) |
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22 |
| 23 |
Paramedical Education Program (specify) |
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23 |
23 |
Paramedical Education Program (specify) |
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23 |
23 |
Paramedical Education Program (specify) |
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23 |
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INPATIENT ROUTINE SERVICE COST CENTERS |
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INPATIENT ROUTINE SERVICE COST CENTERS |
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INPATIENT ROUTINE SERVICE COST CENTERS |
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| 30 |
Adults and Pediatrics (General Routine Care) |
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30 |
30 |
Adults and Pediatrics (General Routine Care) |
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30 |
30 |
Adults and Pediatrics (General Routine Care) |
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30 |
| 31 |
Intensive Care Unit |
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31 |
31 |
Intensive Care Unit |
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31 |
31 |
Intensive Care Unit |
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31 |
| 32 |
Coronary Care Unit |
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32 |
32 |
Coronary Care Unit |
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32 |
32 |
Coronary Care Unit |
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32 |
| 33 |
Burn Intensive Care Unit |
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33 |
33 |
Burn Intensive Care Unit |
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33 |
33 |
Burn Intensive Care Unit |
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33 |
| 34 |
Surgical Intensive Care Unit |
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34 |
34 |
Surgical Intensive Care Unit |
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34 |
34 |
Surgical Intensive Care Unit |
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34 |
| 35 |
Other Special Care Unit (specify) |
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35 |
35 |
Other Special Care Unit (specify) |
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35 |
35 |
Other Special Care Unit (specify) |
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35 |
| 40 |
Subprovider IPF |
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40 |
40 |
Subprovider IPF |
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40 |
40 |
Subprovider IPF |
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40 |
| 41 |
Subprovider IRF |
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41 |
41 |
Subprovider IRF |
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41 |
41 |
Subprovider IRF |
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41 |
| 42 |
Subprovider (specify) |
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42 |
42 |
Subprovider (specify) |
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42 |
42 |
Subprovider (specify) |
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42 |
| 43 |
Nursery |
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43 |
43 |
Nursery |
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43 |
43 |
Nursery |
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43 |
| 44 |
Skilled Nursing Facility |
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44 |
44 |
Skilled Nursing Facility |
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44 |
44 |
Skilled Nursing Facility |
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44 |
| 45 |
Nursing Facility |
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45 |
45 |
Nursing Facility |
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45 |
45 |
Nursing Facility |
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45 |
| 46 |
Other Long Term Care |
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46 |
46 |
Other Long Term Care |
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46 |
46 |
Other Long Term Care |
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46 |
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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40-553 |
40-556 |
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Rev. 1 |
Rev. 1 |
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40-559 |
| 4090 (Cont.) |
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FORM CMS-2552-10 |
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DRAFT |
DRAFT |
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FORM CMS-2552-10 |
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4090 (Cont.) |
4090 (Cont.) |
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FORM CMS-2552-10 |
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DRAFT |
| COST ALLOCATION - STATISTICAL BASIS |
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PROVIDER NO: |
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PERIOD: |
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WORKSHEET B-1 |
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COST ALLOCATION - STATISTICAL BASIS |
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PROVIDER NO: |
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PERIOD: |
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WORKSHEET B-1 |
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COST ALLOCATION - STATISTICAL BASIS |
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PROVIDER NO: |
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PERIOD: |
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WORKSHEET B-1 |
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FROM ____________ |
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FROM ____________ |
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FROM ____________ |
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TO _______________ |
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TO _______________ |
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TO _______________ |
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CAPITAL RELATED COST |
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ADMINIS- |
MAIN- |
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LAUNDRY |
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MAIN- |
NURSING |
CENTRAL |
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MEDICAL |
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NON- |
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INTERNS & RESIDENTS |
PARA- |
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INTERN & |
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BLDGS. & |
MOVABLE |
EMPLOYEE |
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TRATIVE & |
TENANCE & |
OPERATION |
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& LINEN |
HOUSE- |
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TENANCE OF |
ADMINIS- |
SERVICES & |
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RECORDS & |
SOCIAL |
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OTHER |
PHYSICIAN |
NURSING |
SALARY AND |
PROGRAM |
MEDICAL |
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RESIDENT |
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FIXTURES |
EQUIPMENT |
BENEFITS |
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GENERAL |
REPAIRS |
OF PLANT |
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SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
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GENERAL |
ANES- |
SCHOOL |
FRINGES |
COSTS |
EDUCATION |
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COST & POST |
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COST CENTER DESCRIPTIONS |
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(SQUARE |
(DOLLAR |
(GROSS |
RECONCIL- |
(ACCUM. |
(SQUARE |
(SQUARE |
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|
COST CENTER DESCRIPTIONS |
(POUNDS OF |
(HOURS OF |
(MEALS |
(MEALS |
(NUMBER |
(DIRECT |
(COSTED |
(COSTED |
(TIME |
(TIME |
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COST CENTER DESCRIPTIONS |
SERVICE |
THETISTS |
(ASSIGNED |
(ASSIGNED |
(ASSIGNED |
(ASSIGNED |
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STEPDOWN |
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FEET) |
VALUE) |
SALARIES) |
IATION |
COST) |
FEET) |
FEET) |
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LAUNDRY) |
SERVICE) |
SERVED) |
SERVED) |
HOUSED) |
NURS. HRS) |
REQUIS.) |
REQUIS.) |
SPENT) |
SPENT) |
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(SPECIFY) |
(ASGND TIME) |
TIME) |
TIME) |
TIME) |
TIME) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
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1 |
2 |
4 |
5A |
5 |
6 |
7 |
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8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
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18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
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ANCILLARY SERVICE COST CENTERS |
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ANCILLARY SERVICE COST CENTERS |
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ANCILLARY SERVICE COST CENTERS |
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| 50 |
Operating Room |
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50 |
50 |
Operating Room |
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50 |
50 |
Operating Room |
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50 |
| 51 |
Recovery Room |
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51 |
51 |
Recovery Room |
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51 |
51 |
Recovery Room |
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51 |
| 52 |
Labor Room and Delivery Room |
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52 |
52 |
Labor Room and Delivery Room |
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52 |
52 |
Labor Room and Delivery Room |
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52 |
| 53 |
Anesthesiology |
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53 |
53 |
Anesthesiology |
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53 |
53 |
Anesthesiology |
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53 |
| 54 |
Radiology-Diagnostic |
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54 |
54 |
Radiology-Diagnostic |
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54 |
54 |
Radiology-Diagnostic |
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54 |
| 55 |
Radiology-Therapeutic |
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55 |
55 |
Radiology-Therapeutic |
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55 |
55 |
Radiology-Therapeutic |
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55 |
| 56 |
Radioisotope |
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56 |
56 |
Radioisotope |
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56 |
56 |
Radioisotope |
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56 |
| 57 |
Computed Tomography (CT) Scan |
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57 |
57 |
Computed Tomography (CT) Scan |
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57 |
57 |
Computed Tomography (CT) Scan |
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57 |
| 58 |
Magnetic Resonance Imaging (MRI) |
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58 |
58 |
Magnetic Resonance Imaging (MRI) |
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58 |
58 |
Magnetic Resonance Imaging (MRI) |
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58 |
| 59 |
Cardiac Catheterization |
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59 |
59 |
Cardiac Catheterization |
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59 |
59 |
Cardiac Catheterization |
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59 |
| 60 |
Laboratory |
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60 |
60 |
Laboratory |
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60 |
60 |
Laboratory |
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60 |
| 61 |
PBP Clinical Laboratory Services-Program Only |
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61 |
61 |
PBP Clinical Laboratory Services-Program Only |
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61 |
61 |
PBP Clinical Laboratory Services-Program Only |
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61 |
| 62 |
Whole Blood & Packed Red Blood Cells |
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62 |
62 |
Whole Blood & Packed Red Blood Cells |
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62 |
62 |
Whole Blood & Packed Red Blood Cells |
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62 |
| 63 |
Blood Storing, Processing, & Trans. |
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63 |
63 |
Blood Storing, Processing, & Trans. |
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63 |
63 |
Blood Storing, Processing, & Trans. |
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63 |
| 64 |
Intravenous Therapy |
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64 |
64 |
Intravenous Therapy |
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64 |
64 |
Intravenous Therapy |
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64 |
| 65 |
Respiratory Therapy |
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65 |
65 |
Respiratory Therapy |
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65 |
65 |
Respiratory Therapy |
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65 |
| 66 |
Physical Therapy |
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66 |
66 |
Physical Therapy |
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66 |
66 |
Physical Therapy |
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66 |
| 67 |
Occupational Therapy |
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67 |
67 |
Occupational Therapy |
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67 |
67 |
Occupational Therapy |
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67 |
| 68 |
Speech Pathology |
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68 |
68 |
Speech Pathology |
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68 |
68 |
Speech Pathology |
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68 |
| 69 |
Electrocardiology |
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69 |
69 |
Electrocardiology |
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69 |
69 |
Electrocardiology |
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69 |
| 70 |
Electroencephalography |
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70 |
70 |
Electroencephalography |
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70 |
70 |
Electroencephalography |
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70 |
| 71 |
Medical Supplies Charged to Patients |
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71 |
71 |
Medical Supplies Charged to Patients |
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71 |
71 |
Medical Supplies Charged to Patients |
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71 |
| 72 |
Implantable Devices Charged to Patients |
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72 |
72 |
Implantable Devices Charged to Patients |
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72 |
72 |
Implantable Devices Charged to Patients |
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72 |
| 73 |
Drugs Charged to Patients |
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73 |
73 |
Drugs Charged to Patients |
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73 |
73 |
Drugs Charged to Patients |
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73 |
| 74 |
Renal Dialysis |
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74 |
74 |
Renal Dialysis |
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74 |
74 |
Renal Dialysis |
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74 |
| 75 |
ASC (Non-Distinct Part) |
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75 |
75 |
ASC (Non-Distinct Part) |
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75 |
75 |
ASC (Non-Distinct Part) |
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75 |
| 76 |
Other Ancillary (specify) |
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76 |
76 |
Other Ancillary (specify) |
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76 |
76 |
Other Ancillary (specify) |
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76 |
|
OUTPATIENT SERVICE COST CENTERS |
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OUTPATIENT SERVICE COST CENTERS |
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OUTPATIENT SERVICE COST CENTERS |
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| 88 |
Rural Health Clinic (RHC) |
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88 |
88 |
Rural Health Clinic (RHC) |
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88 |
88 |
Rural Health Clinic (RHC) |
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88 |
| 89 |
Federally Qualified Health Center (FQHC) |
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89 |
89 |
Federally Qualified Health Center (FQHC) |
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89 |
89 |
Federally Qualified Health Center (FQHC) |
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89 |
| 90 |
Clinic |
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90 |
90 |
Clinic |
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90 |
90 |
Clinic |
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|
90 |
| 91 |
Emergency |
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91 |
91 |
Emergency |
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91 |
91 |
Emergency |
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91 |
| 92 |
Observation Beds |
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92 |
92 |
Observation Beds |
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92 |
92 |
Observation Beds |
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|
92 |
| 93 |
Other Outpatient Service (specify) |
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93 |
93 |
Other Outpatient Service (specify) |
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93 |
93 |
Other Outpatient Service (specify) |
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93 |
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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|
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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| 40-554 |
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|
Rev. 1 |
Rev. 1 |
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|
40-557 |
40-560 |
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|
|
Rev. 1 |
| DRAFT |
|
|
|
FORM CMS-2552-10 |
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|
|
|
|
|
4090 (Cont.) |
4090 (Cont.) |
|
|
|
FORM CMS-2552-10 |
|
|
|
|
|
|
|
DRAFT |
DRAFT |
|
|
|
FORM CMS-2552-10 |
|
|
|
|
|
|
4090 (Cont.) |
| COST ALLOCATION - STATISTICAL BASIS |
|
|
|
|
|
PROVIDER NO: |
|
PERIOD: |
|
WORKSHEET B-1 |
|
COST ALLOCATION - STATISTICAL BASIS |
|
|
|
|
|
|
PROVIDER NO: |
|
PERIOD: |
|
WORKSHEET B-1 |
|
COST ALLOCATION - STATISTICAL BASIS |
|
|
|
|
|
PROVIDER NO: |
|
PERIOD: |
|
WORKSHEET B-1 |
|
|
|
|
|
|
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|
|
FROM ____________ |
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|
|
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|
|
FROM ____________ |
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|
|
|
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|
|
FROM ____________ |
|
|
|
|
|
|
|
|
|
_ |
|
TO _______________ |
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|
|
|
|
|
|
|
|
|
_ |
|
TO _______________ |
|
|
|
|
|
|
|
|
|
_ |
|
TO _______________ |
|
|
|
|
|
|
|
CAPITAL RELATED COST |
|
|
ADMINIS- |
MAIN- |
|
|
|
|
LAUNDRY |
|
|
|
MAIN- |
NURSING |
CENTRAL |
|
MEDICAL |
|
|
|
|
|
NON- |
|
INTERNS & RESIDENTS |
PARA- |
|
INTERN & |
|
|
|
|
|
|
BLDGS. & |
MOVABLE |
EMPLOYEE |
|
TRATIVE & |
TENANCE & |
OPERATION |
|
|
|
& LINEN |
HOUSE- |
|
|
TENANCE OF |
ADMINIS- |
SERVICES & |
|
RECORDS & |
SOCIAL |
|
|
|
OTHER |
PHYSICIAN |
NURSING |
SALARY AND |
PROGRAM |
MEDICAL |
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RESIDENT |
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FIXTURES |
EQUIPMENT |
BENEFITS |
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GENERAL |
REPAIRS |
OF PLANT |
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SERVICE |
KEEPING |
DIETARY |
CAFETERIA |
PERSONNEL |
TRATION |
SUPPLY |
PHARMACY |
LIBRARY |
SERVICE |
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GENERAL |
ANES- |
SCHOOL |
FRINGES |
COSTS |
EDUCATION |
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COST & POST |
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COST CENTER DESCRIPTIONS |
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(SQUARE |
(DOLLAR |
(GROSS |
RECONCIL- |
(ACCUM. |
(SQUARE |
(SQUARE |
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COST CENTER DESCRIPTIONS |
(POUNDS OF |
(HOURS OF |
(MEALS |
(MEALS |
(NUMBER |
(DIRECT |
(COSTED |
(COSTED |
(TIME |
(TIME |
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COST CENTER DESCRIPTIONS |
SERVICE |
THETISTS |
(ASSIGNED |
(ASSIGNED |
(ASSIGNED |
(ASSIGNED |
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STEPDOWN |
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FEET) |
VALUE) |
SALARIES) |
IATION |
COST) |
FEET) |
FEET) |
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LAUNDRY) |
SERVICE) |
SERVED) |
SERVED) |
HOUSED) |
NURS. HRS) |
REQUIS.) |
REQUIS.) |
SPENT) |
SPENT) |
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(SPECIFY) |
(ASGND TIME) |
TIME) |
TIME) |
TIME) |
TIME) |
SUBTOTAL |
ADJUSTMENTS |
TOTAL |
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1 |
2 |
4 |
5A |
5 |
6 |
7 |
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8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
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18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
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OTHER REIMBURSABLE COST CENTERS |
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OTHER REIMBURSABLE COST CENTERS |
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OTHER REIMBURSABLE COST CENTERS |
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| 94 |
Home Program Dialysis |
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94 |
94 |
Home Program Dialysis |
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94 |
94 |
Home Program Dialysis |
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94 |
| 95 |
Ambulance Services |
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95 |
95 |
Ambulance Services |
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95 |
95 |
Ambulance Services |
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95 |
| 96 |
Durable Medical Equipment-Rented |
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96 |
96 |
Durable Medical Equipment-Rented |
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96 |
96 |
Durable Medical Equipment-Rented |
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96 |
| 97 |
Durable Medical Equipment-Sold |
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97 |
97 |
Durable Medical Equipment-Sold |
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97 |
97 |
Durable Medical Equipment-Sold |
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97 |
| 98 |
Other Reimbursable (specify) |
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98 |
98 |
Other Reimbursable (specify) |
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98 |
98 |
Other Reimbursable (specify) |
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98 |
| 99 |
Outpatient Rehabilitation Provider (specify) |
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99 |
99 |
Outpatient Rehabilitation Provider (specify) |
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99 |
99 |
Outpatient Rehabilitation Provider (specify) |
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99 |
| 100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
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100 |
100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
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100 |
100 |
Intern-Resident Service (not appvd. tchng. prgm.) |
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100 |
| 101 |
Home Health Agency |
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101 |
101 |
Home Health Agency |
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101 |
101 |
Home Health Agency |
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101 |
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SPECIAL PURPOSE COST CENTERS |
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SPECIAL PURPOSE COST CENTERS |
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SPECIAL PURPOSE COST CENTERS |
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| 105 |
Kidney Acquisition |
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105 |
105 |
Kidney Acquisition |
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105 |
105 |
Kidney Acquisition |
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105 |
| 106 |
Heart Acquisition |
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106 |
106 |
Heart Acquisition |
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106 |
106 |
Heart Acquisition |
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106 |
| 107 |
Liver Acquisition |
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107 |
107 |
Liver Acquisition |
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107 |
107 |
Liver Acquisition |
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107 |
| 108 |
Lung Acquisition |
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108 |
108 |
Lung Acquisition |
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108 |
108 |
Lung Acquisition |
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108 |
| 109 |
Pancreas Acquisition |
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109 |
109 |
Pancreas Acquisition |
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109 |
109 |
Pancreas Acquisition |
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109 |
| 110 |
Intestinal Acquisition |
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110 |
110 |
Intestinal Acquisition |
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110 |
110 |
Intestinal Acquisition |
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110 |
| 111 |
Islet Acquisition |
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111 |
111 |
Islet Acquisition |
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111 |
111 |
Islet Acquisition |
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111 |
| 112 |
Other Organ Acquisition (specify) |
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112 |
112 |
Other Organ Acquisition (specify) |
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112 |
112 |
Other Organ Acquisition (specify) |
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112 |
| 115 |
Ambulatory Surgical Center (Distinct Part) |
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115 |
115 |
Ambulatory Surgical Center (Distinct Part) |
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115 |
115 |
Ambulatory Surgical Center (Distinct Part) |
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115 |
| 116 |
Hospice |
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116 |
116 |
Hospice |
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116 |
116 |
Hospice |
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116 |
| 117 |
Other Special Purpose (specify) |
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117 |
117 |
Other Special Purpose (specify) |
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117 |
117 |
Other Special Purpose (specify) |
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117 |
| 118 |
SUBTOTALS (sum of lines 1-117) |
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118 |
118 |
SUBTOTALS (sum of lines 1-117) |
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118 |
118 |
SUBTOTALS (sum of lines 1-117) |
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118 |
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NONREIMBURSABLE COST CENTERS |
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NONREIMBURSABLE COST CENTERS |
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NONREIMBURSABLE COST CENTERS |
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| 190 |
Gift, Flower, Coffee Shop, & Canteen |
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190 |
190 |
Gift, Flower, Coffee Shop, & Canteen |
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190 |
190 |
Gift, Flower, Coffee Shop, & Canteen |
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190 |
| 191 |
Research |
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191 |
191 |
Research |
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191 |
191 |
Research |
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191 |
| 192 |
Physicians' Private Offices |
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192 |
192 |
Physicians' Private Offices |
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192 |
192 |
Physicians' Private Offices |
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192 |
| 193 |
Nonpaid Workers |
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193 |
193 |
Nonpaid Workers |
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193 |
193 |
Nonpaid Workers |
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193 |
| 194 |
Other Nonreimbursable (specify) |
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194 |
194 |
Other Nonreimbursable (specify) |
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194 |
194 |
Other Nonreimbursable (specify) |
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194 |
| 200 |
Cross foot adjustments |
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200 |
200 |
Cross foot adjustments |
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200 |
200 |
Cross foot adjustments |
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200 |
| 201 |
Negative cost centers |
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201 |
201 |
Negative cost centers |
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201 |
201 |
Negative cost centers |
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201 |
| 202 |
Cost to be allocated (per Wkst. B, Part I) |
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202 |
202 |
Cost to be allocated (per Wkst. B, Part I) |
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202 |
202 |
Cost to be allocated (per Wkst. B, Part I) |
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202 |
| 203 |
Unit cost multiplier (Wkst. B, Part I) |
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203 |
203 |
Unit cost multiplier (Wkst. B, Part I) |
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203 |
203 |
Unit cost multiplier (Wkst. B, Part I) |
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203 |
| 204 |
Cost to be allocated (per Wkst. B, Part II) |
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204 |
204 |
Cost to be allocated (per Wkst. B, Part II) |
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204 |
204 |
Cost to be allocated (per Wkst. B, Part II) |
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204 |
| 205 |
Unit cost multiplier (Wkst. B, Part II) |
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205 |
205 |
Unit cost multiplier (Wkst. B, Part II) |
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205 |
205 |
Unit cost multiplier (Wkst. B, Part II) |
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205 |
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| FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4020) |
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| Rev. 1 |
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40-555 |
40-558 |
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Rev. 1 |
Rev. 1 |
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40-561 |