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

DRAFT

CHAPTER 41

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-10

Section

General 4100

Rounding Standards for Fractional Computations 4100.1

Acronyms and Abbreviations 4100.2

Recommended Sequence for Completing an SNF Cost Report 4101

Recommended Sequence for Completing an SNF or SNF

Health Care Complex - Full Cost Report 4101.1

Recommended Sequence for Completing an SNF Cost Report

Under The Simplified Method - Less Than 1500 Medicare Days 4101.2

Sequence of Assembly 4102

Worksheet S - Skilled Nursing Facility and Skilled

Nursing Facility Health Care Complex Cost Report

Certification and Settlement Summary 4103

Part I - Certification 4103.1

Part II - Settlement Summary 4103.2

Worksheet S-2 - Skilled Nursing Facility and Skilled Nursing

Facility Health Care Complex Identification Data 4104

…Form 339 Questions 4104.2

Worksheet S-3 - Skilled Nursing Facility and Skilled Nursing

Facility Health Care Complex Statistical Data 4105

Part II - SNF Wage Index Information 4105.1

Part III - Overhead Cost - Direct Salaries 4105.2

Worksheet S-4 - SNF-Based Home Health Agency Statistical

Data 4106

Part I - Home Health Agency Visits 4106.1

Part II - Employment Data 4106.2

Part III - Compilation of PPS Activity Data 4106.3

Worksheet S-5 - SNF-Based Rural Health Clinic / Federally Qualified

Health Center Statistical Data 4107

Worksheet S-6 - Skilled Nursing Facility-Based

C.M.H.C Statistical Data 4108

Worksheet S-7 - PPS Statistical Data 4109

Worksheet S-8 - Hospice Identification Data 4110

Part I - Enrollment Days Based on Level of Care 4110.1

Part II - Census Data 4110.2

Worksheet A - Reclassification and Adjustment of Trial

Balance of Expenses 4113

Worksheet A-6 - Reclassifications 4114

Worksheet A-7 - Analysis of Changes During Cost Reporting

Period in Capital Asset Balances 4115

Worksheet A-8 - Adjustments to Expenses 4116

Worksheet A-8-1 - Statement of Costs of Services From

Related Organizations 4117

Worksheet A-8-2 - Provider-Based Physician Adjustments 4118

Worksheet B, Part I - Cost Allocation - General

Service Costs and Worksheet B-1 - Cost Allocation -

Statistical Basis 4120

Worksheet B, Part III - Cost Allocation - General Service Costs and

Worksheet B-1, Part II - Cost Allocation - Statistical Basis (With Less

Than 1500 Medicare Days 4121

Rev. 1 41-1

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-10

Section

Worksheet B, Part II - Allocation of Capital-Related Cost 4121.2

Worksheet B-2 - Post Step Down Adjustments 4122

Worksheet C - Computation of Ratio of Cost to Charges

For Ancillary and Outpatient cost 4123

Worksheet D - Apportionment of Ancillary and Outpatient Cost and

Reduction of Therapy Cost 4124

Part I - Calculation of Ancillary Cost and Outpatient 4124.1

Part II - Apportionment of Vaccine Cost 4124.2

Part III - Calculation of Pass Through Costs for Interns and Residents 4124.3

Worksheet D-1 - Computation of Inpatient Routine Costs 4125

Part I - Calculation of Inpatient Routine Costs 4125.1

Part II - Calculation of Inpatient Intern and Resident

Cost for PPS Pass through 4125.2

Worksheet D-2 - Apportionment of Cost of Services

Rendered By Interns and Residents 4126

Part I - Not in Approved Teaching Program 4126.1

Part II - In Approved Teaching Program (Title

XVIII, Part B Inpatient Routine Costs Only) 4126.2

Worksheet E - Calculation of Reimbursement Settlement 4130

Part I - SNF Reimbursement Under PPS 4130.1

Part II - Part B - Medical and Other Health Services 4130.2

Worksheet E-1 - Analysis of Payments to Providers for

Services Rendered 4131

Worksheet G - Balance Sheet 4140

Worksheet G-1 - Statement of Changes in Fund

Balances 4140.1

Worksheet G-2 - Statement of Patient Revenues and

Operating Expenses 4140.2

Worksheet G-3 - Statement of Revenues and Expenses 4140.3

Worksheet H - Analysis of Provider-Based

Home Health Agency Costs 4141

Worksheet H-1 – Part I -Cost Allocation – HHA General Service Cost 4142

Part II – Cost Allocation – HHA Statistical Basis………………………………. 4142

Worksheet H-2 – Part I – Allocation of General Service Costs to

HHA Cost Centers…………………………….…………………………...……4143

Part II Allocation of General Service Costs to HHA Cost Centers

Statistical Basis. 4143

Worksheet H-3 – Apportionment of Patient Service costs- 4144

Worksheet H-4 – Calculation of HHA Reimbursement Settlement 4145

Worksheet H-5 - Analysis of Payments to Provider-based HHA

For Services Rendered to Program Beneficiaries 4146

Worksheet I-1 - Analysis of SNF-Based Rural Health Clinic/Federally

Qualified Health Center Costs. 4148

Worksheet I-2 - Allocation of Overhead to RHC/FQHC Services 4149

Worksheet I-3 - Calculation of Reimbursement Settlement for RHC/FQHC

Services 4150

Worksheet I-4 –Computation of Pneumococcal and Influenza Cost 4151

Worksheet I-5 - Analysis of Payments to SNF-Based Rural Health Clinic

And Federally Qualified Health Centers 4152

41-2 Rev.1

SKILLED NURSING FACILITY AND SKILLED NURSING

FACILITY HEALTH CARE COMPLEX COST REPORT

FORM CMS 2540-10

Section

Worksheet J-1 - Allocation of General Service Costs to

Cost Centers for C.M.H.C 4153

Worksheet J-2 – Computation of C.M.H.C rehabilitation Costs 4154

Worksheet J-3 - Calculation of Reimbursement

Settlement of C.M.H.C. Services 4155

Worksheet J-4 - Analysis of Payments to Provider-based

C.M.H.C. for Services Rendered to Program Beneficiaries 4156

Worksheet K – Analysis of SNF - Based Hospice Cost 4157 Worksheet K-1 – Hospice Compensation Analysis Salaries and Wages 4158

Worksheet K-2 – Hospice Compensation Analysis - Employee Benefits

(Payroll Related) 4159

Worksheet K-3 – Hospice Compensation Analysis - Contracted Services/

Purchased Services 4160

Worksheet K-4, Part I - Cost Allocation – Hospice General Service Cost

and Part II - Cost Allocation - Hospice Statistical Basis 4161

Worksheet K-5, Allocation of General Service Costs to Hospice Cost Centers 4162

Part I - Allocation of General Service Costs to Hospice Cost Centers 4162.1

Part II - Allocation of General Service Costs to Hospice Cost Centers -

Statistical Basis 4162.2

Part III – Apportionment of Hospice Shared Services 4162.3

Worksheet K-6, Calculation of Per Diem Cost 4163

Exhibit 1- Form CMS 2540-10 Worksheets 4190

Electronic Reporting Specifications for Form CMS 2540-10 4195

Rev. 1 41-3