CMS-2540-10 Skilled Nursing Facility and Skilled Facility Health Car

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

06-10 DRAFT 2540-10P.xls

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

OMB: 0938-0463

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0463 can be found here:

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A81
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B
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DII
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E1
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H
H1-1
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H2-1
H2-II
H3-I
H4
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I1
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J-1-I
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Sheet 1: S

DRAFT

FORM CMS 2540-10

4190 (Cont.)

DRAFT as of May 2010

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim

FORM APPROVED

payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).

OMB NO. DRAFT

SKILLED NURSING FACILITY AND

PROVIDER NO.:

PERIOD:

SKILLED NURSING FACILITY HEALTH

FROM ___________________

WORKSHEET S

CARE COMPLEX COST REPORT

______________________

TO ______________________

PARTS I II & III

CERTIFICATION AND

SETTLEMENT SUMMARY

PART I - COST REPORT STATUS

Provider

[ ]

Electronic filed cost report

Date:____________

Time:____________

use only

[ ]

Manually submitted cost report

Contractor

[ ] Cost Report Status

If # 3 or 4:

Date Received _____________

use only:

[ 1 ]

As Submitted:

[ ] Desk Reviewed

Contractor No. _____________

[ 2 ]

Amended:

[ ] Audited

[ ] First Cost Report Processed by Contractor

[ 3 ]

Settled:

[ 4 ]

Reopened: If number 4, Enter

[ ] Last Cost Report to be Processed by Contractor

Number of times reopened [ ]

PART II - CERTIFICATION

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVAL, AND ADMINISTRATIVE

ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED THROUGH THE PAYMENT

DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL, AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDERS)

I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost

report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Names) and Numbers)}

for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief, it is a true, correct

and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further

certify that I am familiar with the laws and regulations regarding the provision of health care services identified in this cost report were provided in

compliance with such laws and regulations.

(Signed)________________________________________________

Officer or Administrator of Providers)

______________________________________________

Title

______________________________________________

Date

PART III - SETTLEMENT SUMMARY

TITLE XVIII

TITLE V

TITLE XIX

SKILLED NURSING FACILITY

NURSING FACILITY

I C F / M R

SNF - BASED HHA

SNF - BASED RHC

SNF - BASED FQHC

SNF - BASED CMHC

SNF - BASED O.L.T.C.

100

TOTAL

100

The above amounts represent "due to" or "due from" the applicable Program for the element of the above complex indicated.

(Indicate Overpayments in Brackets.)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938-0463. The time required to complete this information collection is estimated 60 hours per response, including the time to review instructions,

search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate's) or suggestions

for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS

PUB. 15-II, SECTIONS 4103 )

Rev. 1

41-303

Sheet 2: S2

4190 (Cont.)			FORM CMS 2540-10							DRAFT
SKILLED NURSING FACILITY AND SKILLED NURSING				PROVIDER NO.:		PERIOD			WORKSHEET
FACILITY HEALTH CARE COMPLEX						FROM_____________			S - 2
IDENTIFICATION DATA				_______________	____________________	TO_____________				Part I
Skilled Nursing Facility and Skilled Nursing Facility Complex Address:
1	Street:				P.O. Box:						1
2	City:				State:		Zip Code:				2
3	County:				CBSA Code:		Urban / Rural:				3
SNF and SNF-Based Component Identification:
								Payment System
		Component Name			Provider No.	Date		(P, O, or N)
	Component					Certified		V	XVIII	XIX
	0	1			2	3		4	5	6
4	S N F										4
5	Nursing Facility										5
6	I C F / M R		*DRAFT*								6
7	SNF-Based H.H.A.										7
8	SNF-Based RHC										8
9	SNF-Based FQHC										9
10	SNF-Based CMHC										10
11	SNF-Based O.L.T.C.										11
12	SNF-Based HOSPICE										12
13	Cost Reporting Period (mm/dd/yyyy)			From:		To:					13
14	Type of Control (See Instructions)										14
Type of Freestanding Skilled Nursing Facility										Y / N
15	Is this a distinct part skilled nursing facility theat meets the requirements set forth in 42 CFR section 483.5?										15
16	Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?										16
17	Are there any costs included in Worksheet A which resulted from transactions with related										17
	organizations as defined in CMS Pub. 15-I, chapter 10? If yes, complete Worksheet A-8-1.
Miscellaneous Cost Reporting information
18	If this is a low or no Medicare utilization cost report, enter "L" for low Medicare Utilization, or										18
	enter "N" for No Medicare Utilization.
19											19
Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on Lines 22 - 24.
20	Straight Line										20
21	Declining Balance										21
22	Sum of the Year's Digits										22
23	Sum of line 20 through 22										23
24	If depreciation is funded, enter the balance as of the end of the period.										24
25	Were there any disposal of capital assets during the cost reporting period? (Y/N)										25
26	Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)										26
27	Did you cease to participate in the Medicare program at end of the period to which this cost report applies										27
28	Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports										28
FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4104
41-304											Rev. 1

DRAFT			FORM CMS 2540-10								4190 (Cont.)
SKILLED NURSING FACILITY AND SKILLED NURSING				PROVIDER NO.:		PERIOD			WORKSHEET
FACILITY HEALTH CARE COMPLEX						FROM_____________			S - 2 Part I
IDENTIFICATION DATA				_______________	____________________	TO__________			(Continued)
If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of
costs or charges enter "Y" for each component and type of service that qualifies for the exemption.								Part A	Part B	Other
29	Skilled Nursing Facility										29
30	Nursing Facility										30
31	I C F / M R										31
32	SNF-Based H.H.A.										32
33	SNF-Based RHC										33
34	SNF-Based FQHC										34
35	SNF-Based CMHC										35
										Y / N
36	Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients.										36
37	Are you legally-required to carry malpractice insurance?										37
38	Is the malpractice a "claims-made:", or "occurance" policy? If the policy is "claims-maid" enter 1. If policy is "occurance", enter 2.										38
39	What is the liability limit for the malpractice policy? Enter in column 1 the monetary										39
	limit per lawsuit. Enter in column 2 the monetary limit per policy year.
				Premiums		Paid Losses		Self insurance
40	List malpractice premiums and paid losses:										40
41	Are malpractice premiums and paid losses reported in other than the Administrative and General cost center?									Y / N
	Enter Y or N. If yes, check box, and submit supporting schedule listing cost centers and amounts.										41
42	Did this facility report less than 1500 Medicare days in its previous year's cost report? (See instructions.)										42
43	If line 42 is yes, did you file your previous years cost report using the "Simplified" step-down method of cost										43
	finding? See instructions for qualifications to use the simplified step-down method before answering line 44.
44	Is this cost report being filed under 42 CFR 413.321, the "simplified" cost report? Enter "Y" for yes or "N" for no.										44
45	Are there any related organizations or home office costs as defined in CMS Pub. 15-1, chapter 10?										45
46	If yes, and there are costs, for the home office, enter the applicable provider number					Provider #					46
	If this facility is part of a chain organization, enter the name and address of the home office on the lines below
47	Name:		Contractor name			Contractor Number					47
48	Street:					PO Box					48
49	City					State		Zip			49








		*DRAFT*
FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4104
Rev.1											41-305

Sheet 3: SII

4190 (Cont.)			FORM CMS-2540-10						DRAFT
SKILLED NURSING FACILITY AND SKILLED NURSING			PROVIDER NO.:		PERIOD:		WORKSHEET S-2
FACILITY HEALTH CARE COMPLEX					FROM		Part II
IDENTIFICATION DATA					TO
General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No
		For all the dates responses the format will be (mm/dd/yyyy)
Completed by All Skilled Nursing Facilities

	Provider Organization and Operation					1	2
						Y/N	Date
1	Has the Provider changed ownership immediately prior to the beginning of the cost reporting period?								1
	If column 1 is "Y", enter the date of the change in column 2. (see instructions)
						1	2	3
						Y/N	Date	V/I
2	Has the provider terminated participation in the Medicare Program? If column 1 is yes,								2
	enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary
3	Is the provider involved in business transactions, including management contracts, with individuals or								3
	entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or
	its officers, medical staff, management personnel, or members of the board of directors through
	ownership, control, or family and other similar relationships? (see instructions)

Financial Data and Reports
						1	2	3
						Y/N	Type	Date
4	Were the financial statements prepared by a Certified Public Accountant? If column 1 is "Y" enter "A"								4
	for Audited, "C" for Compiled, or "R" for Reviewed in column 2. Submit complete copy or enter
	date available in column 3. (see instructions) If column 1 is "N" see instructions.
5	Are the cost report total expenses and total revenues different from those on the filed financial								5
	statements? If column 1 is "Y", submit reconciliation.

							1	2
Approved Educational Activities							Y/N	Legal Oper.
6	Were costs claimed for Nursing School? If column 1 is "Y", enter "Y" or "N" in column 2 to indicate whether the								6
	provider is the legal operator of the program
7	Were costs claimed for Allied Health Programs? If "Y" see instructions.								7
8	Were approvals and/or renewals obtained during the cost reporting period for Nursing School and/or								8
	Allied Health Program? If "Y", see instructions.
9	Are Intern-Resident costs claimed on the current cost report? If "Y" see instructions.								9
10	Has an Intern-Resident program been initiated or renewed in the current cost reporting period? If "Y" see instructions.								10

Bad Debts
								1
								Y/N
11	Is the provider seeking reimbursement for bad debts? If "Y", see instructions.								11
12	If line 11 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy.								12
13	If line 11 is "Y", are patient deductibles and/or coinsurance waived? If "Y", see instructions.								13

Bed Complement
14	Have total beds available changed from prior cost reporting period? If "Y", see instructions.								14

					1	2	3	4
					Y/N	Date	Y/N	Date
PS&R Data					Part A	Part A	Part B	Part B
15	Was the cost report prepared using the PS&R only?								15
	If either col. 1 or 3 is "Y", enter the paid through date of the PS&R used
	to prepare this cost report in cols. 2 and 4 .(see Instructions.)
16	Was the cost report prepared using the PS&R for total and the provider's records								16
	for allocation? If either col. 1 or 3 is "Y" enter the paid through date of the PS&R
	used to prepare this cost report in columns 2 and 4.
17	If line 15 or 16 is "Y", were adjustments made to PS&R data for additional claims that								17
	have been billed but are not included on the PS&R used to file this cost report?
	If "Y", see Instructions.
18	If line 15 or 16 is "Y", then were adjustments made to PS&R data for corrections of other								18
	PS&R information? If "Y", see Instructions.
19	If line 15 or 16 is "Y", then were adjustments made to PS&R data for Other?								19
	Describe the other adjustments:		_________________________________
20	Was the cost report prepared only using the provider's records? If "Y" see Instructions.								20




		*D R A F T*



FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4104)
41-306									Rev. 1

DRAFT			FORM CMS-2540-10						4190 (Cont.)
SKILLED NURSING FACILITY AND SKILLED NURSING				PROVIDER NO.:	PERIOD:		WORKSHEET S-2
FACILITY HEALTH CARE COMPLEX					FROM		Part II
IDENTIFICATION DATA					TO







		*D R A F T*





	THIS PAGE IS INTENTIONALLY BLANK



















































FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4104)
Rev. 1									41-307

Sheet 4: S3

4190 (Cont.)						FORM CMS 2540-10							DRAFT
SKILLED NURSING FACILITY AND						PROVIDER NO.:			PERIOD			WORKSHEET S-3
SKILLED NURSING FACILITY HEALTH CARE COMPLEX									FROM____________________			PART I
STATISTICAL DATA
		Number	Bed	I n p a t i e n t D a y s					D i s c h a r g e s
		of	Days	Title	Title	Title		Total	Title	Title	Title		Total
	Component	Beds	Available	V	XVIII	XIX	Other		V	XVIII	XIX	Other
		1	2	3	4	5	6	7	8	9	10	11	12
1	Skilled Nursing Facility													1
2	Nursing Facility													2
3	ICF/MR													3
4	Home Health Agency													4
5	Other Long Term Care													5
6	SNF-Based CMHC													6
7	Hospice													7
8	Total (Sum of lines 1-7)													8

												Full Time
			Average Length of Stay				A d m i s s i o n s					Equivalent
			Title	Title	Title	Total	Title	Title	Title		Total	Employees	Nonpaid
			V	XVIII	XIX		V	XVIII	XIX	Other		on Payroll	Workers
			13	14	15	16	17	18	19	20	21	22	23
1	Skilled Nursing Facility													1
2	Nursing Facility													2
3	ICF/MR													3
4	Home Health Agency													4
5	Other Long Term Care													5
6	SNF-Based CMHC													6
7	Hospice													7
8	Total (Sum of lines 1-7)													8










FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4105.

41-308
														Rev. 1

Sheet 5: S-3II

DRAFT		FORM CMS 2540-10					4190(Cont.)
		PROVIDER NO.:		PERIOD:		WORKSHEET S-3
SNF WAGE INDEX INFORMATION				FROM __________		PARTS II & III
		______________		TO _____________
			Reclass.	Adjusted	Paid Hours	Average
			of Salaries	Salaries	Related	Hourly Wage
PART II DIRECT SALARIES		Amount	from Wkst.	(col. 1 ±	to Salary	(col. 3 ÷
		Reported	A-6	col. 2)	in col. 3	col. 4)
		1	2	3	4	5
1	Total salary (See Instructions)						1
2	Physician salaries-Part A						2
3	Physician salaries-Part B						3
4	Interns & Residents (approved)						4
5	Home office personnel						5
6	Sum of lines 2 thru 5						6
7	Revised wages (line 1 minus line 6)						7
8	Other Long Term Care						8
9	Interns & Residents						9
	(Not In Approved Program)
10	H.H.A.						10
11	CMHC						11
12	Hospice						12
13	Non-reimbursable						13
14	Total Excluded salary						14
	(Sum of lines 8 through 13)
15	Subtotal (line 7 minus line 14)						15
16	Contract Labor: Patient Related & Mgmt						16
17	Home office salaries & wage related costs						17
18	Wage related costs core. (See Part IV)						18
19	Wage related costs other (See Part IV)						19
20	Wage related costs (excluded units)						20
21	Subtotal (see instructions)						21
22	Total (see instructions)						22
23	Contract Labor: Physician services-Part A						23
PART III - OVERHEAD COST - DIRECT SALARIES
			Reclass.	Adjusted	Paid Hours	Average
			of Salaries	Salaries	Related	Hourly Wage
		Amount	from	(col. 1 ±	to Salary	(col. 3 ÷
		Reported	Wkst. A-6	col. 2)	in col. 3	col. 4)
		1	2	3	4	5
1	Employee Benefits						1
2	Administrative & General						2
3	Plant Operation, Maintenance & Repairs						3
4	Laundry & Linen Service						4
5	Housekeeping						5
6	Dietary						6
7	Nursing Administration						7
8	Central Services and Supply						8
9	Pharmacy						9
10	Medical Records & Medical Records Library						10
11	Social Service						11
12	Interns & Records (Apprvd Tching Prog)						12
13	Other General Service (specify)						13
14	Total (sum lines 1 thru 13)						14
FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4105.1 - 4105.2)

Rev. 1							41-309

Sheet 6: S-3IV

4190 (Cont.)		FORM CMS 2540-10				DRAFT
SNF WAGE RELATED COSTS			PROVIDER NO.:	PERIOD:	WORKSHEET
				FROM __________	S-3
			______________	TO _____________	PART IV
PART IV - Wage Related Cost

Part A - Core List


					Amount
					Reported

	RETIREMENT COST
1	401K Employer Contributions					1
2	Tax Sheltered Annuity (TSA) Employer Contribution					2
3	Qualified and Non-Qualified Pension Plan Cost					3
4	Prior Year Pension Service Cost					4
	PLAN ADMINISTRATIVE COSTS (Paid to External Organization):
5	401K/TSA Plan Administration fees					5
6	Legal/Accounting/Management Fees-Pension Plan					6
7	Employee Managed Care Program Administration Fees					7
	HEALTH AND INSURANCE COST
8	Health Insurance (Purchased or Self Funded)					8
9	Prescription Drug Plan					9
10	Dental, Hearing and Vision Plan					10
11	Life Insurance (If employee is owner or beneficiary)					11
12	Accidental Insurance (If employee is owner or beneficiary)					12
13	Disability Insurance (If employee is owner or beneficiary)					13
14	Long-Term Care Insurance (If employee is owner or beneficiary)					14
15	Workers' Compensation Insurance					15
16	Retirement Health Care Cost (Only current year, not the extraordinary					16
	accrual required by FASB 106 Non cumulative portion)
	TAXES
17	FICA-Employers Portion Only					17
18	Medicare Taxes - Employers Portion Only					18
19	Unemployment Insurance					19
20	State or Federal Unemployment Taxes					20
	OTHER
21	Executive Deferred Compensation					21
22	Day Care Cost and Allowances					22
23	Tuition Reimbursement					23
24	Total Wage Related cost (Sum of lines 1 -23)					24

Part B Other than Core Related Cost
25	Other Wage Related Costs (specify)_________________________________________					25


			*D R A F T*






FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4105)

41-308						Rev. 1

Sheet 7: S4

DRAFT			FORM CMS-2540-10						4190 (Cont.)
		PROVIDER NO.:		PERIOD:						{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
S.N.F. -BASED HOME HEALTH AGENCY				FROM ____________			WORKSHEET S-4
STATISTICAL DATA		HHA NO.:		TO _______________				DRAFT

HOME HEALTH AGENCY STATISTICAL DATA
1	County								1
				Title	Title	Title
	DESCRIPTION			V	XVIII	XIX	Other	Total
				1	2	3	4	5
2	Home Health Aide Hours								2
3	Unduplicated Census Count (see instructions)								3
HOME HEALTH AGENCY - NUMBER OF EMPLOYEES
	(FULL TIME EQUIVALENT)			*DRAFT*		Staff	Contract	Total
						1	2	3
4	Enter the number of hours in your normal work week								4
5	Administrator and Assistant Administrator(s)								5
6	Directors and Assistant Director(s)								6
7	Other Administrative Personnel								7
8	Direct Nursing Service								8
9	Nursing Supervisor			*DRAFT*					9
10	Physical Therapy Service								10
11	Physical Therapy Supervisor								11
12	Occupational Therapy Service								12
13	Occupational Therapy Supervisor								13
14	Speech Pathology Service								14
15	Speech Pathology Supervisor								15
16	Medical Social Service								16
17	Medical Social Service Supervisor			*DRAFT*					17
18	Home Health Aide								18
19	Home Health Aide Supervisor								19
20	Other (specify)								20
HOME HEALTH AGENCY CBSA CODES
21	Enter the number of hours in your normal work week								21
22	How many CBSAs in column 1 did you provide services to during this cost reporting period.								22
23	List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code).								23

PPS ACTIVITY DATA - Applicable for Medicare Services Rendered on or after October 1, 2000
				Full Episodes		LUPA	PEP	TOTAL
				Without	With		only
		*DRAFT*		Outliers	Outliers	Episodes	Episodes	(cols. 1-4)
				1	2	3	4	5
24	Skilled Nursing Visits								24
25	Skilled Nursing Visit Charges								25
26	Physical Therapy Visits								26
27	Physical Therapy Visit Charges								27
28	Occupational Therapy Visits								28
29	Occupational Therapy Visit Charges								29
30	Speech Pathology Visits	*DRAFT*							30
31	Speech Pathology Visit Charges								31
32	Medical Social Service Visits								32
33	Medical Social Service Visit Charges								33
34	Home Health Aide Visits								34
35	Home Health Aide Visit Charges								35
36	Total visits (sum of lines 23, 25, 27, 29, 31 and 33)								36
37	Other Charges								37
38	Total Charges (sum of lines 24, 26, 28, 30, 32, 34 and 36)								38
39	Total Number of Episodes (standard/non outlier)								39
40	Total Number of Outlier Episodes								40
41	Total Non-Routine Medical Supply Charges								41
		*DRAFT*
FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4106)
Rev. 1									41-310

Sheet 8: S5

DRAFT						FORM CMS 2540-10										4190 (Cont.)
SNF - BASED RURAL HEALTH CLINIC					PROVIDER NO:				PERIOD:
FEDERALLY QUALIFIED HEALTH					_______________________________				FROM____________________					WORKSHEET
CENTER STATISTICAL DATA					COMPONENT NO:				TO_______________________					S - 5
					________________________
Check applicable box:				[ ] RHC		[ ] FQHC
PART I - STATISTICAL DATA
1	Street:											County:				1
2	City:							State:				Zip Code:				2
3	Designation (for FQHC's only) - Enter "R" for rural or "U" for urban															3
Source of Federal funds:												Grant Award		Date
4	Community Health Center (Section 330(d), PHS Act)															4
5	Migrant Health Center (Section 329(d), PHS Act)															5
6	Health Services for the Homeless (Section 340(d), PHS Act)															6
7	Appalachian Regional Commission															7
8	Look - Alikes															8
9	Other (specify)															9
10	Does the facility operate as other than an RHC or FQHC? If yes, indicate the number of other operations in column 2.													1	2
	(Enter in subscripts of line 10 the type of other operation(s) and the operating hours.)															10
	NOTE: Line 11 (Clinic) is to be completed regardless of the response to line 10.
	Facility hours of operations (1)
		Sunday		Monday		Tuesday		Wednesday		Thursday		Friday		Saturday
		from	to	from	to	from	to	from	to	from	to	from	to	from	to
	0	1	2	3	4	5	6	7	8	9	10	11	12	13	14
11	Clinic															11
	(1) List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.
12	Have you received an approval for an exception to the productivity standard?															12
13	Is this a consolidated cost report in accordance with CMS Pub 27, section 508D. If yes, enter in column 2 the number of															13
	providers included in this report. List the names of all providers and numbers on subscripted lines below.
14	Provider Name									NPI Number						14
15	Have you provided all or substantially all GME cost. If yes, enter in column 2 the number of program visits performed by I&R															15




FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4107)
Rev. 1																41-311

Sheet 9: S6

4190 (Cont.)		FORM CMS 2540-10				DRAFT
			PROVIDER NO.:	PERIOD:
SKILLED NURSING FACILITY BASED				FROM ____________	WORKSHEET S-6
C.M.H.C. STATISTICAL DATA			C.M.H.C. NO.: _______________	TO _______________

	NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
	Employment Category: Enter the number of hours		Staff	Contract	Total
	in your normal work week ( ).		1	2	3
1	Administrator and Assistant Administrators					1
2	Directors and Assistant Directors					2
3	Other Administrative Personnel					3
4	Directing Nursing Service					4
5	Nursing Supervisor					5
6	Physical Therapy Service					6
7	Physical Therapy Supervisor					7
8	Occupational Therapy Service					8
9	Occupational Therapy Supervisor					9
10	Speech Pathology Service					10
11	Speech Pathology Supervisor					11
12	Medical Social Service					12
13	Medical Social Service Supervisor					13
14	Respiratory Therapy Service					14
15	Respiratory Therapy Supervisor					15
16	Psychological Service					16
17	Psychological Service Supervisor					17
18						18
19						19








FORM CMS - 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4108 )
41-312						Rev. 1

Sheet 10: S7a

DRAFT		FORM CMS 2540-10						4190 (Cont.)
PROSPECTIVE PAYMENT		PROVIDER NO.:		PERIOD:		WORKSHEET S-7
FOR SNF				FROM:
STATISTICAL DATA				TO:
	GROUP						Days
	1		*D R A F T*				2
1	RUX							1
2	RUL							2
3	RVX							3
4	RVL							4
5	RHX		*D R A F T*					5
6	RHL							6
7	RMX							7
8	RML							8
9	RLX							9
10	RUC		*D R A F T*					10
11	RUB							11
12	RUA							12
13	RVC							13
14	RVB							14
15	RVA		*D R A F T*					15
16	RHC							16
17	RHB							17
18	RHA							18
19	RMC							19
20	RMB		*D R A F T*					20
21	RMA							21
22	RLB							22
23	RLA							23
24	ES3							24
25	ES2		*D R A F T*					25
26	ES1							26
27	HE2							27
28	HE1							28
29	HD2							29
30	HD1		*D R A F T*					30
31	HC2							31
32	HC1							32
33	HB2							33
34	HB1							34
35	LE2		*D R A F T*					35
36	LE1							36
37	LD2							37
38	LD1							38
39	LC2							39
40	LC1		*D R A F T*					40
41	LB2							41
42	LB1							42
43	CE2							43
44	CE1							44
45	CD2		*D R A F T*					45
46	CD1							46
47	CC2							47
48	CC1							48
49	CB2							49
50	CB1							50

FORM CMS-2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4109)
Rev. 1								41-313
DRAFT		FORM CMS 2540-10						4190 (Cont.)
PROSPECTIVE PAYMENT FOR SNF			PROVIDER NO.:		PERIOD:		WORKSHEET
STATISTICAL DATA					FROM:		S-7
					TO:
	GROUP						Days
	1		*D R A F T*				2
51	CA2							51
52	CA1							52
53	SE3							53
54	SE2							54
55	SE1							55
56	SSC							56
57	SSB							57
58	SSA							58
59	IB2							59
60	IB1							60
61	IA1							61
62	IA2							62
63	BB2							63
64	BB1							64
65	BA2							65
66	BA1							66
67	PE2							67
68	PE1							68
69	PD2							69
70	PD1							70
71	PC2							71
72	PC1							72
73	PB2							73
74	PB1							74
75	PA2							75
76	PA1							76
99	AAA							99
100	Total							100

	Enter in column 1 the expense for each category. Enter in column 2 the percentage of total expense for each
	category to total SNF revenue from Worksheet G-2, Part I, line 6, column 3. Indicate in column 3 "Y" for yes or "N"
	for no if the spending reflects increases associated with direct patient care and related expenses for each category.
	(See instructions)
					Expenses	Percentage	Y/N
					1	2	3
101	Staffing		*D R A F T*					101
102	Recruitment							102
103	Retention of employees							103
104	Training							104
105	Other (Specify)							105

		*DRAFT*


				*DRAFT*


						*DRAFT*


FORM CMS-2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4109)
Rev. 1								41-314

Sheet 11: S8

4190 (Cont.)

FORM CMS-2540-10

DRAFT

PROVIDER NO.:

PERIOD:

HOSPICE IDENTIFICATION DATA

FROM _____________

WORKSHEET S - 8

HOSPICE NO.:

_____________

TO ________________

PART I Enrollment Days Based on Level of Care

Title XVIII

Title XIX

Title XVIII

Title XIX

Unduplicated

Other

Total

Unduplicated

Skilled Nursing

Nursing

Unduplicated

Enrollment Days

Medicare Days

Medicaid Days

Facility Days

Days

Continuous Home Care

Routine Home Care

Inpatient Respite Care

General Inpatient Care

HCFA Software Control:

Total Hospice Days

PART II Census Data

Title XVIII

Title XIX

Skilled

Title XVIII

Title XIX

Nursing facility

Nursing Facility

Other

Total

Number of Patients Receiving Hospice Care

Total Number of Unduplicated Continuous

Care Hours Billable to Medicare

Average Length of Stay

Unduplicated Census Count

DRAFT

FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4110 )

41-315

Rev. 1

Sheet 12: A

DRAFT					FORM CMS 2540-10						4190 (Cont.)
					PROVIDER NO.:		PERIOD:					.
RECLASSIFICATION AND ADJUSTMENT							FROM ________________		WORKSHEET A
OF TRIAL BALANCE OF EXPENSES					_________________		TO ________________
							RECLASSI-	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
							FICATIONS	TRIAL	TO EXPENSES	FOR COST
			COST CENTER	SALARIES	OTHER	TOTAL	Increase/Decrease	BALANCE	Increase/Decrease	ALLOCATION
			(Omit Cents)			( Col 1 + Col 2 )	( Fr Wkst A-6 )	( Col 3 +/- Col 4 )	( Fr Wkst A-8 )	( Col 5 +/- Col 6 )
A	B	C	D	1	2	3	4	5	6	7	A
GENERAL SERVICE COST CENTERS
1	00100	x	Capital-Related Costs - Building & Fixture								1
2	00200	x	Capital-Related Costs - Movable Equipment								2
3	00300	x	Employee Benefits								3
4	00400	x	Administrative and General								4
5	00500	x	Plant Operation, Maintenance and Repairs								5
6	00600	x	Laundry and Linen Service								6
7	00700	x	Housekeeping								7
8	00800	x	Dietary								8
9	00900	x	Nursing Administration								9
10	01000		Central Services and Supply								10
11	01100		Pharmacy								11
12	01200		Medical Records and Library								12
13	01300		Social Service								13
14	01400		Intern & Residents (Apprvd Tchng Prog.)								14
15			Other General Service Cost								15
DIRECT CARE EXPENDITURES				*LINES 16 THROUGH 29 ARE RESERVED FOR FUTURE USE*
INPATIENT ROUTINE SERVICE COST CENTERS
30	03000	x	Skilled Nursing Facility								30
31	03100	x	Nursing Facility								31
32	03200	x	Intermediate Care Facility - Mentally Challenged								32
33		x	Other Long Term Care								33
ANCILLARY SERVICE COST CENTERS
40	04000	x	Radiology								40
41	04100	x	Laboratory								41
42	04200	x	Intravenous Therapy								42
43	04300	x	Oxygen (Inhalation) Therapy								43
44	04400	x	Physical Therapy								44
45	04500	x	Occupational Therapy								45
46	04600	x	Speech Pathology								46
47	04700	x	Electro cardiology								47








FORM CMS-2540-10 ( Draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4113 )
Rev. 1											41-316


4190 (Cont.)					FORM CMS 2540-10						DRAFT
					PROVIDER NO.:		PERIOD:					.
RECLASSIFICATION AND ADJUSTMENT							FROM ________________		WORKSHEET A
OF TRIAL BALANCE OF EXPENSES					_________________		TO ________________
			COST CENTER				RECLASSI-	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
				SALARIES	OTHER	TOTAL	FICATIONS	TRIAL	TO EXPENSES	FOR COST
			(Omit Cents)				Increase/Decrease	BALANCE	Increase /Decrease	ALLOCATION
						( Col 1 + Col 2 )	( Fr Wkst A-6 )	( Col 3 +/- Col 4 )	( Fr Wkst A-8 )	( Col 5 +/- Col 6 )
A	B	C	D	1	2	3	4	5	6	7
48	04800	x	Medical Supplies Charged to Patients								48
49	04900	x	Drugs Charged to Patients								49
50	05000	x	Dental Care - Title XIX only								50
51	05100	x	Support Surfaces								51
52		x	Other Ancillary Service Cost Center								52
OUTPATIENT SERVICE COST CENTERS
60	06000		Clinic								60
61	06100		Rural Health Clinic (RHC)								61
62	6200		FQHC								62
63	6300		Other Outpatient Service Cost								63
OTHER REIMBURSABLE COST CENTERS
70	07000		Home Health Agency Cost								70
71	07100		Ambulance								71
72	07200		Intern and Resident (Not Apprvd Tchng Prog)								72
73	07300		C.M.H.C.								73
74	07400		Other Reimbursable Cost								74
SPECIAL PURPOSE COST CENTERS
80	08000		Malpractice Premiums & Paid Losses							-0-	80
81	08100		Interest Expense							- 0 -	81
82	08200	x	Utilization Review -- SNF							- 0 -	82
83	08300		Hospice								83
84		x	Other Special Purpose Cost								84
NON REIMBURSABLE COST CENTERS
90	09000		Gift, Flower, Coffee Shops and Canteen								90
91	09100	x	Barber and Beauty Shop								91
92	09200		Physicians' Private Offices								92
93	09300		Nonpaid Workers								93
94	09400		Patients Laundry								94
95		x	Other Non Reimbursable Cost								95
100		x	TOTAL								100







FORM CMS-2540-10 ( Draft ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4113 )
41-317											Rev. 1

Sheet 13: A6

DRAFT					FORM CMS 2540-10						4190 (Cont.)
					PROVIDER NO:		PERIOD:
	RECLASSIFICATIONS						FROM _________________________		WORKSHEET A-6
					__________________________________		TO __________________
	EXPLANATION OF	CODE		I N C R E A S E				D E C R E A S E
	RECLASSIFICATION ENTRY	(1)	COST CENTER	LN NO.	SALARY	NON SALARY	COST CENTER	LN NO.	SALARY	NON SALARY
		1	2	3	4	5	6	7	8	9
1											1
2											2
3											3
4											4
5											5
6											6
7											7
8											8
9											9
10											10
11											11
12											12
13											13
14											14
15											15
16											16
17											17
18											18
19											19
20											20
21											21
22											22
23											23
24											24
25											25
26											26
27											27
28											28
29											29
30											30
31											31
32											32
33											33
34											34
35											35
	TOTAL RECLASSIFICATIONS (Sum of column 4 and 5 must
	equal total line - sum of column 8 and 9			(2)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.						(2) Transfer to Worksheet A, column 4, line as appropriate.
FORM CMS-2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4114 )
Rev. 1											41-318

Sheet 14: A7

4190 (Cont.)			FORM CMS-2540-10							DRAFT
					PROVIDER NO.:		PERIOD:		WORKSHEET A-7,
	RECONCILIATION OF CAPITAL COSTS CENTERS						FROM _________		PARTS I, II & III
					_____________		TO __________
PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
					Acquisitions		Disposals		Fully
			Beginning				and	Ending	Depreciated
	Description		Balances	Purchases	Donation	Total	Retirements	Balance	Assets
			1	2	3	4	5	6	7
1	Land									1
2	Land Improvements									2
3	Buildings and Fixtures									3
4	Building Improvements									4
5	Fixed Equipment									5
6	Movable Equipment									6
7	Subtotal (sum of lines 1-6)									7
8	Reconciling Items									8
9	Total (line 6 minus line 8)									9
PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2
7					SUMMARY OF CAPITAL
								Other Capital-	Total (1)
						Insurance	Taxes	Related Costs	(sum of
	Description		Depreciation	Lease	Interest	(see instru.)	(see instru.)	(see instru.)	cols. 9-14)
*			9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)									3
(1)	The amount in columns 9 thru 14 must equal the amount on Worksheet A, column 2, lines 1 and 2. Enter in each column the appropriate amounts including any directly assigned cost
	which may have been included in Worksheet A, column 2, lines 1 and 2.
*	All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers.
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS
			COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL
				Gross Assets					Total
			Capitalized	for Ratio	Ratio			Other Capital-	(sum of
	Description	Gross Assets	Leases	(col. 1 - col. 2)	(see instru.)	Insurance	Taxes	Related Costs	cols. 5-7)
*		1	2	3	4	5	6	7	8
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)				1.000000					3
					SUMMARY OF CAPITAL
								Other Capital-	Total (1)
						Insurance	Taxes	Related Costs	(sum of
	Description		Depreciation	Lease	Interest	(see instru.)	(see instru.)	(see instru.)	cols. 9-14)
*			9	10	11	12	13	14	15
1	Capital Related Costs-Buildings and Fixtures									1
2	Capital Related Costs-Movable Equipment									2
3	Total (sum of lines 1-2)									3
(1) The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2. Columns 9 through 14 should include related
	Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1 related organizations and home office costs. (See instructions.)
FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4015)
41-319										Rev. 1

Sheet 15: A8

DRAFT		FORM CMS 2540-10						4190 (Cont.)
		PROVIDER NO.		PERIOD:
	ADJUSTMENTS TO EXPENSES			FROM ____________		WORKSHEET A-8
		________________		TO _____________
		(2)			EXPENSE CLASSIFICATION ON
	(1)	BASIS FOR			WORKSHEET A - TO / FROM WHICH
	DESCRIPTION	ADJUST-	AMOUNT	SALARY	THE AMOUNT IS TO BE ADJUSTED
		MENT			COST CENTER		LINE NO.
	1	2	3	4	5		6
1	Investment income on restricted funds							1
	(Chapter 2)
2	Trade, quantity and time discounts							2
	on purchases (Chapter 8)
3	Refunds and rebates of expenses							3
	Chapter 8)
4	Rental of provider space by suppliers							4
	Chapter 8)
5	Telephone services (pay stations							5
	excluded) (Chapter 21)
6	Television and radio service							6
	(Chapter 21)
7	Parking lot (chapter 21)							7

8	Remuneration applicable to provider-	Worksheet						8
	based physician adjustment	A-8-2
9	Home office costs (chapter 21)							9

10	Sale of scrap, waste, etc.							10
	(Chapter23)
11	Nonallowable costs related to certain							11
	Capital expenditures (chapter 24)
12	Adjustment resulting from transactions	Worksheet						12
	with related organizations (chapter 10)	A-8-1
13	Laundry and Linen service							13

14	Revenue - Employee meals							14

15	Cost of meals - Guests							15

16	Sale of medical supplies to other than patients							16

17	Sale of drugs to other than patients							17

18	Sale of medical records and abstracts							18

19	Vending machines							19

20	Income from imposition of interest,							20
	finance or penalty charges (chapter 21)
21	Interest expense on Medicare overpayments							21
	and borrowings to repay Medicare overpayments
22	Depreciation--buildings and fixtures				Capital Related Cost- Building		1	22

23	Depreciation--movable equipment				Capital Related Cost-Movable			23
					Equipment		2
24	Other Adjustment							24

100	TOTAL (Sum of lines 1 through 24)							100
	(Transfer to Worksheet A, col. 6, line 100)
(1) Description--all chapter references in this column pertain to CMS Pub. 15-I
(2) Basis for adjustment		A. Costs--if costs, including applicable overhead, can be determined.
		B. Amount Received--if cost cannot be determined.
FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,
SECTION 4116 )
Rev. 1								41-320

Sheet 16: A81

4190 (Cont.)				FORM CMS 2540-10						DRAFT
STATEMENT OF COSTS				PROVIDER NO:		PERIOD:
OF SERVICES FROM						FROM _____________		WORKSHEET A-8-1
RELATED ORGANIZATIONS				___________________		TO ___________
Part I Costs incurred and adjustments required as a result of transactions with related
		organizations. Location and amount included on Worksheet A, Column 5					Amount		Adjustments
							Allowable		(Col 4 minus
	Line No.	Cost Center	Expense Items			Amount	In Cost		Col 5)
	1	2	3			4	5		6
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
100	TOTALS (Sum of lines 1-9)									100
	Transfer column 6, line 100 to Worksheet A-8, column 3, line 12)
Part II Interrelationship to related organization(s):

	The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you
	furnish the information requested under Part II of this worksheet.

	This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable
	to services, facilities and supplies furnished by organizations related to you by common ownership or control, represent reasonable
	costs as determined under section 1861 of the Social Security Act. If you do not provide all or any part of the requested information,
	the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.
					Related Organization(s)
(1)			Percentage				Percentage
Symbol		Name	of		Name		of		Type of
			Ownership				Ownership		Business
	1	2	3			4	5		6
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
(1) Use the following symbols to indicate interrelationship to related organizations:
	A. Individual has financial interest (stockholder, partner, etc.)				E. Individual is director, officer, administrator or key person of provider
	in both related organization and in provider.				and related organization.
	B. Corporation, partnership or other organization has financial				F. Director, officer, administrator or key person of related organization
	interest in provider.				or relative of such person has financial interest in provider.
	C. Provider has financial interest in corporation, partnership,				G. Other (financial or non-financial) specify ______________________
	or other organization.				_____________________________________________________
	D. Director, officer, administrator or key person of provider or
	relative of such person has financial interest in related
	organization.
FORM CMS - 2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II SECTION 4117 )

41-321										Rev. 1

Sheet 17: A82

DRAFT				FORM CMS 2540-10					4139 (CONT.)
				PROVIDER NO:		PERIOD:
PROVIDER-BASED PHYSICIANS ADJUSTMENTS						FROM ______________________		WORKSHEET A-8-2
				________________________		TO _________________
		Cost Center /					Physician /		5 Percent of
	Wkst A	Physician	Total	Professional	Provider	R C E	Provider	Unadjusted	Unadjusted
	Line No.	Identifier	Remuneration	Component	Component	Amount	Component Hours	R C E Limit	R C E Limit
	1	2	3	4	5	6	7	8	9
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
100		TOTAL								100

			Cost of	Provider	Physician	Provider
		Cost Center /	Memberships	Component	Cost of	Component	Adjusted	R C E
	Wkst A	Physician	& Continuing	Share of	Malpractice	Share of	R C E Limit	Disallowance	Adjustment
	Line No.	Identifier	Education	Col 12	Insurance	Column 14
	10	11	12	13	14	15	16	17	18
1										1
2										2
3										3
4										4
5										5
6										6
7										7
8										8
9										9
10										10
11										11
100		TOTAL								100
FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4118 )

Rev. 1										41-322

Sheet 18: B

DRAFT				FORM CMS 2540-10						4190 (Cont.)
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B
				_________________		TO ________________		PART I
				NET EXPENSES	CAP. REL.	CAP. REL.	EMPLOYEE		ADMINIS-
				FOR COST	BUILDINGS	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE
		COST CENTER		ALLOCATION	& FIXTURES	EQUIPMENT		( Sum of	& GENERAL
		(Omit Cents)		Fr. Wkst A, Col 7				Columns 0 - 3 )
				0	1	2	3	3 A	4
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Apprvd Tchng Prog.)									14
15	Other General Service Cost									15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility									30
31	Nursing Facility									31
32	Intermediate Care Facility - Mentally Retarded									32
33	Other Long Term Care									33
ANCILLARY SERVICE COST CENTERS
40	Radiology									40
41	Laboratory									41
42	Intravenous Therapy									42
43	Oxygen (Inhalation) Therapy									43
44	Physical Therapy									44
45	Occupational Therapy									45
46	Speech Pathology									46
47	Electro cardiology									47
48	Medical Supplies Charged to Patients									48
49	Drugs Charged to Patients									49
50	Dental Care - Title XIX only									50
51	Support Surfaces									51
52	Other Ancillary Service Cost Center									52





FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

Rev. 1										41-323
4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B
				_________________		TO ________________		PART I
				NET EXPENSES	CAP. REL.	CAP. REL.	EMPLOYEE		ADMINIS-
				FOR COST	BUILDINGS	MOVABLE	BENEFITS	SUBTOTAL	TRATIVE
		COST CENTER		ALLOCATION	& FIXTURES	EQUIPMENT		( Sum of	& GENERAL
		(Omit Cents)		Fr. Wkst A, Col 7				Columns 0 - 3 )
				0	1	2	3	3 A	4
OUTPATIENT SERVICE COST CENTERS
60	Clinic									60
61	Rural Health Clinic (RHC)									61
62	FQHC									62
63	Other Outpatient Service Cost									63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost									70
71	Ambulance									71
72	Intern and Resident (Not Apprvd Tchng Prog)									72
73	C.M.H.C.									73
74	Other Reimbursable Cost									74
SPECIAL PURPOSE COST CENTERS
83	Hospice									83
84	Other Special Purpose Cost									84
89	Subtotals									89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen									90
91	Barber and Beauty Shop									91
92	Physicians' Private Offices									92
93	Nonpaid Workers									93
94	Patients Laundry									94
95	Other Non Reimbursable Cost									95
98	Cross Foot Adjustments									98
99	Negative Cost Center									99
100	Total									100











FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

41-324										Rev. 1


DRAFT				FORM CMS 2540-10						4190 (Cont.)
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B
				_________________		TO ________________		PART I
			PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
			MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER	& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)
			5	6	7	8	9	10	11
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Apprvd Tchng Prog.)									14
15	Other General Service Cost									15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility									30
31	Nursing Facility									31
32	Intermediate Care Facility - Mentally Retarded									32
33	Other Long Term Care									33
ANCILLARY SERVICE COST CENTERS
40	Radiology									40
41	Laboratory									41
42	Intravenous Therapy									42
43	Oxygen (Inhalation) Therapy									43
44	Physical Therapy									44
45	Occupational Therapy									45
46	Speech Pathology									46
47	Electro cardiology									47
48	Medical Supplies Charged to Patients									48
49	Drugs Charged to Patients									49
50	Dental Care - Title XIX only									50
51	Support Surfaces									51
52	Other Ancillary Service Cost Center									52





FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

Rev. 1										41-325
4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B
				_________________		TO ________________		PART I
			PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
			MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER	& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)
			5	6	7	8	9	10	11
OUTPATIENT SERVICE COST CENTERS
60	Clinic									60
61	Rural Health Clinic (RHC)									61
62	FQHC									62
63	Other Outpatient Service Cost									63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost									70
71	Ambulance									71
72	Intern and Resident (Not Apprvd Tchng Prog)									72
73	C.M.H.C.									73
74	Other Reimbursable Cost									74
SPECIAL PURPOSE COST CENTERS
83	Hospice									83
84	Other Special Purpose Cost									84
89	Subtotals									89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen									90
91	Barber and Beauty Shop									91
92	Physicians' Private Offices									92
93	Nonpaid Workers									93
94	Patients Laundry									94
95	Other Non Reimbursable Cost									95
98	Cross Foot Adjustments									98
99	Negative Cost Center									99
100	Total									100











FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

41-326										Rev. 1


DRAFT				FORM CMS 2540-10						4190 (Cont.)
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B
				_________________		TO ________________		PART I
			MEDICAL	SOCIAL	INTERNS &	OTHER		POST
		COST CENTER	RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEP-DOWN	TOTAL
		(Omit Cents)	& LIBRARY			SERVICE		ADJUSTMENTS
						COST
			12	13	14	15	16	17	18
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Apprvd Tchng Prog.)									14
15	Other General Service Cost									15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility									30
31	Nursing Facility									31
32	Intermediate Care Facility - Mentally Retarded									32
33	Other Long Term Care									33
ANCILLARY SERVICE COST CENTERS
40	Radiology									40
41	Laboratory									41
42	Intravenous Therapy									42
43	Oxygen (Inhalation) Therapy									43
44	Physical Therapy									44
45	Occupational Therapy									45
46	Speech Pathology									46
47	Electro cardiology									47
48	Medical Supplies Charged to Patients									48
49	Drugs Charged to Patients									49
50	Dental Care - Title XIX only									50
51	Support Surfaces									51
52	Other Ancillary Service Cost Center									52





FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

Rev. 1										41-327
4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B
				_________________		TO ________________		PART I
			MEDICAL	SOCIAL	INTERNS &	OTHER		POST
			RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEP-DOWN	TOTAL
		COST CENTER	& LIBRARY			SERVICE		ADJUSTMENTS
		(Omit Cents)				COST
			12	13	14	15	16	17	18
OUTPATIENT SERVICE COST CENTERS
60	Clinic									60
61	Rural Health Clinic (RHC)									61
62	FQHC									62
63	Other Outpatient Service Cost									63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost									70
71	Ambulance									71
72	Intern and Resident (Not Apprvd Tchng Prog)									72
73	C.M.H.C.									73
74	Other Reimbursable Cost									74
SPECIAL PURPOSE COST CENTERS
83	Hospice									83
84	Other Special Purpose Cost									84
89	Subtotals									89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen									90
91	Barber and Beauty Shop									91
92	Physicians' Private Offices									92
93	Nonpaid Workers									93
94	Patients Laundry									94
95	Other Non Reimbursable Cost									95
98	Cross Foot Adjustments									98
99	Negative Cost Center									99
100	Total									100

FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

41-328										Rev. 1

Sheet 19: B-1

DRAFT				FORM CMS 2540-10						4190 (Cont.)
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B - 1
				_________________		TO ________________
					CAP. REL.	CAP. REL.	EMPLOYEE	RECONCIL-	ADMINIS-
					BUILDINGS	MOVABLE	BENEFITS	IATION	TRATIVE
		COST CENTER			& FIXTURES	EQUIPMENT			& GENERAL
		(Omit Cents)			( Square	( Square	(Gross		(Accumulated
					Feet)	Feet)	Salaries)		Cost)
				0	1	2	3	4 A	4
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Apprvd Tchng Prog.)									14
15	Other General Service Cost									15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility									30
31	Nursing Facility									31
32	Intermediate Care Facility - Mentally Retarded									32
33	Other Long Term care									33
ANCILLARY SERVICE COST CENTERS
40	Radiology									40
41	Laboratory									41
42	Intravenous Therapy									42
43	Oxygen (Inhalation) Therapy									43
44	Physical Therapy									44
45	Occupational Therapy									45
46	Speech Pathology									46
47	Electro cardiology									47
48	Medical Supplies Charged to Patients									48
49	Drugs Charged to Patients									49
50	Dental Care - Title XIX only									50
51	Support Surfaces									51
52	Other Ancillary Service Cost Center									52




FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)
Rev. 1										41-329

4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B - 1
				_________________		TO ________________
					CAP. REL.	CAP. REL.	EMPLOYEE		ADMINIS-
					BUILDINGS	MOVABLE	BENEFITS	RECONCIL-	TRATIVE
		COST CENTER			& FIXTURES	EQUIPMENT		IATION	& GENERAL
		(Omit Cents)			( Square	( Square	(Gross		(Accumulated
					Feet)	Feet)	Salaries)		Cost)
				0	1	2	3	4 A	4
OUTPATIENT SERVICE COST CENTERS
60	Clinic									60
61	Rural Health Clinic (RHC)									61
62	FQHC									62
63	Other Outpatient Service Cost									63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost									70
71	Ambulance									71
72	Intern and Resident (Not Apprvd Tchng Prog)									72
73	C.M.H.C.									73
74	Other Reimbursable Cost									74
SPECIAL PURPOSE COST CENTERS
83	Hospice									83
84	Other Special Purpose Cost									84
89	Subtotals									89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen									90
91	Barber and Beauty Shop									91
92	Physicians' Private Offices									92
93	Nonpaid Workers									93
94	Patients Laundry									94
95	Other Non Reimbursable Cost									95
98	Cross Foot Adjustment									98
99	Negative Cost Center									99
102	Cost to Be Allocated (Per Worksheet B, Part I)									102
103	Unit Cost Multiplier (Worksheet B, Part I)									103
104	Cost to Be Allocated (Per Worksheet B, Part II)									104
105	Unit Cost Multiplier (Worksheet B, Part II)									105








FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)
41-330										Rev. 1



DRAFT				FORM CMS 2540-10						4190 (Cont.)
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B - 1
				_________________		TO ________________
			PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
			MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER	& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)	(Square	(Pounds of	(Hours of	(Meals	(Direct	(Costed	(Costed
			Feet)	Laundry)	Service)	Served)	Nrsing Hrs.)	Requisitions)	Requisitions)
			5	6	7	8	9	10	11
GENERAL SERVICE COST CENTERS
1	Captial-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Apprvd Tchng Prog.)									14
15	Other General Service Cost									15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility									30
31	Nursing Facility									31
32	Intermediate Care Facility - Mentally Retarded									32
33	Other Long Term care									33
ANCILLARY SERVICE COST CENTERS
40	Radiology									40
41	Laboratory									41
42	Intravenous Therapy									42
43	Oxygen (Inhalation) Therapy									43
44	Physical Therapy									44
45	Occupational Therapy									45
46	Speech Pathology									46
47	Electro cardiology									47
48	Medical Supplies Charged to Patients									48
49	Drugs Charged to Patients									49
50	Dental Care - Title XIX only									50
51	Support Surfaces									51
52	Other Ancillary Service Cost Center									52





FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)
Rev. 1										41-331

4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B - 1
				_________________		TO ________________
			PLANT OPER.	LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
			MAINTENANCE	& LINEN	KEEPING		ADMINIS-	SERVICES
		COST CENTER	& REPAIRS	SERVICE			TRATION	& SUPPLY
		(Omit Cents)	(Square	(Pounds of	(Hours of	(Meals	(Direct	(Costed	(Costed
			Feet)	Laundry)	Service)	Served)	Nrsing Hrs.)	Requisitions)	Requisitions)
			5	6	7	8	9	10	11
OUTPATIENT SERVICE COST CENTERS
60	Clinic									60
61	Rural Health Clinic (RHC)									61
62	FQHC									62
63	Other Outpatient Service Cost									63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost									70
71	Ambulance									71
72	Intern and Resident (Not Apprvd Tchng Prog)									72
73	C.M.H.C.									73
74	Other Reimbursable Cost									74
SPECIAL PURPOSE COST CENTERS
83	Hospice									83
84	Other Special Purpose Cost									84
89	Subtotals									89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen									90
91	Barber and Beauty Shop									91
92	Physicians' Private Offices									92
93	Nonpaid Workers									93
94	Patients Laundry									94
95	Other Non Reimbursable Cost									95
98	Cross Foot Adjustment									98
99	Negative Cost Center									99
102	Cost to Be Allocated (Per Worksheet B, Part I)									102
103	Unit Cost Multiplier (Worksheet B, Part I)									103
104	Cost to Be Allocated (Per Worksheet B, Part II)									104
105	Unit Cost Multiplier (Worksheet B, Part II)									105








FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)
41-332										Rev. 1



DRAFT				FORM CMS 2540-10						4190 (Cont.)
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B - 1
				_________________		TO ________________
			MEDICAL	SOCIAL	INTERNS &	OTHER		POST
		COST CENTER	RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEP-DOWN	TOTAL
		(Omit Cents)	& LIBRARY			SERVICE		ADJUSTMENTS
			(Time	(Time	(Assigned	COST
			Spent)	Spent)	Time)
			12	13	14	15	16	17	18
GENERAL SERVICE COST CENTERS
1	Captial-Related Costs - Building & Fixture									1
2	Capital-Related Costs - Movable Equipment									2
3	Employee Benefits									3
4	Administrative and General									4
5	Plant Operation, Maintenance and Repairs									5
6	Laundry and Linen Service									6
7	Housekeeping									7
8	Dietary									8
9	Nursing Administration									9
10	Central Services and Supply									10
11	Pharmacy									11
12	Medical Records and Library									12
13	Social Service									13
14	Intern & Residents (Apprvd Tchng Prog.)									14
15	Other General Service Cost									15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility									30
31	Nursing Facility									31
32	Intermediate Care Facility - Mentally Retarded									32
33	Other Long Term care									33
ANCILLARY SERVICE COST CENTERS
40	Radiology									40
41	Laboratory									41
42	Intravenous Therapy									42
43	Oxygen (Inhalation) Therapy									43
44	Physical Therapy									44
45	Occupational Therapy									45
46	Speech Pathology									46
47	Electro cardiology									47
48	Medical Supplies Charged to Patients									48
49	Drugs Charged to Patients									49
50	Dental Care - Title XIX only									50
51	Support Surfaces									51
52	Other Ancillary Service Cost Center									52


FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)

Rev. 1										41-333

4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO.:		PERIOD:
COST ALLOCATION - GENERAL SERVICE COSTS						FROM ________________		WORKSHEET B - 1
				_________________		TO ________________
			MEDICAL	SOCIAL	INTERNS &	OTHER		POST
			RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEP-DOWN	TOTAL
		COST CENTER	& LIBRARY			SERVICE		ADJUSTMENTS
		(Omit Cents)	(Time	(Time	(Assigned	COST
			Spent)	Spent)	Time)
			12	13	14	15	16	17	18
OUTPATIENT SERVICE COST CENTERS
60	Clinic									60
61	Rural Health Clinic (RHC)									61
62	FQHC									62
63	Other Outpatient Service Cost									63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost									70
71	Ambulance									71
72	Intern and Resident (Not Apprvd Tchng Prog)									72
73	C.M.H.C.									73
74	Other Reimbursable Cost									74
SPECIAL PURPOSE COST CENTERS
83	Hospice									83
84	Other Special Purpose Cost									84
89	Subtotals									89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen									90
91	Barber and Beauty Shop									91
92	Physicians' Private Offices									92
93	Nonpaid Workers									93
94	Patients Laundry									94
95	Other Non Reimbursable Cost									95
98	Cross Foot Adjustment									98
99	Negative Cost Center									99
102	Cost to Be Allocated (Per Worksheet B, Part I)									102
103	Unit Cost Multiplier (Worksheet B, Part I)									103
104	Cost to Be Allocated (Per Worksheet B, Part II)									104
105	Unit Cost Multiplier (Worksheet B, Part II)									105





FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)
41-334										Rev. 1

Sheet 20: B-II

DRAFT			FORM CMS 2540-10						4190 (Cont.)
			PROVIDER NO.:		PERIOD:					.
	ALLOCATION OF CAPITAL - RELATED COSTS				FROM ________________		WORKSHEET B
			_________________		TO ________________		PART II
		DIRECTLY	CAP. REL.	CAP. REL.		EMPLOYEE	ADMINIS-	PLANT OPER.
		ASSIGNED	BUILDINGS	MOVABLE	SUBTOTAL	BENEFITS	TRATIVE	MAINTENANCE
	COST CENTER	CAPITAL	& FIXTURES	EQUIPMENT			& GENERAL	& REPAIRS
	(Omit Cents)	RELATED COSTS
		0	1	2	2 A	3	4	5
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture								1
2	Capital-Related Costs - Movable Equipment								2
3	Employee Benefits								3
4	Administrative and General								4
5	Plant Operation, Maintenance and Repairs								5
6	Laundry and Linen Service								6
7	Housekeeping								7
8	Dietary								8
9	Nursing Administration								9
10	Central Services and Supply								10
11	Pharmacy								11
12	Medical Records and Library								12
13	Social Service								13
14	Intern & Residents (Apprvd Tchng Prog.)								14
15	Other General Service Cost								15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility								30
31	Nursing Facility								31
32	Intermediate Care Facility - Mentally Retarded								32
33	Other Long Term care								33
ANCILLARY SERVICE COST CENTERS
40	Radiology								40
41	Laboratory								41
42	Intravenous Therapy								42
43	Oxygen (Inhalation) Therapy								43
44	Physical Therapy								44
45	Occupational Therapy								45
46	Speech Pathology								46
47	Electro cardiology								47
48	Medical Supplies Charged to Patients								48
49	Drugs Charged to Patients								49
50	Dental Care - Title XIX only								50
51	Support Surfaces								51
52	Other Ancillary Service Cost Center								52





FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )

Rev. 1									41-335

4190 (Cont.)			FORM CMS 2540-10						DRAFT
			PROVIDER NO.:		PERIOD:					.
	ALLOCATION OF CAPITAL - RELATED COSTS				FROM ________________		WORKSHEET B
			_________________		TO ________________		PART II
		DIRECTLY	CAP. REL.	CAP. REL.		EMPLOYEE	ADMINIS-	PLANT OPER.
		ASSIGNED	BUILDINGS	MOVABLE	SUBTOTAL	BENEFITS	TRATIVE	MAINTENANCE
	COST CENTER	CAPITAL	& FIXTURES	EQUIPMENT			& GENERAL	& REPAIRS
	(Omit Cents)	RELATED COSTS
		0	1	2	2 A	3	4	5
OUTPATIENT SERVICE COST CENTERS
60	Clinic								60
61	Rural Health Clinic (RHC)								61
62	FQHC								62
63	Other Outpatient Service Cost								63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost								70
71	Ambulance								71
72	Intern and Resident (Not Apprvd Tchng Prog)								72
73	C.M.H.C.								73
74	Other Reimbursable Cost								74
SPECIAL PURPOSE COST CENTERS
83	Hospice								83
84	Other Special Purpose Cost								84
89	Subtotals								89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen								90
91	Barber and Beauty Shop								91
92	Physicians' Private Offices								92
93	Nonpaid Workers								93
94	Patients Laundry								94
95	Other Non Reimbursable Cost								95
98	Cross Foot Adjustments								98
99	Negative Cost Center								99
100	Total								100












FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )

41-336									Rev. 1

DRAFT			FORM CMS 2540-10						4190 (Cont.)
			PROVIDER NO.:		PERIOD:					.
	ALLOCATION OF CAPITAL - RELATED COSTS				FROM ________________		WORKSHEET B
			_________________		TO ________________		PART II
			LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
			& LINEN	KEEPING		ADMINIS-	SERVICES
	COST CENTER		SERVICE			TRATION	& SUPPLY
	(Omit Cents)
			6	7	8	9	10	11
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture								1
2	Capital-Related Costs - Movable Equipment								2
3	Employee Benefits								3
4	Administrative and General								4
5	Plant Operation, Maintenance and Repairs								5
6	Laundry and Linen Service								6
7	Housekeeping								7
8	Dietary								8
9	Nursing Administration								9
10	Central Services and Supply								10
11	Pharmacy								11
12	Medical Records and Library								12
13	Social Service								13
14	Intern & Residents (Apprvd Tchng Prog.)								14
15	Other General Service Cost								15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility								30
31	Nursing Facility								31
32	Intermediate Care Facility - Mentally Retarded								32
33	Other Long Term care								33
ANCILLARY SERVICE COST CENTERS
40	Radiology								40
41	Laboratory								41
42	Intravenous Therapy								42
43	Oxygen (Inhalation) Therapy								43
44	Physical Therapy								44
45	Occupational Therapy								45
46	Speech Pathology								46
47	Electro cardiology								47
48	Medical Supplies Charged to Patients								48
49	Drugs Charged to Patients								49
50	Dental Care - Title XIX only								50
51	Support Surfaces								51
52	Other Ancillary Service Cost Center								52




FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )

Rev. 1									35-337

4190 (Cont.)			FORM CMS 2540-10						DRAFT
			PROVIDER NO.:		PERIOD:
	ALLOCATION OF CAPITAL - RELATED COSTS				FROM ________________		WORKSHEET B
			_________________		TO ________________		PART II
			LAUNDRY	HOUSE	DIETARY	NURSING	CENTRAL	PHARMACY
			& LINEN	KEEPING		ADMINIS-	SERVICES
	COST CENTER		SERVICE			TRATION	& SUPPLY
	(Omit Cents)
			6	7	8	9	10	11
OUTPATIENT SERVICE COST CENTERS
60	Clinic								60
61	Rural Health Clinic (RHC)								61
62	FQHC								62
63	Other Outpatient Service Cost								63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost								70
71	Ambulance								71
72	Intern and Resident (Not Apprvd Tchng Prog)								72
73	C.M.H.C.								73
74	Other Reimbursable Cost								74
SPECIAL PURPOSE COST CENTERS
83	Hospice								83
84	Other Special Purpose Cost								84
89	Subtotals								89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen								90
91	Barber and Beauty Shop								91
92	Physicians' Private Offices								92
93	Nonpaid Workers								93
94	Patients Laundry								94
95	Other Non Reimbursable Cost								95
98	Cross Foot Adjustments								98
99	Negative Cost Center								99
100	Total								100












FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )

35-338									Rev. 1

DRAFT			FORM CMS 2540-10						4190 (Cont.)
			PROVIDER NO.:		PERIOD:
	ALLOCATION OF CAPITAL - RELATED COSTS				FROM ________________		WORKSHEET B
			_________________		TO ________________		PART II
		MEDICAL	SOCIAL	INTERNS &	OTHER		POST
	COST CENTER	RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEP-DOWN	TOTAL
	(Omit Cents)	& LIBRARY			SERVICE		ADJUSTMENTS
					COST
		12	13	14	15	16	17	18
GENERAL SERVICE COST CENTERS
1	Capital-Related Costs - Building & Fixture								1
2	Capital-Related Costs - Movable Equipment								2
3	Employee Benefits								3
4	Administrative and General								4
5	Plant Operation, Maintenance and Repairs								5
6	Laundry and Linen Service								6
7	Housekeeping								7
8	Dietary								8
9	Nursing Administration								9
10	Central Services and Supply								10
11	Pharmacy								11
12	Medical Records and Library								12
13	Social Service								13
14	Intern & Residents (Apprvd Tchng Prog.)								14
15	Other General Service Cost								15
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility								30
31	Nursing Facility								31
32	Intermediate Care Facility - Mentally Retarded								32
33	Other Long Term care								33
ANCILLARY SERVICE COST CENTERS
40	Radiology								40
41	Laboratory								41
42	Intravenous Therapy								42
43	Oxygen (Inhalation) Therapy								43
44	Physical Therapy								44
45	Occupational Therapy								45
46	Speech Pathology								46
47	Electro cardiology								47
48	Medical Supplies Charged to Patients								48
49	Drugs Charged to Patients								49
50	Dental Care - Title XIX only								50
51	Support Surfaces								51
52	Other Ancillary Service Cost Center								52

FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )




Rev. 1									35-339
4190 (Cont.)			FORM CMS 2540-10						DRAFT
			PROVIDER NO.:		PERIOD:
	ALLOCATION OF CAPITAL - RELATED COSTS				FROM ________________		WORKSHEET B
			_________________		TO ________________		PART II
		MEDICAL	SOCIAL	INTERNS &	OTHER		POST
		RECORDS	SERVICE	RESIDENTS	GENERAL	SUBTOTAL	STEP-DOWN	TOTAL
	COST CENTER	& LIBRARY			SERVICE		ADJUSTMENTS
	(Omit Cents)				COST
		12	13	14	15	16	17	18
OUTPATIENT SERVICE COST CENTERS
60	Clinic								60
61	Rural Health Clinic (RHC)								61
62	FQHC								62
63	Other Outpatient Service Cost								63
OTHER REIMBURSABLE COST CENTERS
70	Home Health Agency Cost								70
71	Ambulance								71
72	Intern and Resident (Not Apprvd Tchng Prog)								72
73	C.M.H.C.								73
74	Other Reimbursable Cost								74
SPECIAL PURPOSE COST CENTERS
83	Hospice								83
84	Other Special Purpose Cost								84
89	Subtotals								89
NON REIMBURSABLE COST CENTERS
90	Gift, Flower, Coffee Shops and Canteen								90
91	Barber and Beauty Shop								91
92	Physicians' Private Offices								92
93	Nonpaid Workers								93
94	Patients Laundry								94
95	Other Non Reimbursable Cost								95
98	Cross Foot Adjustments								98
99	Negative Cost Center								99
100	Total								100





1

41-340									Rev. 1

Sheet 21: B-III

DRAFT		FORM CMS 2540-10						4190 (Cont.)
COST ALLOCATION -		PROVIDER NO.:		PERIOD:					.
GENERAL SERVICE COSTS FOR SNFS WITH				FROM ________________		WORKSHEET B
LESS THAN 1500 MEDICARE INPATIENT DAYS		_________________		TO ________________		PART III
					LAUNDRY &
		NET EXPENSES	CAP-REL COSTS	EMPLOYEE	LINEN SERV.	ADMIN	TOTAL
	COST CENTER	FOR COST	PLANT OPER.	BENEFITS	DIETARY,	& GENERAL	COSTS
	(Omit Cents)	ALLOCATION	MAINT & REPAIR		NURSING
		(Fr. Wkst A, Col 7)	HOUSEKEEPING		ADMIN.
		0	1	2	3	4	5
GENERAL SERVICE COST CENTERS
29	Total							29
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility							30
31	Nursing Facility							31
32	Intermediate Care Facility - Mentally Retarded							32
33	Other Long Term Care							33
ANCILLARY SERVICE COST CENTERS
40	Radiology							40
41	Laboratory							41
42	Intravenous Therapy							42
43	Oxygen (Inhalation) Therapy							43
44	Physical Therapy							44
45	Occupational Therapy							45
46	Speech Pathology							46
47	Electro cardiology							47
48	Medical Supplies Charged to Patients							48
49	Drugs Charged to Patients							49
50	Dental Care - Title XIX only							50
51	Support Surfaces							51
52	Other Ancillary Service Cost Center							52
56								56
NON REIMBURSABLE COST CENTERS
91	Barber and Beauty Shop							91
95	All Other Non Reimbursable Cost							95
100	Total							100
FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)

41-341								Rev. 1

Sheet 22: B-1-2

4190 (Cont.)		FORM CMS 2540-10						DRAFT
COST ALLOCATION -		PROVIDER NO.:		PERIOD:					.
STATISTICAL BASIS FOR SNFS WITH				FROM ________________		WORKSHEET B - 1
LESS THAN 1500 MEDICARE INPATIENT DAYS		_________________		TO ________________		PART II
			CAPITAL RELATED		LAUNDRY, DIET
			COSTS		NURSE ADMIN.	ADMIN
	COST CENTER		PLANT OPERATION		CENTRAL SUPPLY	& GENERAL
	(Omit Cents)		MAINTENANCE &	EMPLOYEE	PHARM / MEDICAL
			REPAIR	BENEFITS	RECORDS / SOCIAL	(Accumulated
			HOUSEKEEPING		SERVICES	Costs)
			(Square Feet)	(Gross Salaries)	(Patient Days)
		0	1	2	3	4	5
INPATIENT ROUTINE SERVICE COST CENTERS
30	Skilled Nursing Facility							30
31	Nursing Facility							31
32	Intermediate Care Facility - Mentally Retarded							32
33	Other Long Term Care							33
ANCILLARY SERVICE COST CENTERS
40	Radiology							21
41	Laboratory							22
42	Intravenous Therapy							23
43	Oxygen (Inhalation) Therapy							24
44	Physical Therapy							25
45	Occupational Therapy							26
46	Speech Pathology							27
47	Electro cardiology							28
48	Medical Supplies Charged to Patients							29
49	Drugs Charged to Patients							30
50	Dental Care - Title XIX only							31
51	Support Surfaces							32
52	Other Ancillary Service Cost							33
56								56
NON REIMBURSABLE COST CENTERS
91	Barber and Beauty Shop							91
95	All Other Non Reimbursable Cost							95
100	Total General Services Costs							100
107	Total Statistics							107
108	Unit Cost Multipliers (Line 100 divided by line 107)							108


FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)

41-342								Rev. 1

									.











































									.

Sheet 23: B-2

DRAFT		FORM CMS 2540-10				4190 ( Cont.)
		PROVIDER NO.:	PERIOD				.
POST STEP DOWN ADJUSTMENTS			FROM_______________		WORKSHEET B-2
		____________________	TO____________
			WORKSHEET B -
	DESCRIPTION		PART NO.	LINE NO.	AMOUNT
	1		2	3	4
1						1
2						2
3						3
4						4
5						5
6						6
7						7
8						8
9						9
10						10
11						11
12						12
13						13
14						14
15						15
16						16
17						17
18						18
19						19
20						20
21						21
22						22
23						23
24						24
25						25
26						26
27						27
28						28
29						29
30						30
31						31
32						32
33						33
34						34
35						35
36						36
37						37
38						38
39						39
40						40
41						41
42						42
43						43
44						44
45						45
46						46
47						47
48						48
49						49
50						50
FORM CMS 2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II SECTION 4122 )



Rev. 1						41-343

Sheet 24: C

4190 ( Cont.)		FORM CMS 2540-10			DRAFT
RATIO OF COST TO CHARGES		PROVIDER NO. :	PERIOD :
FOR ANCILLARY AND OUTPATIENT			FROM _________________	WORKSHEET C
COST CENTERS		______________________	TO ___________




		TOTAL	Total	Ratio
	Cost Center	(From Wkst B,	Charges	(col. 1 divided
		Pt. I, Col. 18)		by col. 2)
		1	2	3
ANCILLARY SERVICE COST CENTERS
40	Radiology				40
41	Laboratory				41
42	Intravenous Therapy				42
43	Oxygen ( Inhalation ) Therapy				43
44	Physical Therapy				44
45	Occupational Therapy				45
46	Speech Pathology				46
47	Electro cardiology				47
48	Medical Supplies Charged				48
49	Drugs Charged to Patients				49
50	Dental Care - Title XIX only				50
51	Support Surfaces				51
52	Other Ancillary Service Cost				52
OUTPATIENT SERVICE COST CENTERS
60	Clinic				60
61	R H C				61
62	FQHC				62
63	Other Outpatient Service Cost				63
71	Ambulance				71
100	Total				100



















FORM CMS-2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15 II, SECTION 4123 )

41-344					Rev. 1

Sheet 25: D

DRAFT

FORM CMS 2540-10

4190 (Cont.)

APPORTIONMENT OF ANCILLARY AND

PROVIDER NO. :

PERIOD :

WORKSHEET D

OUTPATIENT COST AND REDUCTION

FROM ______________

PART I

OF THERAPY COST

______________________

TO ________________

PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST

Check

[ ] Title V

( 1 )

Check One:

[ ] SNF

[ ] NF

[ ] ICF/MR

[ ] Other __________________

One:

[ ] Title XVIII

[ ] PPS - Must also complete Part II

[ ] Title XIX

( 1 )

RATIO OF

HEALTH CARE

COST TO

PROGRAM CHARGES

PROGRAM COST

Cost Center

CHARGES

( Fr. Wkst. C

Part A

Part B

Part A

Part B

Column 3 )

(Col. 1 X Col. 2)

(Col. 1 X Col. 3)

ANCILLARY SERVICE COST CENTERS

Radiology

Laboratory

Intravenous Therapy

Oxygen ( Inhalation )

Therapy

Physical Therapy

Occupational Therapy

Speech Pathology

Electro cardiology

Medical Supplies

Charged To Patients

Drugs Charged to Patients

Dental Care - Title XIX

Support Surfaces

Other Ancillary Services

OUTPATIENT COST CENTERS

Clinic

R H C

FQHC

Other Outpatient Services

Ambulance (2)

100

Total (Sum of lines 40 - 71)

100

( 1 ) For titles V and XIX use columns 1, 2 and 4 only.

( 2 ) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.

FORM CMS- 2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 4124)

Rev. 1

41-345

Sheet 26: DII

4190 (Cont.)				FORM CMS 2540-10					DRAFT
APPORTIONMENT OF ANCILLARY AND				PROVIDER NO. :		PERIOD :		WORKSHEET D
OUTPATIENT COST AND REDUCTION OF						FROM ______________		PARTS II & III
THERAPY COST FOR TITLE XVIII				______________________		TO ________________
Check One:		[ ]	SNF	[ ]	NF	[ ]	ICF/MR

PART II - APPORTIONMENT OF VACCINE COST

1	Drugs charged to patients - ratio of cost to charges ( From Worksheet C, column 3, line 49)								1
2	Program vaccine charges ( From your records, or the P S & R.)								2
3	Program costs ( Line 1 X line 2) ( Title XVIII, PPS providers,								3
	transfer this amount to Worksheet E, Part I, line 23)

PART III - CALCULATION OF PASS THROUGH COSTS FOR INTERNS & RESIDENTS

				Total Cost	Intern and	Ratio of	Program	Program
				(From	Residents Costs	Intern & Residents	Part A Cost	Intern & Residents
	Cost Centers			Worksheet B,	(From Wkst. B,	Costs To Total	(From Wkst. D.	Costs for
				Part I, Col 18)	Part I, Column 14)	Costs - Part A	Part 1, Col. 4)	Pass Through
						(Col. 2 / Col.. 1)		(Col. 3 X Col. 4)
				1	2	3	4	5
ANCILLARY SERVICE COST CENTERS
40	Radiology								40
41	Laboratory								41
42	Intravenous Therapy								42
43	Oxygen ( Inhalation ) Therapy								43
44	Physical Therapy								44
45	Occupational Therapy								45
46	Speech Pathology								46
47	Electro cardiology								47
48	Medical Supplies								48
49	Drugs Charged to Patients								49
50	Dental Care - Title XIX only								50
51	Support Surfaces								51
52	Other Ancillary Service Costs								52
100	Total ( Sum of lines 40 - 52)								100





FORM CMS- 2540-10( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 4124)
41-346									Rev. 1

Sheet 27: D-1

DRAFT			FORM CMS 2540-10			4190 (Cont.)
			PROVIDER NO. :	PERIOD :
COMPUTATION OF INPATIENT				FROM ______________	WORKSHEET D-1
ROUTINE COSTS			______________________	TO ____________	PARTS I & II
Check One:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
Check One:		[ ] SNF	[ ] NF	[ ] ICF/MR
PART I CALCULATION OF INPATIENT ROUTINE COSTS

	INPATIENT DAYS
1	Inpatient days including private room days					1
2	Private room days					2
3	Inpatient days including private room days applicable to the Program					3
4	Medically necessary private room days applicable to the Program					4
5	Total general inpatient routine service cost					5
	PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
6	General inpatient routine service charges					6
7	General inpatient routine service cost/charge ratio (Line 5 divided by line 6)					7
8	Enter private room charges from your records					8
9	Average private room per diem charge (Private room charges					9
	line 8 divided by private room days, line 2)
10	Enter semi-private room charges from your records					10
11	Average semi-private room per diem charge (Semi-private room charges					11
	line 10, divided by semi-private room days)
12	Average per diem private room charge differential ( Line 9 minus line 11 )					12
13	Average per diem private room cost differential ( Line 7 times line 12 )					13
14	Private room cost differential adjustment ( Line 2 times line 13 )					14
15	General inpatient routine service cost net of private room cost differential					15
	( Line 5 minus line 14 )
	PROGRAM INPATIENT ROUTINE SERVICE COSTS
16	Adjusted general inpatient service cost per diem					16
	( Line 15 divided by line 1 )
17	Program routine service cost ( Line 3 times line 16 )					17
18	Medically necessary private room cost applicable to program ( line 4 times line 13 )					18
19	Total program general inpatient routine service cost ( Line 17 plus line 18 )					19
20	Capital related cost allocated to inpatient routine service costs ( From Wkst. B,					20
	Part II column 18, - line 30 for SNF; line 31 for NF,or line 32 for ICF/MR )
21	Per diem capital related costs ( Line 20 divided by line 1 )					21
22	Program capital related cost ( Line 3 times line 21 )					22
23	Inpatient routine service cost ( Line 19 minus line 22 )					23
24	Aggregate charges to beneficiaries for excess costs ( From provider records )					24
25	Total program routine service costs for comparison to the cost limitation					25
	( Line 23 minus line 24 )
26	Enter the per diem limitation (1)					26
27	Inpatientroutine service cost limitation (Line 3 times the per diem limitation line 26) (1)					27
28	Reimbursable inpatient routine service costs ( Line 22 plus the lesser of line 25 or line 27 )					28
	( Transfer to Worksheet E, Part II, line 4) ( See instructions )
	(1) Lines 26 and 27 are not applicable for title XVIII, but may be used for title V and or title XIX

PART II CALCULATION OF INPATIENT INTERN AND RESIDENTS COST FOR PPS PASS-THROUGH
1	Total inpatient days					1
2	Program inpatient days. ( From Worksheet S-3, Part I, cols. 3, or 5, line 1 as applicable)					2
3	Total intern and residence cost. ( From Worksheet B, Part I, column 14, line 14)					3
4	Intern and residents ratio. ( Line 2 divided by line 1)					4
5	Program Intern and resident cost for pass-through. (Line 3 times line 4)					5
FORM CMS-2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4125 )

Rev. 1						41-347

Sheet 28: D-2

4190 (Cont.)

FORM CMS 2540-10

DRAFT

PROVIDER NO.:

PERIOD

APPORTIONMENT OF COST OF SERVICES

FROM_____________

WORKSHEET D-2

RENDERED BY INTERNS AND RESIDENTS

__________________

TO _______________

Percent of

Total

Average Cost

Health Care Program Inpatient Days

Health Care program inpatient cost

Assigned

Expense

Inpatient Days

Per Day

Title V

Title XVIII

Title XIX

Title V

Title XVIII

Title XIX

Cost Centers

Time

All Patients

(Col. 2 ÷ 3)

Part B

Total cost of services rendered

100.00

SNF Inpatient Routine Services:

SNF

Nursing Facility

ICF/MR

Home Health Agency

Other Long Term Care

C M H C

Ambulatory Surgical Center

Hospice

Other Inpatient Routine Service Costs

Subtotal (Sum of lines 2 through 10)

Total Charges

Ratio of

Titles V and XIX Outpatient and

SNF Outpatient Services:

(From Wkst. C.

Cost to Charges

Title XVIII, Part B Charges

Title XVIII, Part B Costs

Col. 2, lines

(Col. 2 ÷

Title V

Title XVIII

Title XIX

Title V

Title XVIII

Title XIX

60 & 61)

by Col. 3)

Part B

Clinic

R H C

FQHC

Subtotal (Sum of lines 12 - 14)

Total (Sum of lines 11 and 15)

100.00

Exp. allocated

Total

Average

Title XVIII

Expenses

Enter the amounts from

Total title

to cost centers

Inpatient

Cost

Part B

Applicable

Column 9,

XVIII Costs

on Wkst. B,

Days

Per Day

Inpatient

To Title XVIII

lines as indicated

(Sum of

Part I Col. 14

All Patients

(Col. 1 ÷ Col. 2)

Days

(Col. 4 X Col. 3)

Cols 5 + 7 )

SNF with an approved teaching program

(Title XVIII, Part B Inpatient Routine Costs Only)

FORM CMS 2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 4126 )

41-348

Rev. 1

Sheet 29: E-I

DRAFT		FORM CMS 2540-10			4190 ( Cont.)
	CALCULATION OF	PROVIDER NO.:	PERIOD:			.	.
	REIMBURSEMENT SETTLEMENT		FROM _____________	WORKSHEET E
	TITLE XVIII	_________________	TO ______________	PART I

PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES
1	Inpatient ancillary services - Part A - ( See Instructions )				1
2	Interns & Residents and Medical Education cost for Title XVIII ( See Instructions )				2
3	Total cost ( Sum of lines 1 and 2)				3
4	Medicare inpatient ancillary charges (see instructions)				4
5	Intern and Resident Charges ( From Provider Records)				5
6	Cost of covered services (lesser of line 3, or the sum of lines 4 and 5)				6
7	Inpatient PPS amount (see instructions)				7
8	Primary payor amounts				8
9	Coinsurance				9
10	Reimbursable bad debts (From your records)				10
11	Reimbursable bad debts for dual eligible beneficiaries (See instructions)				11
12	Adjusted reimbursable bad debts for periods ending on and after 10/01/2005 (See instructions)				12
13	Recovery of bad debts - for statistical records only				13
14	Utilization review				14
15	Recovery of excess depreciation resulting from provider termination or a decrease in Program utilization.				15
16	Amounts applicable to prior cost reporting periods resulting from disposition of assets.				16
	(If minus, enter amount in brackets)
17	Subtotal (See instructions)				17
18	Interim payments (See instructions)				18
19	Tentative adjustment				19
20	OTHER adjustment (See instructions)				20
21	Balance due provider/program (Line 17 minus line 18) (Indicate overpayments in brackets) ( See Instructions)				21
22	Protested amounts (Nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2)				22

PART B - ANCILLARY SERVICES COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY
23	Ancillary services Part B				23
24	Vaccine cost (From Wkst D, Part II, line 3)				24
25	Intern and Resident Cost ( From Worksheet D-2)				25
26	Total reasonable costs (Sum of lines 23, 24, and 25)				26
27	Medicare Part B ancillary charges (See instructions)				27
28	Intern and Resident Charges ( From Provider Records )				28
29	Cost of covered services (Lesser of line 26, or sum of lines 27 and 28)				29
30	Primary payor amounts				30
31	Coinsurance and deductibles				31
32	Reimbursable bad debts (From your records)				32
33	Recovery of excess depreciation resulting from provider termination or a decrease in Program utilization.				33
34	Other Adjustments (See instructions) Specify				34
35	Amounts applicable to prior cost reporting periods resulting from disposition of assets.				35
	(If minus, enter amount in brackets)
36	Subtotal (Sum of lines 29 and, 32, minus lines 30, 31, and 32, plus or minus lines 34 and 35)				36
37	Interim payments (See instructions)				37
38	Tentative adjustment				38
39	OTHER adjustments (See instructions)				39
40	Balance due provider/program (Line 36 minus line 37, 38 and line 39)				40
	(Indicate overpayments in brackets) (See Instructions)
41	Protested amounts (Nonallowable cost report items) in accordance with CMS Pub.15-II, section 115.2				41
FORM CMS 2540-10 DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II SECTION 4130



Rev. 1					41-349

Sheet 30: E-II

DRAFT			FORM CMS 2540-10			4190 (Cont.)
	CALCULATION OF		PROVIDER NO.:	PERIOD:				.
	REIMBURSEMENT SETTLEMENT			FROM __________	WORKSHEET E
	FOR TITLE V and TITLE XIX ONLY		_________________	TO ______________	PART II
Check one:			[ ] Title V	[ ] Title XIX
Check one:		[ ] SNF	[ ] NF	[ ] ICF/MR
	COMPUTATION OF NET COST OF COVERED SERVICES
1	Inpatient ancillary services (See Instructions)					1
2	Intern and Resident Cost (From Worksheet D-2)					2
3	Outpatient services					3
4	Inpatient routine services (See instructions)					4	Total reasonable costs (sum of lines 1, 2 and 3)
5	Utilization review--physicians' compensation (From provider records)					5	Cost of covered services (lesser of lines 4 or 5)
6	Cost of covered services (Sum of lines 1 - 5)					6	Inpatient routine PPS amount (see instructions)
7	Differential in charges between semiprivate accommodations and less					7
	than semiprivate accommodations
8	SUBTOTAL (Line 6 minus line 7)					8	Reimbursable bad debts
9	Primary payor amounts					9	Utilization review
10	Total Reasonable Cost (Line 8 minus line 9)					10	Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges
	REASONABLE CHARGES
11	Inpatient ancillary service charges					11	Subtotal (Sum of lines 6 through 14)
12	Intern and Resident Charges (From Provider Records)					12	Sequestration adjustment
13	Outpatient service charges					13	Interim payments (See instructions)
14	Inpatient routine service charges					14	Balance due provider/program (Line 15 minus the sum of lines 16 and 17)
15	Differential in charges between semiprivate accommodations and less					15	(Indicate overpayments in brackets)
	than semiprivate accommodations						Protested amounts (Nonallowable cost report items in accordance with
16	Total reasonable charges					16	CMS Pub. 15-II, section 115.2)
	CUSTOMARY CHARGES						Balance due provider/program (Line 18 plus or minus line 19)
17	Aggregate amount actually collected from patients liable for payment for					17
	services on a charge basis
18	Amounts that would have been realized from patients liable for payment for services					18
	on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
19	Ratio of line 17 to line 18 (not to exceed 1.000000)					19
20	Total customary charges (See instructions)					20
	COMPUTATION OF REIMBURSEMENT SETTLEMENT
21	Cost of covered services (See Instructions)					21
22	Deductibles					22
23	Subtotal (Line 21 minus line 22)					23
24	Coinsurance					24
25	Subtotal (Line 23 minus line 24)					25
26	Reimbursable bad debts ( From your records)					26
27	Subtotal (Sum of lines 25 and 26)					27
28	Unrefunded charges to beneficiaries for excess costs erroneously collected					28
	based on correction of cost limit
29	Recovery of excess depreciation resulting from provider termination or a decrease					29
	in program utilization
30	Other Adjustments (See instructions) Specify					30
31	Amounts applicable to prior cost reporting periods resulting from disposition of					31
	depreciable assets ( If minus, enter amount in brackets)
32	Subtotal (Line 27 plus or minus lines 30, and 31, minus lines 28 and 29)					32
33	Interim payments					33
34	Balance due provider/program (Line 32 minus line 33)					34
	(Indicate overpayments in brackets) (See Instructions)

FORM CMS 2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTIONS 4130.2 )

Rev. 1						41-350

Sheet 31: E1

DRAFT			FORM CMS 2540-10					4190 ( Cont.)
ANALYSIS OF PAYMENTS TO PROVIDERS			PROVIDER NO.:		PERIOD:
FOR SERVICES RENDERED					FROM ________________		WORKSHEET E - 1
			________________		TO ________________
				Inpatient Part A		Part B
				mm/dd/yyyy	Amount	mm/dd/yyyy	Amount
	Description			1	2	3	4
1	Total interim payments paid to provider							1
2	Interim payments payable on individual bills, either submitted							2
	or to be submitted to the intermediary/contractor for services
	rendered in the cost reporting period. If none, enter zero
3	List separately each retroactive lump sum		.01					3.01
	adjustment amount based on subsequent revision of		.02					3.02
	the interim rate for the cost reporting period	Program to	.03					3.03
	Also show date of each payment.	Provider	.04					3.04
			.05					3.05
	If none, write "NONE," or enter a zero (1)		.50					3.50
			.51					3.51
		Provider to	.52					3.52
		Program	.53					3.53
			.54					3.54
	SUBTOTAL (Sum of lines 3.01 - 3.05 minus sum of lines 3.50 - 3.54)		.99					3.99
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99) Transfer to Wkst E, Part I							4
	line 18 for Part A, and line 35 for Part B. or Transfer to Wkst E, Part II, line 33)
	TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR
5	List separately each tentative settlement	Program to	.01					5.01
	payment after desk review. Also show	Provider	.02					5.02
	date of each payment.		.03					5.03
	If none, write "NONE," or enter a zero.(1)		.50					5.50
		Provider to	.51					5.51
		Program	.52					5.52
	SUBTOTAL (Sum of lines 5.01 - 5.03 minus sum of lines 5.50 - 5.52)		.99					5.99
6	Determined net settlement amount (balance	Program to provider	.01					6.01
	due) based on the cost report. (1)	Provider to program	.50					6.50
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)							7
8	Name of Intermediary/Contractor			Intermediary/Contractor Number				8

9	Signature of Authorized Person			Date: (mm/dd/yyyy)				9

(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the provider agrees to the amount of repayment even though total repayment is not accomplished until a later date.
FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4131 )
Rev. 1								41-351

Sheet 32: G

4190 ( Cont.)			FORM CMS 2540-10			Draft
			PROVIDER NO.:	PERIOD:
	BALANCE SHEET			FROM ________	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				TO ___________
accounting records, complete the "General Fund" column only)
			Specific
	Assets	General	Purpose	Endowment	Plant
	(Omit cents)	Fund	Fund	Fund	Fund
		1	2	3	4
	CURRENT ASSETS
1	Cash on hand and in banks					1
2	Temporary investments					2
3	Notes receivable					3
4	Accounts receivable					4
5	Other receivables					5
6	Less: allowances for uncollectible notes	( )	( )	( )	( )	6
	and accounts receivable
7	Inventory					7
8	Prepaid expenses					8
9	Other current assets					9
10	Due from other funds					10
11	TOTAL CURRENT ASSETS					11
	(Sum of lines 1 - 10)
	FIXED ASSETS
12	Land					12
13	Land improvements					13
14	Less: Accumulated depreciation	( )	( )	( )	( )	14
15	Buildings					15
16	Less Accumulated depreciation	( )	( )	( )	( )	16
17	Leasehold improvements					17
18	Less: Accumulated Amortization	( )	( )	( )	( )	18
19	Fixed equipment					19
20	Less: Accumulated depreciation	( )	( )	( )	( )	20
21	Automobiles and trucks					21
22	Less: Accumulated depreciation	( )	( )	( )	( )	22
23	Major movable equipment					23
24	Less: Accumulated depreciation	( )	( )	( )	( )	24
25	Minor equipment - Depreeciable					25
26	Minor equipment nondepreciable					26
27	Other fixed assets					27
28	TOTAL FIXED ASSETS					28
	(Sum of lines 12 - 27)
	OTHER ASSETS
29	Investments					29
30	Deposits on leases					30
31	Due from owners/officers					31
32	Other assets					32
33	TOTAL OTHER ASSETS					33
	(Sum of lines 29 - 34)
34	TOTAL ASSETS					34
	(Sum of lines 11, 28 and 33)
	( ) = contra amount

FORM CMS 2540 10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4140 )

41-352						Rev. 1

Sheet 33: GII

DRAFT			FORM CMS 2540-10			4190 ( Cont.)
			PROVIDER NO.:	PERIOD:
BALANCE SHEET				FROM ________	WORKSHEET G
(If you are nonproprietary and do not maintain fund-type				TO ___________	(Cont.)
accounting records, complete the "General Fund" column only)
	Liabilities and Fund		Specific
	Balances	General	Purpose	Endowment	Plant
	(Omit cents)	Fund	Fund	Fund	Fund
		1	2	3	4
	CURRENT LIABILITIES
35	Accounts payable					35
36	Salaries, wages & fees payable					36
37	Payroll taxes payable					37
38	Notes & loans payable (Short term)					38
39	Deferred income					39
40	Accelerated payments					40
41	Due to other funds					41
42	Other current liabilities					42
43	TOTAL CURRENT LIABILITIES					43
	(Sum of lines 35 - 42)
	LONG TERM LIABILITIES
44	Mortgage payable					44
45	Notes payable					45
46	Unsecured loans					46
47	Loans from owners:					47
48	Other long term liabilities					48
49						49
50	TOTAL LONG TERM LIABILITIES					50
	(Sum of lines 44 - 49)
51	TOTAL LIABILITIES					51
	(Sum of lines 43 and 50)
	CAPITAL ACCOUNTS
52	General fund balance					52
53	Specific purpose fund					53
54	Donor created - endowment fund					54
	balance - restricted
55	Donor created - endowment fund					55
	balance - unrestricted
56	Governing body created - endowment					56
	fund balance
57	Plant fund balance - invested in plant					57
58	Plant fund balance - reserve for					58
	plant improvement, replacement and
	expansion
59	TOTAL FUND BALANCES					59
	(Sum of lines 50 thru 56)
60	TOTAL LIABILITIES AND					60
	FUND BALANCES
	(Sum of lines 51 and 59)
	( ) = contra amount


FORM CMS-2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4140 )

Rev. 1						41-353

Sheet 34: G-1

4190 (Cont.)				FORM CMS 2540-10						DRAFT
				PROVIDER NO:		PERIOD:
	STATEMENT OF CHANGES IN FUND BALANCES					FROM ___________________		WORKSHEET G - 1
				________________________		TO ________________



		GENERAL FUND		SPECIFIC PURPOSE FUND		ENDOWMENT FUND		PLANT FUND
		1	2	3	4	5	6	7	8
1	Fund balances at beginning of									1
	period
2	Net income (loss)									2
	(From Wkst. G-3, line 32)
3	Total (Sum of line 1 and line 2)									3
4	Additions (Credit adjustments)									4
5										5
6										6
7										7
8										8
9										9
10	Total additions (Sum of lines 4 - 9)									10
11	Subtotal (Line 3 plus line 10)									11
12	Deductions (Debit adjustments)									12
13										13
14										14
15										15
16										16
17										17
18	Total deductions									18
	(Sum of lines 12 - 17)
19	Fund balance at end of period per									19
	balance sheet (Line 11 - line 18)








FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4140)
41-354										Rev. 1

Sheet 35: G-2

DRAFT		FORM CMS 2540-10			4190 ( Cont.)
		PROVIDER NO:	PERIOD:
	STATEMENT OF PATIENT REVENUES	______________	FROM _________	WORKSHEET G - 2
	AND OPERATING EXPENSES		TO ___________	PARTS I & II
	PART I - PATIENT REVENUES
	Revenue Center	INPATIENT	OUTPATIENT	TOTAL
		1	2	3
	GENERAL INPATIENT ROUTINE CARE SERVICES
1	Skilled Nursing Facility				1
2	Nursing facility				2
3	ICF/MR				3
4	Other long term care				4
5	Total general inpatient care services				5
	(Sum of lines 1 - 4)
	All Other Care Service
6	Ancillary services				6
7	Clinic				7
8	Home Health Agency				8
9	Ambulance				9
10	Outpatient SNF Based RHC				10
11	Outpatient SNF Based FQHC				11
12	SNF Based CMHC				12
13	SNF Based Hospice				13
14	Total Patient Revenues ( Sum of lines 5 - 13 )				14
	( Transfer column 3 to Worksheet G-3, Line 1 )
	PART II - OPERATING EXPENSES
1	Operating Expenses ( Per Worksheet A, Col. 3, Line 100 )				1

2	Add ( Specify )				2

3					3

4					4

5					5

6					6

7					7

8	Total Additions ( Sum of lines 2 - 7 )				8

9	Deduct ( Specify )				9

10					10

11					11

12					12

13					13

14	Total Deductions ( Sum of lines 9 - 13 )				14

15	Total Operating Expenses ( Sum of lines 1 and 8, minus line 14 )				15
	( Transfer to Worksheet G-3, Line 4 )
FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4140 )
Rev. 1					41-355

Sheet 36: G-3

4190 ( Cont.)		FORM CMS 2540-10			DRAFT
	STATEMENT OF REVENUES	PROVIDER NO:	PERIOD:
	AND EXPENSES	______________	FROM _________	WORKSHEET G - 3
			TO ___________

1	Total patient revenues (From Wkst. G - 2, Part I, col. 3, line 13)				1
2	Less: contractual allowances and discounts on patients accounts				2
3	Net patient revenues (Line 1 minus line 2)				3
4	Less: total operating expenses (From Worksheet G-2, Part II, line 15)				4
5	Net income from service to patients (Line 3 minus 4)				5
6	Other income:				6
7	Contributions, donations, bequests, etc				7
8	Income from investments				8
9	Revenues from communications ( Telephone and Internet service)				9
10	Revenue from television and radio service				10
11	Purchase discounts				11
12	Rebates and refunds of expenses				12
13	Parking lot receipts				13
14	Revenue from laundry and linen service				14
15	Revenue from meals sold to employees and guests				15
16	Revenue from rental of living quarters				16
17	Revenue from sale of medical and surgical supplies to other than patients				17
18	Revenue from sale of drugs to other than patients				18
19	Revenue from sale of medical records and abstracts				19
20	Tuition (fees, sale of textbooks, uniforms, etc.)				20
21	Revenue from gifts, flower, coffee shops, canteen				21
22	Rental of vending machines				22
23	Rental of skilled nursing space				23
24	Governmental appropriations				24
25	Other (specify)				25
26	Total other income (Sum of lines 7 - 25)				26
27	Total (Line 5 plus line 26)				27
28	Other expenses (specify)				28
29					29
30					30
31	Total other expenses (Sum of lines 28 - 30)				31
32	Net income (or loss) for the period (Line 27 minus line 31)				32
















FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB. 15-II, SECTION 4140)
41-356					Rev. 1

Sheet 37: H

DRAFT					FORM CMS-2540-10							4190 (Cont.)
ANALYSIS OF PROVIDER-BASED							PROVIDER NO.: __________		PERIOD:		WORKSHEET
HOME HEALTH AGENCY COSTS									FROM __________		H
							HHA NO.: ________________		TO _____________
				TRANSPOR-	CONTRACTED/	OTHER	TOTAL	RECLASSIFI-	RECLASSIFIED	ADJUST-	NET
		SALARIES	EMPLOYEE	TATION	PURCHASED	COSTS	(sum of cols.	CATIONS	TRIAL BALANCE	MENTS	EXPENSES FOR
	COST CENTER DESCRIPTIONS		BENEFITS	(see	SERVICES		1 thru 5)		(col. 6 + col. 7)		ALLOCATION
	(omit cents)			instructions)							(col. 8 + col. 9)
		1	2	3	4	5	6	7	8	9	10
GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures											1
2	Capital Related-Movable Equipment											2
3	Plant Operation & Maintenance											3
4	Transportation (see instructions)											4
5	Administrative and General											5
HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care											6
7	Physical Therapy											7
8	Occupational Therapy											8
9	Speech Pathology											9
10	Medical Social Services											10
11	Home Health Aide											11
12	Supplies (see instructions)											12
13	Drugs											13
14	DME											14
15	Telemedicine											15
HHA NONREIMBURSABLE SERVICES
16	Home Dialysis Aide Service											16
17	Respiratory Therapy											17
18	Private Duty Nursing											18
19	Clinic											19
20	Health Promotion Activities											20
21	Day Care Program											21
22	Home Delivered Meals Program											22
23	Homemaker Service											23
24	All Others											24
25	Total (sum of lines 1-24)											25
Column, 6 line 25 should agree with the Worksheet A, column 3, line 70, or subscript as applicable.







FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 4141)


Rev. 1												41-357

Sheet 38: H1-1

DRAFT			FORM CMS-2540-10							4190 (Cont.)
					PROVIDER NO.: ___________		PERIOD:		WORKSHEET H-1
COST ALLOCATION - HHA GENERAL SERVICE COST							FROM ________________		PART I
					HHA NO.: ________________		TO ___________________
		NET EXPENSES	CAPITAL
		FOR COST	RELATED COSTS
		ALLOCATION			PLANT			ADMINIS-
		(from Wkst.	BLDGS. &	MOVABLE	OPERATION &	TRANS-	SUBTOTAL	TRATIVE	TOTAL
		H, col. 10)	FIXTURES	EQUIPMENT	MAINTENANCE	PORTATION	(cols. 0-4)	& GENERAL	(cols. 4a + 5)
		0	1	2	3	4	4a	5	6
GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures									1
2	Capital Related-Movable Equipment									2
3	Plant Operation & Maintenance									3
4	Transportation (see instructions)									4
5	Administrative and General									5
HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care									6
7	Physical Therapy									7
8	Occupational Therapy									8
9	Speech Pathology									9
10	Medical Social Services									10
11	Home Health Aide									11
12	Supplies (see instructions)									12
13	Drugs									13
14	DME									14
15	Telemedicine									15
HHA NONREIMBURSABLE SERVICES
16	Home Dialysis Aide Services									16
17	Respiratory Therapy									17
18	Private Duty Nursing									18
19	Clinic									19
20	Health Promotion Activities									20
21	Day Care Program									21
22	Home Delivered Meals Program									22
23	Homemaker Service									23
24	All Others									24
25	Totals (sum of lines 1-24)									25





FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4142)


Rev. 1										41-358

Sheet 39: H1-II

DRAFT		FORM CMS-2540-10							4190 (Cont.)
				PROVIDER NO.: __________		PERIOD:		WORKSHEET H-1,
COST ALLOCATION - HHA STATISTICAL BASIS						FROM _________________		PART II
				HHA NO.: ________________		TO ___________________
			CAPITAL
			RELATED COSTS		PLANT			ADMINIS-
			BLDGS. &	MOVABLE	OPERATION &			TRATIVE
			FIXTURES	EQUIPMENT	MAINTENANCE	TRANS-		& GENERAL
			(SQUARE	(DOLLAR	(SQUARE	PORTATION	RECONCIL-	(ACCUM.
			FEET)	VALUE)	FEET)	(MILEAGE)	IATION	COST)
			1	2	3	4	5a	5
GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures								1
2	Capital Related-Movable Equipment								2
3	Plant Operation & Maintenance								3
4	Transportation (see instructions)								4
5	Administrative and General								5
HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care								6
7	Physical Therapy								7
8	Occupational Therapy								8
9	Speech Pathology								9
10	Medical Social Services								10
11	Home Health Aide								11
12	Supplies (see instructions)								12
13	Drugs								13
14	DME								14
15	Telemedicine								15
HHA NONREIMBURSABLE SERVICES
16	Home Dialysis Aide Services								16
17	Respiratory Therapy								17
18	Private Duty Nursing								18
19	Clinic								19
20	Health Promotion Activities								20
21	Day Care Program								21
22	Home Delivered Meals Program								22
23	Homemaker Service								23
24	All Others								24
25	Total (sum of lines 1-24)								25
26	Cost To Be Allocated								26
27	Unit Cost Multiplier								27

FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4142)

Rev. 1									41-359

Sheet 40: H2-1

DRAFT				FORM CMS-2540-10							4190 (Cont.)	DRAFT				FORM CMS-2540-10					4190 (Cont.)	DRAFT			FORM CMS-2540-10							4190 (Cont.)
ALLOCATION OF GENERAL SERVICE					PROVIDER NO.: ______________			PERIOD:		WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE			PROVIDER NO.: ______________			PERIOD:		WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE			PROVIDER NO.: ______________			PERIOD:		WORKSHEET H-2,
COSTS TO HHA COST CENTERS					HHA NO.: _____________			FROM__________________		PART I		COSTS TO HHA COST CENTERS			HHA NO.: _____________			FROM__________________		PART I (CONT.)		COSTS TO HHA COST CENTERS			HHA NO.: _____________			FROM ______________		PART I (CONT.)
								TO ___________________										TO ___________________										TO _________________
		From		NEW CAPITAL																								INTERN &
		Wkst	HHA	RELATED COSTS																								RESIDENT		ALLOCATED
	HHA COST CENTER	H-1	TRIAL					ADMINIS-		LAUNDRY			CORF COST CENTER			NURSING	CENTRAL		MEDICAL				HHA COST CENTER	INTERNS & RESIDENTS		OTHER	SUBTOTAL	COST & POST		HHA
	(omit cents)	Part I,	BALANCE	BLDGS. &	MOVABLE	EMPLOYEE	SUBTOTAL	TRATIVE &	OPERATION	& LINEN			(omit cents)	HOUSE		ADMINIS-	SERVICES &		RECORDS &	SOCIAL			(omit cents)	SALARY AND	PROGRAM	GENERAL	(sum of cols.	STEPDOWN	SUBTOTAL	A&G (see	TOTAL
		col. 6,	(1)	FIXTURES	EQUIPMENT	BENEFITS	(cols. 0-3)	GENERAL	OF PLANT	SERVICE				KEEPING	DIETARY	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE				FRINGES	COSTS	SERVICE	3a-16)	ADJUSTMENTS	(cols. 17 ± 18)	Part II)	HHA COSTS
		line	0	1	2	3	3A	4	5	6				7	8	9	10	11	12	13				14	15	16	17	18	19	20	21
1	Administrative and General	5									1	1	Administrative and General								1	1	Administrative and General									1
2	Skilled Nursing Care	6									2	2	Skilled Nursing Care								2	2	Skilled Nursing Care									2
3	Physical Therapy	7									3	3	Physical Therapy								3	3	Physical Therapy									3
4	Occupational Therapy	8									4	4	Occupational Therapy								4	4	Occupational Therapy									4
5	Speech Pathology	9									5	5	Speech Pathology								5	5	Speech Pathology									5
6	Medical Social Services	10									6	6	Medical Social Services								6	6	Medical Social Services									6
7	Home Health Aide	11									7	7	Home Health Aide								7	7	Home Health Aide									7
8	Supplies	12									8	8	Supplies								8	8	Supplies									8
9	Drugs	13									9	9	Drugs								9	9	Drugs									9
10	DME	14									10	10	DME								10	10	DME									10
11	Telemedicine	15									11	11	Telemedicine								11	11	Telemedicine									11
12	Home Dialysis Aide Services	16									12	12	Home Dialysis Aide Services								12	12	Home Dialysis Aide Services									12
13	Respiratory Therapy	17									13	13	Respiratory Therapy								13	13	Respiratory Therapy									13
14	Private Duty Nursing	18									14	14	Private Duty Nursing								14	14	Private Duty Nursing									14
15	Clinic	19									15	15	Clinic								15	15	Clinic									15
16	Health Promotion Activities	20									16	16	Health Promotion Activities								16	16	Health Promotion Activities									16
17	Day Care Program	21									17	17	Day Care Program								17	17	Day Care Program									17
18	Home Delivered Meals Program	22									18	18	Home Delivered Meals Program								18	18	Home Delivered Meals Program									18
19	Homemaker Service	23									19	19	Homemaker Service								19	19	Homemaker Service									19
20	All Others	24									20	20	All Others								20	20	All Others									20
21	Totals (sum of lines 1-20) (2)										21	21	Totals (sum of lines 1-20) (2)								21	21	Totals (sum of lines 1-20) (2)									21
22	Unit Cost Multiplier: column 19, line 1										22	22	Unit Cost Multiplier: column 19, line 1								22	22	Unit Cost Multiplier: column 19, line 1									22
	divided by the sum of column 19,												divided by the sum of column 19,										divided by the sum of column 19,
	line 21, minus column 19, line 1,												line 21, minus column 19, line 1,										line 21, minus column 19, line 1,
	rounded to 6 decimal places.												rounded to 6 decimal places.										rounded to 6 decimal places.

(1) Column 0, line 21 must agree with Wkst. A, column 7, line 70.												(2) Columns 0 through 20 line 21 must agree with the corresponding columns of Wkst. B, Part I, line 70.										(2) Columns 0 through 20, line 21 must agree with the corresponding columns of Wkst. B, Part I, line 70.
(2) Columns 0 through 20, line 21 must agree with the corresponding columns of Wkst. B, Part I, line 70.




FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)												FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)										FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)


Rev. 1											41-360	Rev. 1									41-361	Rev. 1										41-362

Sheet 41: H2-II

DRAFT			FORM CMS-2540-10						4190 (Cont.)	DRAFT				FORM CMS-2540-10				4190 (Cont.)	DRAFT			FORM CMS-2540-10					4190 (Cont.)
ALLOCATION OF GENERAL SERVICE		PROVIDER NO.: ___________		PERIOD:			WORKSHEET H-2,			ALLOCATION OF GENERAL SERVICE		PROVIDER NO.: ______________		PERIOD:		WORKSHEET H-2,			ALLOCATION OF GENERAL SERVICE		PROVIDER NO.: __________		PERIOD:		WORKSHEET H-2,
COSTS TO HHA COST CENTERS		HHA NO.: _____________		FROM__________________			PART II			COSTS TO HHA COST CENTERS		HHA NO.: _____________		FROM__________________		PART II (CONT.)			COSTS TO HHA COST CENTERS		HHA NO.: _____________		FROM__________________		PART II (CONT.)
STATISTICAL BASIS				TO ___________________						STATISTICAL BASIS				TO ___________________					STATISTICAL BASIS				TO ___________________
			CAPITAL
			RELATED COST				ADMINIS-					LAUNDRY			NURSING	CENTRAL						MEDICAL		INTERNS & RESIDENTS
			BLDGS. &	MOVABLE	EMPLOYEE		TRATIVE &	OPERATION				& LINEN	HOUSE-		ADMINIS-	SERVICES &						RECORDS &	SOCIAL	SALARY &	PROGRAM	OTHER
	HHA COST CENTER		FIXTURES	EQUIPMENT	BENEFITS		GENERAL	OF PLANT			HHA COST CENTER	SERVICE	KEEPING	DIETARY	TRATION	SUPPLY	PHARMACY			HHA COST CENTER		LIBRARY	SERVICE	FRINGES	COSTS	GENERAL
			(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE				(POUNDS OF	(HOURS OF	(MEALS	(DIRECT	(COSTED	(COSTED					(TIME	(TIME	(ASSIGNED	(ASSIGNED	SERVICE
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)				LAUNDRY)	SERVICE)	SERVED)	NURS. HRS)	REQUIS.)	REQUIS.)					SPENT)	SPENT)	TIME)	TIME)	(SPECIFY)
			1	2	3	3A	4	5				6	7	8	9	10	11					12	13	14	15	16
1	Administrative and General								1	1	Administrative and General							1	1	Administrative and General							1
2	Skilled Nursing Care								2	2	Skilled Nursing Care							2	2	Skilled Nursing Care							2
3	Physical Therapy								3	3	Physical Therapy							3	3	Physical Therapy							3
4	Occupational Therapy								4	4	Occupational Therapy							4	4	Occupational Therapy							4
5	Speech Pathology								5	5	Speech Pathology							5	5	Speech Pathology							5
6	Medical Social Services								6	6	Medical Social Services							6	6	Medical Social Services							6
7	Home Health Aide								7	7	Home Health Aide							7	7	Home Health Aide							7
8	Supplies								8	8	Supplies							8	8	Supplies							8
9	Drugs								9	9	Drugs							9	9	Drugs							9
10	DME								10	10	DME							10	10	DME							10
11	Telemedicine								11	11	Telemedicine							11	11	Telemedicine							11
12	Home Dialysis Aide Services								12	12	Home Dialysis Aide Services							12	12	Home Dialysis Aide Services							12
13	Respiratory Therapy								13	13	Respiratory Therapy							13	13	Respiratory Therapy							13
14	Private Duty Nursing								14	14	Private Duty Nursing							14	14	Private Duty Nursing							14
15	Clinic								15	15	Clinic							15	15	Clinic							15
16	Health Promotion Activities								16	16	Health Promotion Activities							16	16	Health Promotion Activities							16
17	Day Care Program								17	17	Day Care Program							17	17	Day Care Program							17
18	Home Delivered Meals Program								18	18	Home Delivered Meals Program							18	18	Home Delivered Meals Program							18
19	Homemaker Service								19	19	Homemaker Service							19	19	Homemaker Service							19
20	All Others								20	20	All Others							20	20	All Others							20
21	Totals (sum of lines 1-20)								21	21	Totals (sum of lines 1-20)							21	21	Totals (sum of lines 1-20)							21
22	Total cost to be allocated								22	22	Total cost to be allocated							22	22	Total cost to be allocated							22
23	Unit Cost Multiplier								23	23	Unit Cost Multiplier							23	23	Unit Cost Multiplier							23


FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)										FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)									FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)


Rev. 1									41-363	Rev. 1								41-364	Rev. 1								41-365

Sheet 42: H3-I

DRAFT

FORM CMS-2540-10

4190 (Cont.)

PROVIDER NO.:_____________

PERIOD:

WORKSHEET H-3,

APPORTIONMENT OF PATIENT SERVICE COSTS

FROM ______________

Parts I & II

HHA NO.:________________

TO ________________

Check applicable box

[ ] Title V [ ] Title XVIII [ ] Title XIX

PART I - COMPUTATION OF LESSER OF AGGREGATE PROGRAM COST, AGGREGATE OF THE PROGRAM LIMITATION COST, OR BENEFICIARY COST LIMITATION

Cost Per Visit Computation

From,

Facility

Shared

Average

Program Visits

Cost of Services

Wkst.

Costs

Ancillary

Cost

Part B

Total

H-2,

(From

Costs

Total HHA

Per Visit

Not Subject

Subject

Not Subject

Subject

Program Cost

Patient Services

Part I,

Wkst. H-2,

(From

Costs

Total

(col. 3

to Deductibles

(sum of

col. 21,

Part I)

Part II)

(cols. 1 + 2)

Visits

÷ col. 4)

Part A

& Coinsurance

Part A

& Coinsurance

cols. 9-10)

line -

Skilled Nursing Care

Physical Therapy

Occupational Therapy

Speech Pathology

Medical Social Services

Home Health Aide

Total (sum of lines 1-6)

Supplies and Drugs Cost

Program Covered Charges

Cost of Services

Computations

From

Facility

Shared

Total

Part B

Wkst. H-2,

Costs

Ancillary

Total

Charges

Not Subject

Subject

Not Subject

Subject

Other Patient Services

Part I,

(From

Costs

HHA

(from

Ratio

Wkst. H-2,

(From

Cost

HHA

(col. 3

Deductibles

col. 21,

Part I)

Part II)

(cols. 1 + 2)

Record)

÷ col. 4)

Part A

& Coinsurance

Part A

Coinsurance

line -

Cost of Medical Supplies

Cost of Drugs

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED SKILLED NURSING FACILITY DEPARTMENTS

Total

HHA Charge

HHA Shared

Transfer to

From Wkst. C,

Cost to Charge

(From Provider

Ancillary Cost

Part I

col. 3

Ratio

records)

(Col.1 X Col 2)

as indicated

line -

Physical Therapy

col. 2, line 2

Occupational Therapy

col. 2, line 3

Speech Pathology

col. 2, line 4

Cost of Medical Supplies

col. 2, line 8

Cost of Drugs

col. 2, line 9

FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4144

Rev. 1

41-366

Sheet 43: H4

DRAFT		FORM CMS-2540-10				4190 (Cont.)
			PROVIDER NO.:	PERIOD:	WORKSHEET H-4,
CALCULATION OF HHA			______________	FROM___________	Parts I & II
REIMBURSEMENT SETTLEMENT			HHA NO.:	TO______________
			______________
Check Applicable Box		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
				Part B
				Not Subject to	Subject to
				Deductibles	Deductibles
			Part A	& Coinsurance	& Coinsurance
	Description		1	2	3
	Reasonable Cost of Part A & Part B Services
1	Reasonable cost of services (see instructions)					1
2	Total charges					2
	Customary Charges
3	Amount actually collected from patients liable for payment					3
	for services on a charge basis (from your records)
4	Amount that would have been realized from patients liable					4
	for payment for services on a charge basis had such
	payment been made in accordance with 42 CFR 413.13(b)
5	Ratio of line 3 to line 4 (not to exceed 1.000000)					5
6	Total customary charges (see instructions)					6
7	Excess of total customary charges over total reasonable					7
	cost (complete only if line 6 exceeds line 1)
8	Excess of reasonable cost over customary charges					8
	(complete only if line 1 exceeds line 6)
9	Primary payer amounts					9
PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT
				Part A Services	Part B Services
	Description			1	2
10	Total reasonable cost (see instructions)					10
11	Total PPS Reimbursement - Full Episodes without Outliers					11
12	Total PPS Reimbursement - Full Episodes with Outliers					12
13	Total PPS Reimbursement - LUPA Episodes					13
14	Total PPS Reimbursement - PEP Episodes					14
15	Total PPS Outlier Reimbursement - Full Episodes with Outliers					15
16	Total PPS Outlier Reimbursement - PEP Episodes					16
17	Total Other Payments					17
18	DME Payments					18
19	Oxygen Payments					19
20	Prosthetic and Orthotic Payments					20
21	Part B deductibles billed to Medicare patients (exclude coinsurance)					21
22	Subtotal (sum of lines 10 thru 20 minus line 21)					22
23	Excess reasonable cost (from line 8)					23
24	Subtotal (line 22 minus line 23)					24
25	Coinsurance billed to program patients (from your records)					25
26	Net cost (line 24 minus line 25)					26
27	Reimbursable bad debts (from your records)					27
28	Reimbursable bad debts for dual eligible beneficiaries (see instructions)					28
29	Total costs - current cost reporting period (line 26 plus line 27)					29
30	Other adjustments (see instructions) (specify)					30
31	Subtotal (line 29 plus/minus line 30)					31
32	Interim payments (see instructions)					32
33	Tentative settlement (for fiscal intermediary use only)					33
34	Balance due provider/program (line 31 minus lines 32 and 33)					34
35	Protested amounts (nonallowable cost report items) in accordance with CMS					35
	Pub. 15-II, section 115.2









FORM CMS-2510-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4145)
Rev. 1						41-367

Sheet 44: H5

DRAFT				FORM CMS-2540-10						4190 (Cont.)
ANALYSIS OF PAYMENTS TO PROVIDER-				PROVIDER NO.:			PERIOD:		WORKSHEET H-5		{APP4}IALLWAYS~/lp2~q/PCOPB1~Q/pGQ/1
BASED HHAs FOR SERVICES				______________________			FROM _____________
RENDERED TO PROGRAM BENEFICIARIES				HHA NO.:			TO ________________
				______________________

		Description				Part A		Part B
						mm/dd/yyyy	Amount	mm/dd/yyyy	Amount
						1	2	3	4
1	Total interim payments paid to provider									1
2	Interim payments payable on individual bills either submitted or to									2
	be submitted to the intermediary/contractor for services rendered
	in the cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum				.01					3.01
	adjustment amount based on subsequent revision				.02					3.02
	of the interim rate for the cost reporting period.			Program	.03					3.03
	Also show date of each payment. If none, write			to	.04					3.04
	"NONE" or enter a zero.(1)			Provider	.05					3.05
					.50					3.50
					.51					3.51
				Provider	.52					3.52
				to	.53					3.53
				Program	.54					3.54
	Subtotal (sum of lines 3.01-3.49 minus sum
	of lines 3.50-3.98)				.99					3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)									4
	(Transfer to Wkst. H-4, Part II, column as appropriate, line 32)

			TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR

5	List separately each tentative settlement payment			Program	.01					5.01
	after desk review. Also show date of each			to	.02					5.02
	payment. If none, write "NONE" or enter			Provider	.03					5.03
	a zero. (1)			Provider	.50					5.50
				to	.51					5.51
				Program	.52					5.52
	Subtotal (sum of lines 5.01-5.49 minus sum
	of lines 5.50-5.98)				.99					5.99
6	Determine net settlement amount (balance due)			Program
	based on the cost report (see instructions)			to	.01
				Provider						6.01
				Provider
				to	.02
				Program						6.02
7	TOTAL MEDICARE PROGRAM LIABILITY									7
	(see instructions)
8	Name of Intermediary/Contractor						Intermediary Number			8


9	Signature of Authorized Person						Date: (mm/dd/yyyy)			9


(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.





FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4146)

Rev. 1										36-368

Sheet 45: I1

DRAFT			FORM CMS 2540-10						4190 ( Cont.)
ANALYSIS OF SNF-BASED RURAL HEALTH			PROVIDER NO:		PERIOD:
CLINIC/FEDERALLY QUALIFIED					FROM___________________		WORKSHEET I-1
HEALTH CENTER COSTS			COMPONENT NO:		TO____________________
Check Applicable Box:		[ ] RHC	[ ] FQHC
						RECLASSIFIED		NEW EXPENSES
		COMPEN-	OTHER	TOTAL	RECLASSIFI-	TRIAL	ADJUSTMENTS	FOR
		SATION	COSTS	(Col. 1 + Col. 2)	CATIONS	BALANCE		ALLOCATION
						(Col. 3 +/- Col. 4)		(Col. 5 +/- Col.6)
		1	2	3	4	5	6	7
FACILITY HEALTH CARE STAFF COSTS
1	Physician								1
2	Physician Assistant								2
3	Nurse Practitioner								3
4	Visiting Nurse								4
5	Other Nurse								5
6	Clinical Psychologist								6
7	Clinical Social Worker								7
8	Laboratory Technician								8
9	Other Facility Health Care Staff Costs								9
10	Subtotal (Sum of lines 1 - 9)								10
COSTS UNDER AGREEMENT
11	Physician Services Under Agreement								11
12	Physician Supervision Under Agreement								12
13	Other Costs Under Agreement								13
14	Subtotal (Sum of lines 11 - 13)								14
OTHER HEALTH CARE COSTS
15	Medical Supplies								15
16	Transportation (Health Care Staff)								16
17	Depreciation - Medical Equipment								17
18	Professional Liability Insurance								18
19	Other Health Care Costs								19
20	Allowable GME Pass-through cost.								20
21	Subtotal (Sum of lines 15 - 19, less line 20)								21
22	Total Cost of Health Care Services								22
	(Sum of lines 10, 14, and 21)
COSTS OTHER THAN RHC/FQHC SERVICES
23	Pharmacy								23
24	Dental								24
25	Optometry								25
26	All other non reimbursable costs								26
27	Nonallowable GME Pass-through cost								27
28	Total nonreimbursable costs (Sum of lines								28
	23 - 27)
FACILITY OVERHEAD
29	Facility Costs								29
30	Administrative Costs								30
31	Total Facility Overhead (Sum of lines 29-30)								31
32	Total Facility Costs (Sum of lines 22, 28 and 31)								32
	* 'The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet.
FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II. SECTION 4148)
Rev. 1									41-369

Sheet 46: I2

4190 ( Cont. )		FORM CMS 2540-10					DRAFT
		PROVIDER NO:		PERIOD:
ALLOCATION OF OVERHEAD				FROM___________________		WORKSHEET
TO RHC / FQHC SERVICES		COMPONENT NO:				I - 2
				TO____________________
Check Applicable Box:		[ ] RHC	[ ] FQHC

	PART I - VISITS AND PRODUCTIVITY
		Number		Productivity	Minimum	Greater of
		of FTE	Total	Standard	Visits	Column 2 or
		Personnel	Visits	(1)	Col. 1 X Col. 3)	Column 4
		1	2	3	4	5
1	Physicians						1
2	Physician Assistants						2
3	Nurse Practitioners						3
4	Subtotal (Sum of lines 1 - 3)						4
5	Visiting Nurse						5
6	Clinical Psychologist						6
7	Clinical Social Worker						7
8	Total Staff Costs (Sum of lines 4 - 7)						8
9	Physician Services Under Agreements						9

	PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
10	Total costs of Health Care Services ( From Worksheet I - 1, column 7, line 22)						10
11	Total nonreimbursable costs (From Worksheet I - 1, column 7, line 28)						11
12	Cost of all services - excluding overhead (Sum of lines 10 and 11)						12
13	Ratio of RHC / FQHC services ( Line 10 divided by line 12)						13
14	Total facility overhead (From Worksheet I - 1, column 7, line 31)						14
15	GME Overhead (See instructions)						15
16	Net Facility Overhead						16
17	Parent provider overhead allocated to facility ( See instructions)						17
18	Total overhead (Sum of lines 16 and 17)						18
19	Overhead applicable to RHC / FQHC services (Lines 13 X line 18)						19
20	Total allowable cost of RHC / FQHC services ( Sum of lines 10 and 19)						20

(1) Productivity standards established by CMS are: 4200 visits for each physician, and 2100 visits for each nonphysician practitioner.





FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,
SECTION 4149)

41-370							Rev. 1

Sheet 47: I3

DRAFT			FORM CMS 2540-10				4190 (Cont.)
CALCULATION OF		PROVIDER NO.:		PERIOD:
REIMBURSEMENT		______________________		FROM__________________		WORKSHEET
SETTLEMENT FOR		COMPONENT NO.:				I - 3
RHC/FQHC SERVICES		_______________		TO_____________________
Check one:		[ ] Title V	[ ] Title XVIII		[ ] Title XIX
Check Applicable Box:		[ ] RHC	[ ] FQHC
PART I - DETERMINATION OF RATE FOR RHC / FQHC SERVICES
1	Total Allowable Cost of RHC/FQHC Services (From Worksheet I - 2, Part II, line 20)						1
2	Cost of vaccines and their administration (From Worksheet I-4, line 15)						2
3	Total Allowable Cost Excluding Vaccine (Line 1 minus line 2)						3
4	Total FTE's and VISITS (From Worksheet I-2, column 5, line 8)						4
5	Physicians Visits Under Agreement (From Worksheet I - 2, column 5, line 9)						5
6	Total Adjusted Visits (line 4 plus line 5)						6
7	Adjusted Cost Per Visit (line 3 divided by line 6)						7
CALCULATION OF LIMIT					Prior to	On or after
	Lines 8 through 14: Fiscal year providers use columns 1 and 2.				January 1	January 1
	Lines 8 through 14: Calendar year providers use column 2 only.				1	2
8	Rate per visit limit (From your intermediary/contractor)						8
9	Rate for Medicare Covered Visits (See instructions)						9
PART II - CALCULATION OF SETTLEMENT
10	Medicare Covered Visits Excluding Mental Health Services						10
	(From intermediary/contractor Records)
11	Medicare Cost Excluding Costs for Mental Health Services						11
	(Line 9 x line 10)
12	Medicare Covered Visits for Mental Health Services						12
	(From Intermediary/Contractor Records)
13	Medicare Covered Cost from Mental Health Services						13
	(Line 9 x line 12)
14	Limit Adjustment for Mental Health Services						14
	(See instructions)
15	Allowable GME Pass-through Cost (See instructions)						15
16	Total Medicare Cost (Sum of line 11 column 1 and 2, plus line 14 columns 1 and 2, plus line 15.						16
17	Primary payer amounts						17
18	Less: Beneficiary Deductible for RHC only. (See instructions)(From intermediary/contractor records)						18
19	Net Medicare Cost Excluding Vaccines (Line 16 minus sum of lines 17 and 18)						19
20	Reimbursable Cost of RHC/FQHC Services, Excluding Vaccine (80% of line 19)						20
21	Program cost of vaccines and their administration (From Worksheet I -4 line 16)						21
22	Total Reimbursable Program Cost (Line 20 plus 21)						22
23	Reimbursable Bad Debts						23
24	Reimbursable Bad Debts for dual eligible beneficiaries (See Instructions)						24
25	Other Adjustments						25
26	Net reimbursable amount (Line 22 plus line 23, plus or minus line 25 )						26
27	Interim payments (From Worksheet I-5, line 4)						27
28	Tentative settlement (for fiscal intermediary/contractor use only)						28
29	Balance due Component/Program (line 26 minus lines 27 and 28)						29
30	Protested amounts (nonallowable cost report items) in accordance with						30
	CMS Pub. 15-II, section 115.2
FORM CMS 2540-10 (DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 4150 )

Rev. 1							41-371

Sheet 48: I4

4190 (Cont.)		FORM CMS 2540-10			DRAFT
		PROVIDER NO.:	PERIOD:
COMPUTATION OF PNEUMOCOCCAL		_______________	FROM____________	WORKSHEET
AND INFLUENZA VACCINE COST		COMPONENT NO.:		I - 4
		_______________	TO_______________
Check one:		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
Check Applicable Box:		[ ] RHC	[ ] FQHC
	CALCULATION OF COST		PNEUMOCOCCAL	INFLUENZA
			1	2
1	Health care staff cost (from Worksheet I -1, column 7, line 10)				1
2	Ratio of PNEUMOCOCCAL and influenza vaccine staff time to				2
	total health care staff time
3	PNEUMOCOCCAL and influenza vaccine health care staff cost				3
	(Line 1 x line 2)
4	Medical supplies cost - PNEUMOCOCCAL and influenza vaccine				4
	(From your records)
5	Direct cost of PNEUMOCOCCAL and influenza vaccine				5
	(Sum of lines 3 and 4)
6	Total direct cost of the facility (From Wkst. I -1, col. 7, line 22)				6
7	Total overhead (From Worksheet I - 2, line 18)				7
8	Ratio of PNEUMOCOCCAL and influenza vaccine direct cost to				8
	Total direct cost (Line 5 divided by Line 6)
9	Overhead cost - PNEUMOCOCCAL and influenza vaccine				9
	(Line 7 x Line 8)
10	Total PNEUMOCOCCAL and influenza vaccine cost and its (their)				10
	administration (Sum of lines 5 and 9)
11	Total number of PNEUMOCOCCAL and influenza vaccine injections				11
	(From your records)
12	Cost per PNEUMOCOCCAL and influenza vaccine injection				12
	(Line 10 divided by Line 11)
13	Number of PNEUMOCOCCAL and influenza vaccine injections				13
	Administered to medicare beneficiaries
14	Medicare cost of PNEUMOCOCCAL and influenza vaccine and				14
	its (their) administration (Line 12 x line 13)
15	Total Cost of PNEUMOCOCCAL and influenza vaccine and its (their) administration				15
	(Sum of columns 1 and 2, line 10) (Transfer this amount to Worksheet I-3, line 2)
16	Total medicare cost of PNEUMOCOCCAL and influenza vaccine and its (their) administration				16
	(Sum of columns 1 and 2, line 14) (Transfer this amount to Worksheet I-3, line 21)





FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 4151 )

41-372					Rev. 1

Sheet 49: I-5

DRAFT			FORM CMS 2540-10				4190 ( Cont. )
ANALYSIS OF PAYMENTS TO		PROVIDER NO.:		PERIOD:
SNF-BASED RURAL HEALTH		___________________		FROM ______________		WORKSHEET I - 5
CLINIC AND FEDERALLY		COMPONENT NO.:
QUALIFIED HEALTH CENTERS		___________________		TO
Check Applicable Box:			[ ] R.H.C.	[ ] F.Q.H.C.
					mm/dd/yyyy	Amount
	Description				1	2
1	Total interim payments paid to provider						1
2	Interim payments payable on individual bills, either submitted or to						2
	be submitted to the intermediary/contractor, for services rendered in
	the cost reporting period. If none, write "none", or enter zero.
3	List separately each retroactive lump sum			.01			3.01
	adjustment amount based on subsequent			.02			3.02
	revision of the interim rate for the cost		Program to	.03			3.03
	reporting period.		Provider	.04			3.04
				.05			3.05
	Also show date of each payment.			.50			3.50
	If none, write "NONE," or enter a zero.(1)			.51			3.51
			Provider to	.52			3.52
			Program	.53			3.53
				.54			3.54
	SUBTOTAL (Sum of lines 3.01 - 3.05			.99			3.99
	minus sum of lines 3.50 - 3.55)
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)						4
	(Transfer to Worksheet I-3: line 27)

	TO BE COMPLETED BY INTERMEDIARY / CONTRACTOR
5	List separately each tentative settlement		Program to	.01			5.01
	payment after desk review.		Provider	.02			5.02
				.03			5.03
	Also show date of each payment.		Provider to	.50			5.50
	If none, write "NONE," or enter a zero.(1)		Program	.51			5.51
				.52			5.52
	SUBTOTAL (Sum of lines 5.01 - 5.03			.99			5.99
	minus sum of lines 5.50 - 5.52)
6	Determined net settlement		Program to	.01			6.01
	amount (balance due) based		Provider	.02			6.02
	on the cost report. (1)		Provider to	.50			6.50
			Program	.51			6.51
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)						7
8	Name of Intermediary/Contractor				Intermediary/Contractor Number		8


9	Signature of Authorized Person				Date (mm/dd/yyy)		9


(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
	provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

FORM CMS 2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
	SECTION 4152)

Rev. 1							41-373

Sheet 50: J-1-I

4190 ( Cont. )			FORM CMS 2540-10						DRAFT
			PROVIDER NO.:		PERIOD:
ALLOCATION OF GENERAL SERVICE COSTS					FROM ____________		WORKSHEET J - 1
TO COST CENTERS FOR C.M.H.C.			COMPONENT NO.: _______________		TO _______________		PART I


			NET	CAPITAL RELATED. COST				ADMINIS-
			EXPENSES			EMPLOYEE	SUBTOTAL	TRATIVE
	COMPONENT COST CENTER		FOR COST	BUILDS. &	MOVABLE	BENEFITS		&
	(Omit Cents)		ALLOCATION	FIXTURES	EQUIPMENT		(COLS. 0-3)	GENERAL
			0	1	2	3	3a	4
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	Appr. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21)	(1)							22

	(1) Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).





FORM CMS 2540-10 (DRAFT) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)

41-374									Rev. 1
DRAFT			FORM CMS 2540-10						4190 ( Cont. )
			PROVIDER NO.:		PERIOD:
ALLOCATION OF GENERAL SERVICE COSTS					FROM ____________		WORKSHEET J - 1
TO COST CENTERS FOR C.M.H.C.			COMPONENT NO.: _______________		TO _______________		PART I (CONT. )


				PLANT
				OPERATION	LAUNDRY	HOUSE -		NURSING
	COMPONENT COST CENTER			MAINTENANCE	& LINEN	KEEPING	DIETARY	ADMINIS-
	(Omit Cents)			& REPAIRS	SERVICE			TRATION
				5	6	7	8	9
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	Appr. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21)	(1)							22

	(1) Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).






FORM CMS 2540-10 (DRAFT) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)
Rev. 1									41-375
4190 ( Cont. )			FORM CMS 2540-10						DRAFT
			PROVIDER NO.:		PERIOD:
ALLOCATION OF GENERAL SERVICE COSTS					FROM ____________		WORKSHEET J - 1
TO COST CENTERS FOR C.M.H.C.			COMPONENT NO.: _______________		TO _______________		PART I (CONT. )



			CENTRAL		MEDICAL	SOCIAL	INTERNS	OTHER
	COMPONENT COST CENTER		SERVICES	PHARMACY	RECORDS	SERVICES	&	GENERAL
	(Omit Cents)		& SUPPLY		& LIBRARY		RESIDENTS	SERVICE
			10	11	12	13	14	15
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	Appr. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21)	(1)							22
	(1) Columns 0 through 15, line 22 must agree with the corresponding columns of Worksheet B, Part I, line 73, (subscripted line).






FORM CMS 2540-10 (DRAFT) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )

41-376									Rev. 1
DRAFT			FORM CMS 2540-10						4190 ( Cont. )
			PROVIDER NO.:		PERIOD:		WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE COSTS					FROM ____________		PART I ( CONT. )
TO COST CENTERS FOR C.M.H.C.			COMPONENT NO.: ______		TO _______________



					POST		ALLOCATED	TOTAL
	COMPONENT COST CENTER			SUBTOTAL	STEP-DOWN	SUBTOTAL	A & G	(SUM OF COLS
	(Omit Cents)				ADJUSTMENTS		(SEE PART II)	18 AND 19)
				16	17	18	19	20
1	Administrative and General								1
2	Skilled Nursing								2
3	Physical Therapy								3
4	Occupational Therapy								4
5	Speech Pathology								5
6	Medical Social Services								6
7	Respiratory Therapy								7
8	Psychiatric/Psychological Services								8
9	Individual Therapy								9
10	Group Therapy								10
11	Individualized Activity Therapy								11
12	Family Counseling								12
13	Diagnostic Services								13
14	App. Patient Training & Education								14
15	Prosthetic and Orthotic Devices								15
16	Drugs and Biologicals								16
17	Medical Supplies								17
18	Medical Appliances								18
19	Durable Medical Equipment - Rented								19
20	Durable Medical Equipment - Sold								20
21	Other General Service Cost								21
22	Totals ( Sum of lines 1-21)								22
23	Unit Cost Multiplier (See Instructions)								23

FORM CMS 2540-10 (DRAFT) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)
Rev. 1									41-377

Sheet 51: J-1-II

4190 (Cont.)		FORM CMS 2540-10						DRAFT
0		PROVIDER NO.:		PERIOD:
ALLOCATION OF GENERAL SERVICE COSTS				FROM ____________		WORKSHEET J - 1
	0	COMPONENT NO.: ______		TO _______________		PART II


				CAPITAL RELATED COST			ADMINIS-
				COST BUILDS.	COST MOVABLE	EMPLOYEE	TRATIVE
	COMPONENT COST CENTER			& FIXTURES	EQUIPMENT	BENEFITS	& GENERAL
				(Square Feet)	(Value or	(Gross Salaries)	(Accumulated
					Square Feet		Cost)
	(Omit Cents)			1	2	3	4
1	Administrative and General							1
2	Skilled Nursing							2
3	Physical Therapy							3
4	Occupational Therapy							4
5	Speech Pathology							5
6	Medical Social Services							6
7	Respiratory Therapy							7
8	Psychiatric/Psychological Services							8
9	Individual Therapy							9
10	Group Therapy							10
11	Individualized Activity Therapy							11
12	Family Counseling							12
13	Diagnostic Services							13
14	App. Patient Training & Education							14
15	Prosthetic and Orthotic Devices							15
16	Drugs and Biologicals							16
17	Medical Supplies							17
18	Medical Appliances							18
19	Durable Medical Equipment - Rented							19
20	Durable Medical Equipment - Sold							20
21	Other General Service Cost							21
22	Totals ( Sum of lines 1-21)							22
23	Total Cost to be Allocated							23
24	Unit Cost Multiplier							24




FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )

41-378								Rev. 1
DRAFT		FORM CMS 2540-10						4190 (Cont.)
0		PROVIDER NO.:		PERIOD:
ALLOCATION OF GENERAL SERVICE COSTS				FROM ____________		WORKSHEET J - 1
	0	COMPONENT NO.: ______		TO _______________		PART II (Cont.)


			PLANT	LAUNDRY			NURSING
			OPERATION	& LINEN	HOUSE -		ADMINIS
			MAINTENANCE	SERVICE	KEEPING	DIETARY	TRATION
	COMPONENT COST CENTER		& REPAIRS	(Pounds of	(Hours of	(Meals	(Direct Nursing
			(Square Feet)	Laundry)	Service)	Served)	Hours of Service)
	(Omit Cents)		5	6	7	8	9
1	Administrative and General							1
2	Skilled Nursing							2
3	Physical Therapy							3
4	Occupational Therapy							4
5	Speech Pathology							5
6	Medical Social Services							6
7	Respiratory Therapy							7
8	Psychiatric/Psychological Services							8
9	Individual Therapy							9
10	Group Therapy							10
11	Individualized Activity Therapy							11
12	Family Counseling							12
13	Diagnostic Services							13
14	App. Patient Training & Education							14
15	Prosthetic and Orthotic Devices							15
16	Drugs and Biologicals							16
17	Medical Supplies							17
18	Medical Appliances							18
19	Durable Medical Equipment - Rented							19
20	Durable Medical Equipment - Sold							20
21	Other General Service Cost							21
22	Totals ( Sum of lines 1-21)							22
23	Total Cost to be Allocated							23
24	Unit Cost Multiplier							24





FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )
Rev. 1								41-379
4190 (Cont.)		FORM CMS 2540-10						DRAFT
	ALLOCATION OF GENERAL SERVICE COSTS	PROVIDER NO.:		PERIOD:
	TO COST CENTERS			FROM ______________________		WORKSHEET J - 1
	0	COMPONENT NO.: ______		TO ____________________		PART II (Cont.)


		CENTRAL
		SERVICES		MEDICAL		INTERNS &	OTHER
		& SUPPLY	PHARMACY	RECORDS &	SOCIAL	RESIDENTS	GENERAL
	COMPONENT COST CENTER	(Costed	(Costed	LIBRARY	SERVICES		SERVICE
	(Omit Cents)	Requisitions)	Requisitions)	(Time Spent)	(Time Spent)	(Assigned Time)	( )
		10	11	12	13	14	15
1	Administrative and General							1
2	Skilled Nursing							2
3	Physical Therapy							3
4	Occupational Therapy							4
5	Speech Pathology							5
6	Medical Social Services							6
7	Respiratory Therapy							7
8	Psychiatric/Psychological Services							8
9	Individual Therapy							9
10	Group Therapy							10
11	Individualized Activity Therapy							11
12	Family Counseling							12
13	Diagnostic Services							13
14	App. Patient Training & Education							14
15	Prosthetic and Orthotic Devices							15
16	Drugs and Biologicals							16
17	Medical Supplies							17
18	Medical Appliances							18
19	Durable Medical Equipment - Rented							19
20	Durable Medical Equipment - Sold							20
21	Other General Service Cost							21
22	Totals ( Sum of lines 1-21)							22
23	Total Cost to be Allocated							23
24	Unit Cost Multiplier							24
	`
FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )




41-380								Rev. 1

Sheet 52: J-2

DRAFT					FORM CMS 2540-10							DRAFT
COMPUTATION OF C.M.H.C.				PROVIDER NO.:			PERIOD:
REHABILITATION COSTS							FROM ____________			WORKSHEET J - 2
				COMPONENT NO.: __________			TO _______________			PART I
PART I - APPORTIONMENT OF REHABILITATION COST CENTERS
			TOTAL COSTS		RATIO OF	TITLE V		TITLE XVIII		TITLE XIX
			(FR. WKST. J-1	TOTAL	COSTS TO	CHARGES	COSTS	CHARGES	COSTS	CHARGES	COSTS
			PART I, Col. 20)	CHARGES	CHARGES (1)		(Col 3 X Col 4)		(Col 3 X col 6)		(Col. 3 X Col 6)
			1	2	3	4	5	6	7	8	9
1	Administrative and General											1
2	Skilled Nursing Care											2
3	Physical Therapy											3
4	Occupational Therapy											4
5	Speech Pathology											5
6	Medical Social Services											6
7	Respiratory Therapy											7
8	Psychiatric/Psychological Services											8
9	Individual Therapy											9
10	Group Therapy											10
11	Individualized Activity Therapy											11
12	Family Counseling											12
13	Diagnostic Services											13
14	App. Patient Training & Education											14
15	Prosthetic and Orthotic Devices											15
16	Drugs and Biologicals											16
17	Medical Supplies											17
18	Medical Appliances											18
19	Durable Medical Equipment - Rented											19
20	Durable Medical Equipment - Sold											20
21	Other General Service Cost											21
22	Totals ( Sum of lines 2-21)	(2)										22












FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4154)

Rev. 1												35-381

DRAFT					FORM CMS 2540-10							DRAFT
COMPUTATION OF C.M.H.C.				PROVIDER NO.:			PERIOD:
REHABILITATION COSTS							FROM ____________			WORKSHEET J - 2
				COMPONENT NO.: __________			TO _______________			PART II
PART II - APPORTIONMENT OF COST OF REHAB SERVICES FURNISHED BY SHARED DEPARTTMENTS
					RATIO OF	TITLE V		TITLE XVIII		TITLE XIX
					COSTS TO	CHARGES	COSTS	CHARGES	COSTS	CHARGES	COSTS
					CHARGES		(Col 3 X Col 4)		(Col 3 X col 6)		(Col. 3 X Col 8)
					3	4	5	6	7	8	9
23	Oxygen (Inhalation) Therapy											23
24	Physical Therapy											24
25	Occupational Therapy											25
26	Speech Pathology											26
27	Medical Supplies Charged to Patients											27
28	Drugs Charged to Patients											28
29	Other Costs Furnished by shared Departments											29
30	Total (Sum of lines 23 through 29)											30
31	Total component cost. Add the amount from Part I, line											31
	22 and the amount from line 30, columns 5, 7, and 9.
	(Transfer Titles V , XVIII, and XIX amounts
	to Worksheet J-3, columns 1,2 & 3 respectively.)
(1) Ratio of cost to charges: Part I - column 1 divided by column 2; Part II - From Wkst. C, col. 3, lines as applicable										i
(2) Charges for Part II, col. 2 are obtained from provider records



FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4154 )

Rev. 1												35-382

Sheet 53: J-3

DRAFT		FORM CMS 2540-10			4190 (Cont.)
CALCULATION OF		PROVIDER NO.:	PERIOD:
REIMBURSEMENT SETTLEMENT			FROM ____________	WORKSHEET J - 3
OF C.M.H.C. SERVICES		COMPONENT NO.:	TO ______________

		Title V	Title XVIII	Title XIX
		PROGRAM	PROGRAM	PROGRAM
		COST	COST	COST
		1	2	3
1	Cost of REHAB services (From Wkst. J-2,				1	2
	Part II, line. 31: Title V - col. 5; Title
	XVIII 'col 7; Title XIX - column 9)
2	Amounts paid and payable by Worker's				2	5
	Compensation and other primary payers
3	Subtotal (Line 1 minus line 2)				3	7

4	Part B deductible billed to Program				4	9
	patients (Exclude coinsurance amounts)
5	Net Cost (Line 3 minus line 4)				5	11

6	80% of Part B cost (80% X line 5)				6	13

7	Actual coinsurance billed to Program				7	15
	patients (From provider records)
8	Net cost less actual billed coinsurance				8
	(Line 5 minus line 7)
9	Reimbursable bad debts (See Instructions)				9

10	Reimbursable bad debts for dual eligible				10
	beneficiaries (see instructions)
11	Net reimbursable amount (See Instructions)				11

12	Amounts applicable to prior cost reporting				12
	periods resulting from disposition of
	depreciable assets
13	Recovery of excess depreciation resulting				13
	from facility's termination or a decrease
	in Program utilization
14	Other Adjustments				14

15	Total cost - reimbursable to provider				15

16	Interim payments				16

17	Balance due Component/Program				17
	(Line 15 minus line 16)
	(Indicate overpayments in brackets)
18	Protested amounts (Non allowable				18
	cost report items) in accordance with
	CMS Pub. 15-II, section 115.2
FORM CMS 2540-10 ( DRAFT ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN
CMS PUB 15-II, SECTION 4155 )

Rev. 1					41-383

Sheet 54: J-4

DRAFT			FORM CMS 2540-10				4190 (Cont.)
ANALYSIS OF PAYMENTS TO		PROVIDER NO.:		PERIOD:
PROVIDER - BASED C.M.H.C.		___________________		FROM ______________		WORKSHEET J - 4
FOR SERVICES RENDERED		COMPONENT NO.:
TO PROGRAM BENEFICIARIES		___________________		TO
					mm/dd/yyyy	Amount
	Description				1	2
1	Total interim payments paid to provider						1
2	Interim payments payable on individual bills, either submitted or to						2
	be submitted to the intermediary, for services rendered in the cost
	reporting period. If none, write "none", or enter zero.
3	List separately each retroactive			.01			3.01
	lump sum adjustment amount			.02			3.02
	based on subsequent revision		Program to	.03			3.03
	of the interim rate for the cost		Provider	.04			3.04
	reporting period.			.05			3.05
				.50			3.50
	Also show date of each payment.			.51			3.51
			Provider to	.52			3.52
	If none, write "NONE," or enter a zero.(1)		Program	.53			3.53
				.54			3.54
	SUBTOTAL (Sum of lines 3.01 - 3.05			.99			3.99
	minus sum of lines 3.50 - 3.55)
4	TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)						4
	(Transfer to Worksheet J-3: Part I line 17)

	TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR
5	List separately each tentative		Program to	.01			5.01
	settlement payment after desk review.		Provider	.02			5.02
				.03			5.03
	Also show date of each payment.		Provider to	.50			5.50
	If none, write "NONE," or enter a zero.(1)		Program	.51			5.51
				.52			5.52
	SUBTOTAL (Sum of lines 5.01 - 5.03			.99			5.99
	minus sum of lines 5.50 - 5.52)
6	Determined net settlement		Program to	.01			6.01
	amount (balance due) based		Provider	.02			6.02
	on the cost report. (1)		Provider to	.50			6.50
			Program	.51			6.51
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)						7
8	Name of Intermediary/Contractor				Intermediary/Contractor Number		8


9	Signature of Authorized Person				Date (mm/dd/yyyy)		9


(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the
	provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

FORM CMS 2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
	SECTION 4156)


Rev. 1							41-384

Sheet 55: K

DRAFT					FORM CMS-2540-10							4190 (Cont.)
							PROVIDER NO.: ___________		PERIOD:
ANALYSIS OF PROVIDER-BASED HOSPICE COSTS									FROM ____________		WORKSHEET K
							HOSPICE NO.: ____________		TO _______________
					CON-
			EMPLOYEE		TRACTED
		SALARIES	BENEFITS	TRANSPOR-	SERVICES				SUBTOTAL		TOTAL
	COST CENTER DESCRIPTIONS	(from	(from	TATION	(from		TOTAL	RECLASSI-	(col. 6	ADJUST-	(col. 8
		Wkst. K-1)	Wkst. K-2)	(see inst.)	Wkst. K-3)	OTHER	(cols. 1-5)	FICATION	± col. 7)	MENTS	± col. 9)
		1	2	3	4	5	6	7	8	9	10
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.											1
2	Capital Related Costs-Movable Equip.											2
3	Plant Operation and Maintenance											3
4	Transportation - Staff											4
5	Volunteer Service Coordination											5
6	Administrative and General											6
	INPATIENT CARE SERVICE
7	Inpatient - General Care											7
8	Inpatient - Respite Care											8
	VISITING SERVICES
9	Physician Services											9
10	Nursing Care											10
11	Nursing Care-Continuous Home Care											11
12	Physical Therapy											12
13	Occupational Therapy											13
14	Speech/ Language Pathology											14
15	Medical Social Services											15
16	Spiritual Counseling											16
17	Dietary Counseling											17
18	Counseling - Other											18
19	Home Health Aide and Homemaker											19
20	HH Aide & Homemaker-Cont. Home Care											20
21	Other											21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biological and Infusion Therapy											22
23	Analgesics											23
24	Sedatives / Hypnotics											25
25	Other - Specify											25
26	Durable Medical Equipment/Oxygen											26
27	Patient Transportation											27
28	Imaging Services											28
29	Labs and Diagnostics											29
30	Medical Supplies											30
31	Outpatient Services (including E/R Dept.)											31
32	Radiation Therapy											32
33	Chemotherapy											33
34	Other											34
	HOSPICE NONREIMBURSABLE SERVICE
35	Bereavement Program Costs											35
36	Volunteer Program Costs											36
37	Fundraising											37
38	Other Program Costs											38
39	Total (sum of lines 1 thru 38)											39
FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4157)
Rev. 1												41-385

Sheet 56: K-1

DRAFT				FORM CMS-2540-10							4190 (Cont.)
			PROVIDER NO:		HOSPICE NO:		PERIOD:
HOSPICE COMPENSATION ANALYSIS							FROM ________________		WORKSHEET K-1
SALARIES AND WAGES				_			TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care- Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemaker										19
20	HH Aide & Homaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS		D R A F T		D R A F T		D R A F T		D R A F T
22	Drugs, Biological and Infusion Therapy										22
23	Analgesics										23
24	Sedative/Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (incl. E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERV.
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total										39
(1) Transfer the amount in column 9 to Wkst K, column 1
FORM CMS-2540-10 ( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4158)
Rev. 1											41-386

Sheet 57: K-2

4190 (Cont.)					FORM CMS-2540-10						DRAFT
			PROVIDER NO:		HOSPICE NO:		PERIOD:
HOSPICE COMPENSATION ANALYSIS							FROM ____________________		WORKSHEET K-2
EMPLOYEE BENEFITS (PAYROLL RELATED)							TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care- Continuous Home Care										10
11	Nursing Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemaker										19
20	HH Aide & Homaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs Biological and Infusion Therapy										22
23	Analgesics										23
24	Sedative/Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/ Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (incl. E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERV.
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total										39
(1) Transfer the amounts in column 9 to Wkst K, column 2
FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4159)
41-387											Rev. 1

Sheet 58: K-3

DRAFT					FORM CMS-2540-10						4190 (Cont.)
			PROVIDER NO:		HOSPICE NO:		PERIOD:
HOSPICE COMPENSATION ANALYSIS							FROM ___________________		WORKSHEET K-3
CONTRACTED SERVICES / PURCHASED SERVICES				_			TO _______________
	COST CENTER DESCRIPTIONS	ADMINIS		SOCIAL	SUPER-		TOTAL
	(omit cents)	TRATOR	DIRECTOR	SERVICES	VISORS	NURSES	THERAPISTS	AIDES	ALL OTHER	TOTAL (1)
		1	2	3	4	5	6	7	8	9
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Moveable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care- Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemaker										19
20	HH Aide & Homaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biological and Infusion Therapy										22
23	Analgesics										23
24	Sedative/Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (incl. E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERV.
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total										39
(1) Transfer the amounts in column 9 to Wkst K, column 4
FORM CMS-2540-10 ( DRAFT (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4160)
Rev. 1											41-388

Sheet 59: K-4-1

4190 (Cont.)					FORM CMS-2540-10						DRAFT
			PROVIDER NO:		HOSPICE NO:		PERIOD:
COST ALLOCATION - HOSPICE							FROM ____________		WORKSHEET K-4
GENERAL SERVICE COST					_		TO _______________		PART I
		FR. WKST. K		CAPITAL
		COL. 10: NET	CAPITAL	RELATED			VOLUNTEER
		EXPENSES	RELATED	COST	PLANT		SERV.		ADMINIS-
	COST CENTER DESCRIPTIONS	FOR COST	COST BLDG	MOVABLE	OPERATION		COORDI-	SUBTOTAL	TRATIVE &
		ALLOC. (1)	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	(col. 0 - 5)	GENERAL	TOTAL
		0	1	2	3	4	5	5A	6	7
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Bldg and Fixt.										1
2	Capital Related Costs-Movable Equip.										2
3	Plant Operation and Maintenance										3
4	Transportation - Staff										4
5	Volunteer Service Coordination										5
6	Administrative and General										6
	INPATIENT CARE SERVICE
7	Inpatient - General Care										7
8	Inpatient - Respite Care										8
	VISITING SERVICES
9	Physician Services										9
10	Nursing Care										10
11	Nursing Care- Continuous Home Care										11
12	Physical Therapy										12
13	Occupational Therapy										13
14	Speech/ Language Pathology										14
15	Medical Social Services - Direct										15
16	Spiritual Counseling										16
17	Dietary Counseling										17
18	Counseling - Other										18
19	Home Health Aide and Homemakers										19
20	HH Aide & Homaker - Cont. Home Care										20
21	Other										21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biologicals and Infusion										22
23	Analgesics										23
24	Sedative/Hypnotics										24
25	Other - Specify										25
26	Durable Medical Equipment/Oxygen										26
27	Patient Transportation										27
28	Imaging Services										28
29	Labs and Diagnostics										29
30	Medical Supplies										30
31	Outpatient Services (incl. E/R Dept.)										31
32	Radiation Therapy										32
33	Chemotherapy										33
34	Other										34
	HOSPICE NONREIMBURSABLE SERV.
35	Bereavement Program Costs										35
36	Volunteer Program Costs										36
37	Fundraising										37
38	Other Program Costs										38
39	Total										39
	(1) Column 0, line 29 must agree with Wkst. A, column 7, line 83.
FORM CMS-2540-10( DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4161)
41-389											Rev. 1

Sheet 60: K-4-2

DRAFT				FORM CMS-2540-10					4190 (Cont.)
		PROVIDER NO:		HOSPICE NO:		PERIOD:
COST ALLOCATION -						FROM ____________		WORKSHEET K-4
HOSPICE STATISTICAL BASIS				_		TO _______________		PART II
			CAPITAL
		CAPITAL	RELATED			VOLUNTEER
		RELATED	COST	PLANT		SERV.		ADMINIS-
		COST BLDG	MOVABLE	OPERATION	TRANS-	COORDI-		TRATIVE &
	COST CENTER DESCRIPTIONS	& FIXTURES	EQUIPMENT	& MAINT.	PORTATION	NATOR	RECONCI-	GENERAL
		(SQ. FT.)	$ VALUE)	(SQ. FT.)	MILEAGE	(HOURS)	LIATION	(ACC. COST)
		1	2	3	4	5	6A	6
	GENERAL SERVICE COST CENTERS
1	Capital Related Costs-Buildings and Fixtures								1
2	Capital Related Costs-Movable Equipment								2
3	Plant Operation and Maintenance								3
4	Transportation-staff								4
5	Volunteer Service Coordination								5
6	Administrative and General								6
	INPATIENT CARE SERVICE
7	Inpatient - General Care								7
8	Inpatient - Respite Care								8
	VISITING SERVICES
9	Physician Services								9
10	Nursing Care								10
11	Nursing Care- Continuous Home Care								11
12	Physical Therapy								12
13	Occupational Therapy								13
14	Speech/ Language Pathology								14
15	Medical Social Services - Direct								15
16	Spiritual Counseling								16
17	Dietary Counseling								17
18	Counseling - Other								18
19	Home Health Aide and Homemakers								19
20	HH Aide & Homaker - Cont. Home Care								20
21	Other								21
	OTHER HOSPICE SERVICE COSTS
22	Drugs, Biologicals and Infusion								22
23	Analgesics								23
24	Sedative/Hypnotics								24
25	Other - Specify								25
26	Durable Medical Equipment/Oxygen								26
27	Patient Transportation								27
28	Imaging Services								28
29	Labs and Diagnostics								29
30	Medical Supplies								30
31	Outpatient Services (incl. E/R Dept.)								31
32	Radiation Therapy								32
33	Chemotherapy								33
34	Other								34
	HOSPICE NONREIMBURSABLE SERV.
35	Bereavement Program Costs								35
36	Volunteer Program Costs								36
37	Fundraising								37
38	Other Program Costs								38
49	Cost To be Allocated (per Wkst K-4, Part I)								49
50	Unit Cost Multiplier								50
FORM CMS-2540-10( DRAFT (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4161)
Rev. 1									41-390

Sheet 61: K-5-1

4190 (Cont.)			FORM CMS-2540-10						DRAFT	DRAFT				FORM CMS-2540-10					4190 (Cont.)	4190 (Cont.)				FORM CMS-2540-10					DRAFT
			PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD
ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		PART I			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part I (Cont.)			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part I (Cont.)
		From
		Wkst.	HOSPICE	CAPITAL	CAPITAL							PLANT															ALLOCATED
	HOSPICE COST CENTER	K-4	TRIAL	RELATED	RELATED			ADMINIS-			HOSPICE COST CENTER	OPERATION	LAUNDRY			NURSING	CENTRAL				HOSPICE COST CENTER	MEDICAL			OTHER	SUBTOTAL	HOSPICE	TOTAL
	(omit cents)	Part I,	BALANCE	BLDGS. &	MOVABLE	EMPLOYEE	SUBTOTAL	TRATIVE &			(omit cents)	MAINTENANCE	& LINEN	HOUSE		ADMINIS-	SERVICES &				(omit cents)	RECORDS &	SOCIAL	INTERNS &	GENERAL	(Sum of Columns	A&G (see	HOSPICE
		col. 6,	(1)	FIXTURES	EQUIPMENT	BENEFITS	(cols. 0-3)	GENERAL				& REPAIRS	SERVICE	KEEPING	DIETARY	TRATION	SUPPLY	PHARMACY				LIBRARY	SERVICE	RESIDENTS	SERVICE	4a through 15)	Part II)	COSTS
		line -	0	1	2	3	4a	4				5	6	7	8	9	10	11				12	13	14	15	16	17	18
6	Administrative and General	6							6	6	Administrative and General								6	6	Administrative and General								6
7	Inpatient - General Care	7							7	7	Inpatient - General Care								7	7	Inpatient - General Care								7
8	Inpatient - Respite Care	8							8	8	Inpatient - Respite Care								8	8	Inpatient - Respite Care								8
9	Physician Services	9							9	9	Physician Services								9	9	Physician Services								9
10	Nursing Care	10							10	10	Nursing Care								10	10	Nursing Care								10
11	Nursing Care- Continuous Home Care	11							11	11	Nursing Care- Continuous Home Care								11	11	Nursing Care- Continuous Home Care								11
12	Physical Therapy	12							12	12	Physical Therapy								12	12	Physical Therapy								12
13	Occupational Therapy	13							13	13	Occupational Therapy								13	13	Occupational Therapy								13
14	Speech/ Language Pathology	14							14	14	Speech/ Language Pathology								14	14	Speech/ Language Pathology								14
15	Medical Social Services - Direct	15							15	15	Medical Social Services - Direct								15	15	Medical Social Services - Direct								15
16	Spiritual Counseling	16							16	16	Spiritual Counseling								16	16	Spiritual Counseling								16
17	Dietary Counseling	17							17	17	Dietary Counseling								17	17	Dietary Counseling								17
18	Counseling - Other	18							18	18	Counseling - Other								18	18	Counseling - Other								18
19	Home Health Aide and Homemakers	19							19	19	Home Health Aide and Homemakers								19	19	Home Health Aide and Homemakers								19
20	HH Aide & Homaker - Cont. Home Care	20							20	20	HH Aide & Homaker - Cont. Home Care								20	20	HH Aide & Homaker - Cont. Home Care								20
21	Other	21							21	21	Other								21	21	Other								21
22	Drugs, Biologicals and Infusion	22							22	22	Drugs, Biologicals and Infusion								22	22	Drugs, Biologicals and Infusion								22
23	Analgesics	23							23	23	Analgesics								23	23	Analgesics								23
24	Sedative/Hypnotics	24							24	24	Sedative/Hypnotics								24	24	Sedative/Hypnotics								24
25	Other - Specify	25							25	25	Other - Specify								25	25	Other - Specify								25
26	Durable Medical Equipment/Oxygen	26							26	26	Durable Medical Equipment/Oxygen								26	26	Durable Medical Equipment/Oxygen								26
27	Patient Transportation	27							27	27	Patient Transportation								27	27	Patient Transportation								27
28	Imaging Services	28							28	28	Imaging Services								28	28	Imaging Services								28
29	Labs and Diagnostics	29							29	29	Labs and Diagnostics								29	29	Labs and Diagnostics								29
30	Medical Supplies	30							30	30	Medical Supplies								30	30	Medical Supplies								30
31	Outpatient Services (incl. E/R Dept.)	31							31	31	Outpatient Services (incl. E/R Dept.)								31	31	Outpatient Services (incl. E/R Dept.)								31
32	Radiation Therapy	32							32	32	Radiation Therapy								32	32	Radiation Therapy								32
33	Chemotherapy	33							33	33	Chemotherapy								33	33	Chemotherapy								33
34	Other	34							34	34	Other								34	34	Other								34
35	Bereavement Program Costs	35							35	35	Bereavement Program Costs								35	35	Bereavement Program Costs								35
36	Volunteer Program Costs	36							36	36	Volunteer Program Costs								36	36	Volunteer Program Costs								36
37	Fundraising	37							37	37	Fundraising								37	37	Fundraising								37
38	Other Program Costs	38							38	38	Other Program Costs								38	38	Other Program Costs								38
39	Totals (sum of lines 1-28)								39	39	Totals (sum of lines 1-28) (2)								39	39	Totals (sum of lines 1-28) (2)								39
50	Unit Cost Multiplier:								50	50	Unit Cost Multiplier:								50	50	Unit Cost Multiplier:								50
	Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.										Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.										Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.
(2) Columns 0 through 16 , line 29 must agree with the corresponding columns of Wkst. B, Part I, line 83.
FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)										FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)										FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)

41-391									Rev. 1	Rev. 1									41-392	41-393									Rev. 1

Sheet 62: K-5-II

DRAFT			FORM CMS-2540-10					41190 (Cont.)	4190 (Cont.)			FORM CMS-2540-10						DRAFT	DRAFT			FORM CMS-2540-10				4190 (Cont.)
		PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD								PROVIDER NO.:		PERIOD
ALLOCATION OF GENERAL SERVICE				FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________		WORKSHEET K-5,			ALLOCATION OF GENERAL SERVICE					FROM:_______________	WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS		HOSPICE NO.:		TO: _________________		PART II			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________		Part II (Cont.)			COSTS TO HOSPICE COST CENTERS			HOSPICE NO.:		TO: _________________	Part II (Cont.)
			CAPITAL	CAPITAL							PLANT	LAUNDRY			NURSING	CENTRAL
	HOSPICE COST CENTER		RELATED	RELATED			ADMINIS-			HOSPICE COST CENTER	OPERATION	& LINEN	HOUSE		ADMINIS-	SERVICES &				HOSPICE COST CENTER	MEDICAL			OTHER
	(omit cents)		BLDGS. &	MOVABLE	EMPLOYEE	RECONCIL	TRATIVE &			(omit cents)	MAINTENANCE	SERVICE	KEEPING		TRATION	SUPPLY	PHARMACY			(omit cents)	RECORDS &	SOCIAL	INTERNS &	GENERAL
			FIXTURES	EQUIPMENT	BENEFITS	LATION	GENERAL				& REPAIRS	(Pounds of		DIETARY	(Direct Nursing	(Costed	(Costed				LIBRARY	SERVICE	RESIDENTS	SERVICE
			(Square Feet)	(Dollar Value)	(Gross Salaries)		(Accum. Cost)				(Square Feet)	Laundry)	(Hours of Service)	(Meals Served)	Hours)	Requisitions)	Requisitions)				(Time Spent)	(Time Spent)	(Assigned Time)	(Specify)
			1	2	3	4a	4				5	6	7	8	9	10	11				12	13	14	15
6	Administrative and General							6	6	Administrative and General								6	6	Administrative and General						6
7	Inpatient - General Care							7	7	Inpatient - General Care								7	7	Inpatient - General Care						7
8	Inpatient - Respite Care							8	8	Inpatient - Respite Care	D R A F T							8	8	Inpatient - Respite Care	D R A F T					8
9	Physician Services							9	9	Physician Services								9	9	Physician Services						9
10	Nursing Care							10	10	Nursing Care								10	10	Nursing Care						10
11	Nursing Care- Continuous Home Care	D R A F T						11	11	Nursing Care- Continuous Home Care								11	11	Nursing Care- Continuous Home Care						11
12	Physical Therapy							12	12	Physical Therapy		D R A F T						12	12	Physical Therapy						12
13	Occupational Therapy							13	13	Occupational Therapy								13	13	Occupational Therapy						13
14	Speech/ Language Pathology							14	14	Speech/ Language Pathology								14	14	Speech/ Language Pathology						14
15	Medical Social Services - Direct		D R A F T					15	15	Medical Social Services - Direct								15	15	Medical Social Services - Direct						15
16	Spiritual Counseling							16	16	Spiritual Counseling								16	16	Spiritual Counseling						16
17	Dietary Counseling							17	17	Dietary Counseling			D R A F T					17	17	Dietary Counseling						17
18	Counseling - Other							18	18	Counseling - Other								18	18	Counseling - Other		D R A F T				18
19	Home Health Aide and Homemakers							19	19	Home Health Aide and Homemakers								19	19	Home Health Aide and Homemakers						19
20	HH Aide & Homaker - Cont. Home Care			D R A F T				20	20	HH Aide & Homaker - Cont. Home Care								20	20	HH Aide & Homaker - Cont. Home Care						20
21	Other							21	21	Other				D R A F T				21	21	Other						21
22	Drugs, Biologicals and Infusion							22	22	Drugs, Biologicals and Infusion								22	22	Drugs, Biologicals and Infusion						22
23	Analgesics							23	23	Analgesics								23	23	Analgesics						23
24	Sedative/Hypnotics							24	24	Sedative/Hypnotics								24	24	Sedative/Hypnotics						24
25	Other - Specify				D R A F T			25	25	Other - Specify					D R A F T			25	25	Other - Specify						25
26	Durable Medical Equipment/Oxygen							26	26	Durable Medical Equipment/Oxygen								26	26	Durable Medical Equipment/Oxygen						26
27	Patient Transportation							27	27	Patient Transportation								27	27	Patient Transportation						27
28	Imaging Services							28	28	Imaging Services								28	28	Imaging Services			D R A F T			28
29	Labs and Diagnostics							29	29	Labs and Diagnostics						D R A F T		29	29	Labs and Diagnostics						29
30	Medical Supplies					D R A F T		30	30	Medical Supplies								30	30	Medical Supplies						30
31	Outpatient Services (incl. E/R Dept.)							31	31	Outpatient Services (incl. E/R Dept.)								31	31	Outpatient Services (incl. E/R Dept.)						31
32	Radiation Therapy							32	32	Radiation Therapy								32	32	Radiation Therapy						32
33	Chemotherapy							33	33	Chemotherapy							D R A F T	33	33	Chemotherapy						33
34	Other							34	34	Other								34	34	Other						34
35	Bereavement Program Costs						D R A F T	35	35	Bereavement Program Costs								35	35	Bereavement Program Costs						35
36	Volunteer Program Costs							36	36	Volunteer Program Costs								36	36	Volunteer Program Costs						36
37	Fundraising							37	37	Fundraising								37	37	Fundraising						37
38	Other Program Costs							38	38	Other Program Costs								38	38	Other Program Costs				D R A F T		38
39	Totals (sum of lines 1-28)							39	39	Totals (sum of lines 1-28)								39	39	Totals (sum of lines 1-28)						39
50	Unit Cost Multiplier							50	50	Unit Cost Multiplier								50	50	Unit Cost Multiplier						50
FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)									FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)										FORM CMS-2540-10 ( DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)
Rev. 1								41-394	41-395									Rev. 1	Rev. 1							41-396

Sheet 63: K-5-III

4190 (Cont.)				FORM CMS-2540-10						DRAFT
				PROVIDER NO.:		PERIOD:		WORKSHEET
APPORTIONMENT OF HOSPICE SHARED SERVICES						From:			K-5
				HOSPICE NO.:		To:			Part III

PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS
Hospice shared cost computation							Total Hospice		Hospice Shared
		Facility Cost		Cost to Charge Ratio			Charges		Ancillary Costs
		From Worksheet K-5, Part I		From Worksheet C, Col. 3			(From Provider		(col. 4 x col. 5)
	COST CENTER	Line:	Amount:	Line :	Ratio		Records)
		1	2	3	4		5		6
ANCILLARY SERVICE COST CENTERS
1	Physical Therapy	12		44						1
2	Occupational Therapy	13		45						2
3	Speech/ Language Pathology	14		46						3
4	Drugs, Biologicals and Infusion	22		49						4
5	Labs and Diagnostics	29		41						5
6	Medical Supplies	30		48						6
7	Radiation Therapy	32		40						7
8	Other	34		52						8
9	Total (sum of lines 1-8)									9













FORM CMS-2540-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)

41-397										Rev. 1

Sheet 64: K6

DRAFT			FORM CMS-2540-10				4190 (Cont.)
	CALCULATION OF	PROVIDER NO.		PERIOD:
	PER DIEM COST			FROM ________________		WORKSHEET K-6
		_________________		TO ________________


	COMPUTATION OF PER DIEM COST		TITLE XVIII	TITLE XIX	OTHER	TOTAL
			1	2	3	4
1	Total cost (Worksheet K, line 39 less line 38, col. 7)						1
2	Total Unduplicated Days (Worksheet S-8, line 5, col. 6)						2
3	Average cost per diem (line 1 divided by line 2)						3
4	Unduplicated Medicare Days (Worksheet S-8, line 5, col. 1)						4
5	Average Medicare cost (line 3 times line 4)						5
6	Unduplicated Medicaid Days (Worksheet S-8, line 5, col. 2)						6
7	Average Medicaid cost (line 3 times line 6)						7
8	Unduplicated SNF days (Worksheet S-8, line 5, col. 3)						8
9	Average SNF cost (line 3 times line 8)						9
10	Unduplicated NF days (Worksheet S-8, line 5, col. 4)						10
11	Average NF cost (line 3 times line 10)						11
12	Other Unduplicated days (Worksheet S-8, line 5, col. 5)						12
13	Average cost for other days (line 3 times line 12)						13

















FORM CMS 2540-10 (DRAFT ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4163)
Rev. 1							41-398

File Type	application/vnd.ms-excel
Last Modified By	CMS
File Modified	2010-06-08
File Created	1999-10-19