Form CMS-2008-92 Cost Report

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Overview

Notes
S^
S_4^
S-1^
A^
A_2^
A1^
A3
A31
B^
B_2^
B_3^
B-1^
B-1_2
B-1_3
C
C_2
D^
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A82
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Sheet 1: Notes

^ Indicates revised worksheets in current transmittal.

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Sheet 2: S^

12-04				FORM CMS 2088-92					1890 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result
in all interim payments made since the beginning of the cost reporting period being deemed							FORM APPROVED
as overpayments (42 USC 1395g).							OMB NO. 0938-0037
OUTPATIENT REHABILITATION PROVIDER COST				PROVIDER NO.:		PERIOD:		WORKSHEET S,
REPORT IDENTIFICATION DATA, CERTIFICATION						From: ___________		PARTS I - III
AND SETTLEMENT SUMMARY				_______________		To: ___________
	Intermediary Use Only:
	[ ] Audited	Date Received		_______________		[ ] Initial		[ ] Re-opened
	[ ] Desk Reviewed	Intermediary No.		_______________		[ ] Final
PART I - IDENTIFICATION DATA
Outpatient Rehabilitation Facility:
1	Name:								1
1.01	Street:					P.O. Box:			1.01
1.02	City:		State:			Zip Code:			1.02
1.03	Cost Reporting Period (mm/dd/yyy)		From:			To:			1.03
		Type of Control			Type of Provider
	Provider No.	(see instructions)			(see instructions)		Date Certified
	1	2	3		4		5
2									2
3	List malpractice premiums and paid losses:								3
3.01	Premiums								3.01
3.02	Paid Losses								3.02
3.03	Self Insurance								3.03
4	Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center?								4
	If yes, submit a supporting schedule listing cost centers and amounts contained therein.
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY
CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF
SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED 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 DIRECTOR OF THE AGENCY
	I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Outpatient Rehabilitation Provider
	Cost Report and the Balance Sheet and Statement of Revenue and Expenses prepared by _______________________________________
	(Provider name(s) and number(s)) for the cost report beginning _____________________and ending __________________________, and
	that to the best of my knowledge and belief, it is a true, correct and complete report 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, and that the services identified in this cost report were provided in compliance with such laws and
	regulations.
		(Signed)	__________________________________________
			Officer or Director
			__________________________________________
			Title
			__________________________________________
			Date
PART III - SETTLEMENT SUMMARY
						TITLE XVIII
						PART B
						1
6	OUTPATIENT REHABILITATION PROVIDER (specify type)								6
"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 0938-0037. The
time required to complete this information collection is estimated to average 100 hours per response, including the time to
review instructions, search existing data 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, C4-06-25 Baltimore, Maryland 21244-1850."
FORM CMS-2088-92-S (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS. 1802-1802.3)
Rev. 7									18-303

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Sheet 3: S_4^

1890 (Cont.)																										FORM CMS 2088-92												12-04
OUTPATIENT REHABILITATION																				PERIOD:										PROVIDER NO:					WORKSHEET S
PROVIDER COST REPORT																				FROM __________________															PART IV
STATISTICAL DATA																				TO _____________________										___________________
													VISITS										PATIENTS									FTE ON PAYROLL
	REIMBURSABLE												Medicare				Other															Staff		Social
	COST CENTERS												Patients				Patients			Total			Medicare				Other			Total		Therapists	Physicians	Workers	Others
													1				2			3			4				5			6		7	8	9	10
	CORF
1	Skilled Nursing Care																																					1
2	Physical Therapy																																					2
3	Speech Pathology																																					3
4	Occupational Therapy																																					4
5	Respiratory Therapy																																					5
6	Medical Social Services																																					6
7	Psychological Services																																					7
8	Prosthetic and Orthotic Devices																																					8
8	Drugs and Biologicals																																					8
10	Medical Supplies																																					10
11	DME-Sold																																					11
12	DME-Rented																																					12
13	Other Services																																					13
	CMHC
14	Drugs and Biologicals																																					14
15	Occupational Therapy																																					15
16	Psychiatric/Psychological Services																																					16
17	Individual Therapy																																					17
18	Group Therapy																																					18
19	Individualized Activity Therapies																																					19
20	Family Counseling																																					20
21	Diagnostic Services																																					21
22	Patient Training & Education																																					22
23	Other Services																																					23
	OTHER PROVIDERS
24	Physical Therapy																																					24
25	Speech Pathology																																					25
26	Occupational Therapy																																					26
27	Other Services																																					27
28	Total (Sum of lines 1-27)																																					28
29	Unduplicated Census Count																																					29
FORM CMS-2088-92-S (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II,SECS.1802.4)
18-304																																						Rev. 7

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Sheet 4: S-1^

12-04				FORM CMS 2088-92					1890 (Cont.)
ANALYSIS OF PAYMENTS TO				PROVIDER NO.:	PERIOD:			SUPPLEMENTAL
OUTPATIENT REHABILITATION					FROM: ______________			WORKSHEET S-1
PROVIDERS FOR SERVICES RENDERED				______________	TO: _______________
TO PROGRAM BENEFICIARIES
	DESCRIPTION						PART B
							1	2
							mm/dd/yyyy	Amount
1	Total interim payments paid to Outpatient Rehabilitation 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 a zero.
3	List separately each retroactive lump sum					.01			3.01
	adjustment amount based on subsequent revision				Program	.02			3.02
	of the interim rate for the cost reporting period.				to	.03			3.03
	Also show date of each payment. If none write				Provider	.04			3.04
	"NONE" or enter a zero. (1)					.05			3.05
						.50			3.50
					Provider	.51			3.51
					to	.52			3.52
					Program	.53			3.53
						.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 D, Part I, line 18)
			TO BE COMPLETED BY INTERMEDIARY
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) based				Program
	on the cost report (SEE INSTRUCTIONS). (1)				to
					Provider	.01			6.01
					Provider
					to
					Program	.02			6.02
7	TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)								7
Name of Intermediary						Intermediary Number
Signature of Authorized Person						Date: (Month, Day, Year)
(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-2088-92-S-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.
1806)
Rev. 7									18-305

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Sheet 5: A^

1890 (Cont.)				FORM CMS 2088-92						12-04
					PROVIDER NO:		PERIOD:		WORKSHEET A
	RECLASSIFICATION AND ADJUSTMENT OF						FROM ___________		Page 1 of 2
	TRIAL BALANCE OF EXPENSES (Omit Cents)				___________		TO ___________
						RECLASS.	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
					TOTAL	(from	TRIAL BALANCE	(from	FOR ALLOCATION
		COST CENTERS	SALARIES	OTHER	(Col 1 + Col 2)	Wkst. A-1)	(Col 3 +/- Col 4)	Wkst. A-3)	(Col 5 +/- Col 6)
			1	2	3	4	5	6	7
		GENERAL SERVICE COST CENTERS
1	0100	Capital Related Costs--Buildings and Fixtures								1
2	0200	Capital Related Costs--Movable Equipment								2
3	0300	Employee Benefits								3
4	0400	Administrative and General								4
5	0500	Maintenance and Repairs								5
6	0600	Operation of Plant								6
7	0700	Laundry and Linen Service								7
8	0800	Housekeeping								8
9	0900	Cafeteria								9
10	1000	Central Services and Supply								10
11	1100	Medical Records and Library								11
12	1200	Professional Education and Training (1)								12
13		Other (specify)								13
14		Other (specify)								14
		REIMBURSABLE SERVICE COST CENTERS
		CORF
15	1500	Skilled Nursing Care								15
16	1600	Physical Therapy								16
17	1700	Speech Pathology								17
18	1800	Occupational Therapy								18
19	1900	Respiratory Therapy								19
20	2000	Medical Social Services								20
21	2100	Psychological Services								21
22	2200	Prosthetic and Orthotic Devices								22
23	2300	Drugs and Biologicals								23
24	2400	Medical Supplies Charged to Patients								24
25	2500	DME-Sold								25
26	2600	DME-Rented								26
27		Other (specify)								27
		CMHC
29	2900	Drugs and Biologicals								29
30	3000	Occupational Therapy								30
31	3100	Psychiatric/Psychological Services								31
32	3200	Individual Therapy								32
33	3300	Group Therapy								33
34	3400	Individualized Activity Therapies								34
35	3500	Family Counseling								35
36	3600	Diagnostic Services								36
37	3700	Patient Training & Education								37
38		Other (specify)								38
FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,SEC.1804)
18-306										Rev. 7

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Sheet 6: A_2^

12-04					FORM CMS 2088-92					1890 (Cont.)
					PROVIDER NO:		PERIOD:		WORKSHEET A
	RECLASSIFICATION AND ADJUSTMENT OF						FROM ___________		Page 2 of 2
	TRIAL BALANCE OF EXPENSES (Omit Cents)				___________		TO ____________
						RECLASS.	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
					TOTAL	(from	TRIAL BALANCE	(from	FOR ALLOCATION
		COST CENTERS	SALARIES	OTHER	(Col 1 + Col 2)	Wkst. A-1)	(Col 3 +/- Col 4)	Wkst. A-3)	(Col 5 +/- Col 6)
			1	2	3	4	5	6	7
		OTHER PROVIDERS
40	4000	Physical Therapy								40
41	4100	Speech Therapy								41
42	4200	Occupational Therapy								42
43	4300	Other (specify)								43
		NONREIMBURSABLE COST CENTERS
45	4500	Sheltered Workshops								45
46	4600	Recreational Programs								46
47	4700	Resident Day Camps								47
48	4800	Pre-school Programs								48
49	4900	Diagnostic Clinics								49
50	5000	Home Employment Programs								50
51	5100	Equipment Loan Service								51
52	5200	Physicians' Private Offices								52
53	5300	Fund Raising								53
54	5400	Coffee Shops and Canteen								54
55	5500	Research								55
56	5600	Investment Property								56
57	5700	Advertising								57
58	5800	Franchise Fees and Other Assessments								58
59	5900	Professional Education and Training(2)								59
60		Other (specify)								60
		CMHC NON-REIMBURSABLE COST CENTERS
61	6100	Meals and Transportation								61
62	6200	Activity Therapies								62
63	6300	Psychosocial Programs								63
64	6400	Vocational Training								64
65		TOTAL(sum of lines 1- 64)								65
		(1) Approved Educational Activity
		(2) Not An Approved Educational Activity
FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1804)
Rev. 7										18-307

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Sheet 7: A1^

1890 (Cont.)				FORM CMS 2088-92					12-04
				PROVIDER NO:		PERIOD:		WORKSHEET A-1
	RECLASSIFICATIONS					FROM ___________
				___________		TO ___________
	EXPLANATION OF	CODE		INCREASE			DECREASE
	RECLASSIFICATION ENTRY	(1)	COST CENTER	LINE NO.	AMOUNT(2)	COST CENTER	LINE NO.	AMOUNT(2)
		1	2	3	4	5	6	7
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	TOTAL RECLASSIFICATIONS(Sum of Col. 4								30
	must equal Col. 7)
	(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-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1805)
18-308									Rev. 7

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Sheet 8: A3

08-99			FORM CMS 2088-92						1890 (Cont.)
ADJUSTMENTS TO EXPENSES			PROVIDER NO.:		PERIOD:		WORKSHEET A-3
					FROM ____________
			____________		TO _______________
					EXPENSE CLASSIFICATION ON
					WORKSHEET A TO/FROM WHICH
	DESCRIPTION (1)				THE AMOUNT IS TO BE ADJUSTED
		BASIS (2)	AMOUNT		COST CENTER		LINE NO.
		1	2		3		4
1	Payments received from							1
	specialists	B
2	Investment income							2
	(chapter 2)
3	Trade, quantity and time discounts	B						3
	(chapter 8)
4	Refunds and rebates of expenses	B						4
	(chapter 8)
5	Laundry and linen service				Laundry and Linen Service		7	5
6	Cafeteria--employees,							6
	guests, etc.				Cafeteria		9
7	Sale of medical and surgical				Central Services and			7
	supplies to other than patients				Supply		10
8	Sale of workshop products							8
	or services
9	Coffee shops and canteen							9
10	Vending Machines							10
11	Rental of building or office							11
	space to others
12	Sale of scrap, waste,							12
	etc.(Chapter 23)
13	Related organization transactions	Supp. Wks						13
	(chapter 10)	A-3-1
14	Provider-based physician	Supp. Wks.						14
	adjustment	A-8-2
15	Respiratory Therapy limit	Supp. Wks.						15
	adjustment	A-8-4
16	Physical therapy limit	Supp. Wks.						16
	adjustment	A-8-3
17	Respiratory Therapy limit	Supp. Wks.						17
	adjustment	A-8-5
17.1	Physical therapy limit	Supp. Wks.						17.1
	adjustment	A-8-5
17.2	Occupational therapy limit	Supp. Wks.						17.2
	adjustment	A-8-5
17.3	Speech pathology limit	Supp. Wks.						17.3
	adjustment	A-8-5
18	Other (Specify) (3)							18
19	Other (Specify) (3)							19
20	Capital Related Costs-Buildings				Capital Related Costs			20
	and fixtures	A			Buildings & Fixtures		1
21	Capital Related Costs- Movable				Capital Related Costs			21
	Equipment	A			Movable Equipment		2
22	TOTAL (Sum of lines 1-21)							22
	(Transfer to Worksheet A, col.6, line 65)
	(1) Include amounts not already applied against expenses included on Worksheet A, column 3
	(2) Basis for adjustment (SEE INSTRUCTIONS).
	A. Costs -- if cost, including applicable overhead, can be determined.
	B. Amount Received -- if cost cannot be determined.
	(3) Additional adjustments may be made on subscripts of this line.
	Chapter references are to CMS Pub.15-I
FORM CMS-2088-92 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1806)
Rev. 3									18-309

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Sheet 9: A31

1890 (Cont.)

FORM CMS 2088-92

08-99

PROVIDER NO:

PERIOD:

SUPPLEMENTAL

STATEMENT OF COSTS OF SERVICES

FROM ___________

WORKSHEET A-3-1

FROM RELATED ORGANIZATIONS

___________

TO ___________

A. Are there any costs included in Worksheet A which resulted from transactions with related

organizations as defined in CMS Pub. 15-I, chapter 10?

[ ] Yes (If "Yes," complete Parts B and C)

[ ] No

B. Costs incurred and adjustments required as a result of transactions with related organizations:

Net

Location and amount included on Worksheet A, Column 5

Amount

Adjustments

Allowable

(Col 3 minus

Line No.

Cost Center

Amount

In Cost

Col 4)

1

2

3

4

5

1

2

3

4

5

TOTALS (Sum of lines 1-4)

(Transfer col. 5, line 5 to

Worksheet A-3, line 13)

C. 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 C of this worksheet.

This information is used by the Centers for Medicare and Medicaid Services and its intermediaries 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)

Percentage

Percentage

Symbol

Name

of

Name

of

Type of

(1)

Ownership

Ownership

Business

1

2

3

4

5

6

1

2

3

4

5

(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related

organization and in provider.

B. Corporation, partnership or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator or key person of provider or relative of such

person has financial interest in related organization.

E. Individual is director, officer, administrator or key person of provider and

related organization.

F. Director, officer, administrator or key person of related organization or relative

of such person has financial interest in provider.

G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1807)

18-310

Rev. 3

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Sheet 10: B^

12-04			FORM CMS 2088-92						1890 (Cont.)
				PROVIDER NO:		PERIOD:		WORKSHEET B
	COST ALLOCATION					FROM ___________		Page 1 of 3
	GENERAL SERVICE COSTS			____________		TO ___________
		Net Expenses	Capital Related
		(from Wkst.A,	Buildings &	Movable	Employee	Subtotal	Administrative	Maintenance
	COST CENTERS	Col.7)	Fixtures	Equipment	Benefits	(cols. 0-4)	& General	& Repairs
		0	1	2	3	3A	4	5
	Gen. Service Cost Ctrs.
1	Cap. Rel. Costs--Bldg.&Fixt.								1
2	Cap. Rel. Costs--Movable Eqp.								2
3	Employee Benefits								3
4	Administrative and General								4
5	Maintenance and Repairs								5
6	Operation of Plant								6
7	Laundry and Linen Service								7
8	Housekeeping								8
9	Cafeteria								9
10	Central Services and Supply								10
11	Medical Records and Library								11
12	Prof. Educ. & Training(1)								12
13									13
14									14
	REIMBURSABLE COST CTRS.
	CORF
15	Skilled Nursing Care								15
16	Physical Therapy								16
17	Speech Pathology								17
18	Occupational Therapy								18
19	Respiratory Therapy								19
20	Medical Social Services								20
21	Psychological Services								21
22	Prosthetic and Orthotic Devices								22
23	Drugs and Biologicals								23
24	Supplies Charged to Patients								24
25	DME-Sold								25
26	DME-Rented								26
27									27
	CMHC
29	Drugs and Biologicals								29
30	Occupational Therapy								30
31	Psychiatric/Psychological Service								31
32	Individual Therapy								32
33	Group Therapy								33
34	Individualized Activity Therapies								34
35	Family Counseling								35
36	Diagnostic Services								36
37	Patient Training & Education								37
38									38
	OTHER PROVIDERS
40	Physical Therapy								40
41	Speech Pathology								41
42	Occupational Therapy								42
43									43
	NON-REIM. COST CENTERS
45	Sheltered Workshops								45
46	Recreational Programs								46
47	Resident Day Camps								47
48	Preschool Programs								48
49	Diagnostic Clinics								49
50	Home Employment Programs								50
51	Equipment Loan Service								51
52	Physicians' Private Office								52
53	Fundraising								53
54	Coffee Shops &Canteen								54
55	Research								55
56	Investment Property								56
57	Advertising								57
58	Franchise & Other Ass'mt								58
59	Prof. Ed. & Training(2)								59
60									60
	CMHC NON-REIMBURSABLE
61	Meals and Transportation								61
62	Activity Therapies								62
63	Psychosocial Programs								63
64	Vocational Training								64
65	Negative Cost Center								65
66	TOTAL								66
	(1) Approved Educational Activity
	(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)
Rev. 7									18-311

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Sheet 11: B_2^

1890 (Cont.)			FORM CMS 2088-92					12-04
			PROVIDER NO:		PERIOD:		WORKSHEET B
	COST ALLOCATION				FROM ____________		Page 2 of 3
	GENERAL SERVICE COSTS		___________		TO ____________
		Operation	Laundry			Medical	Medical
		of	and Linen	House-		Supplies	Records
	COST CENTERS	Plant	Services	keeping	Cafeteria		Library
		6	7	8	9	10	11
	Gen. Service Cost Ctrs.
1	Cap. Rel. Costs--Bldg.&Fixt.							1
2	Cap. Rel. Costs--Movable Eqp.							2
3	Employee Benefits							3
4	Administrative and General							4
5	Maintenance and Repairs							5
6	Operation of Plant							6
7	Laundry and Linen Service							7
8	Housekeeping							8
9	Cafeteria							9
10	Central Services and Supply							10
11	Medical Records and Library							11
12	Prof. Educ. & Training(1)							12
13								13
14								14
	REIMBURSABLE COST CTRS.
	CORF
15	Skilled Nursing Care							15
16	Physical Therapy							16
17	Speech Pathology							17
18	Occupational Therapy							18
19	Respiratory Therapy							19
20	Medical Social Services							20
21	Psychological Services							21
22	Prosthetic and Orthotic Devices							22
23	Drugs and Biologicals							23
24	Supplies Charged to Patients							24
25	DME-Sold							25
26	DME-Rented							26
27								27
	CMHC
29	Drugs and Biologicals							29
30	Occupational Therapy							30
31	Psychiatric/Psychological Service							31
32	Individual Therapy							32
33	Group Therapy							33
34	Individualized Activity Therapies							34
35	Family Counseling							35
36	Diagnostic Services							36
37	Patient Training & Education							37
38								38
	OTHER PROVIDERS
40	Physical Therapy							40
41	Speech Pathology							41
42	Occupational Therapy							42
43								43
	NON-REIM. COST CENTERS
45	Sheltered Workshops							45
46	Recreational Programs							46
47	Resident Day Camps							47
48	Preschool Programs							48
49	Diagnostic Clinics							49
50	Home Employment Programs							50
51	Equipment Loan Service							51
52	Physicians' Private Office							52
53	Fundraising							53
54	Coffee Shops &Canteen							54
55	Research							55
56	Investment Property							56
57	Advertising							57
58	Franchise & Other Ass'mt							58
59	Prof. Ed. & Training(2)							59
60								60
	CMHC NON-REIMBURSABLE
61	Meals and Transportation							61
62	Activity Therapies							62
63	Psychosocial Programs							63
64	Vocational Training							64
65	Negative Cost Center							65
66	TOTAL							66
	(1) Approved Educational Activity
	(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)
18-312								Rev. 7

---

Sheet 12: B_3^

12-04			FORM CMS 2088-92					1890 (Cont.)
			PROVIDER NO:		PERIOD:		WORKSHEET B
	COST ALLOCATION				FROM _____________		Page 3 of 3
	GENERAL SERVICE COSTS		____________		TO ____________
		Prof.
		Education
		and
	COST CENTERS	Training					Total
		12	13	14	15	16	17
	Gen. Service Cost Ctrs.
1	Cap. Rel. Costs--Bldg.&Fixt.							1
2	Cap. Rel. Costs--Movable Eqp.							2
3	Employee Benefits							3
4	Administrative and General							4
5	Maintenance and Repairs							5
6	Operation of Plant							6
7	Laundry and Linen Service							7
8	Housekeeping							8
9	Cafeteria							9
10	Central Services and Supply							10
11	Medical Records and Library							11
12	Prof. Educ. & Training(1)							12
13								13
14								14
	REIMBURSABLE COST CTRS.
	CORF
15	Skilled Nursing Care							15
16	Physical Therapy							16
17	Speech Pathology							17
18	Occupational Therapy							18
19	Respiratory Therapy							19
20	Medical Social Services							20
21	Psychological Services							21
22	Prosthetic and Orthotic Devices							22
23	Drugs and Biologicals							23
24	Supplies Charged to Patients							24
25	DME-Sold							25
26	DME-Rented							26
27								27
	CMHC
29	Drugs and Biologicals							29
30	Occupational Therapy							30
31	Psychiatric/Psychological Service							31
32	Individual Therapy							32
33	Group Therapy							33
34	Individualized Activity Therapies							34
35	Family Counseling							35
36	Diagnostic Services							36
37	Patient Training & Education							37
38								38
	OTHER PROVIDERS
40	Physical Therapy							40
41	Speech Pathology							41
42	Occupational Therapy							42
43								43
	NON-REIM. COST CENTERS
45	Sheltered Workshops							45
46	Recreational Programs							46
47	Resident Day Camps							47
48	Preschool Programs							48
49	Diagnostic Clinics							49
50	Home Employment Programs							50
51	Equipment Loan Service							51
52	Physicians' Private Office							52
53	Fundraising							53
54	Coffee Shops &Canteen							54
55	Research							55
56	Investment Property							56
57	Advertising							57
58	Franchise & Other Ass'mt							58
59	Prof. Ed. & Training(2)							59
60								60
	CMHC NON-REIMBURSABLE
61	Meals and Transportation							61
62	Activity Therapies							62
63	Psychosocial Programs							63
64	Vocational Training							64
65	Negative Cost Center							65
66	TOTAL							66
	(1) Approved Educational Activity
	(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)
Rev. 7								18-313

---

Sheet 13: B-1^

1890 (Cont.)			FORM CMS 2088-92						12-04
				PROVIDER NO:		PERIOD:		WORKSHEET B-1
	COST ALLOCATION					FROM ____________		Page 1 of 3
	(STATISTICAL BASIS)			____________		TO ____________
			Capital Related
			Buildings &	Movable	Employee		Administrative	Maintenance
	COST CENTERS		Fixtures	Equipment	Benefits		& General	& Repairs
			(Square	(Square	(Gross	Reconcil-	(Accum.	(Square
			Feet)	Feet)	Salaries)	iation	Cost)	Feet)
		0	1	2	3	4A	4	5
	Gen. Service Cost Ctrs.
1	Cap. Rel. Costs--Bldg.&Fixt.								1
2	Cap. Rel. Costs--Movable Eqp.								2
3	Employee Benefits								3
4	Administrative and General								4
5	Maintenance and Repairs								5
6	Operation of Plant								6
7	Laundry and Linen Service								7
8	Housekeeping								8
9	Cafeteria								9
10	Central Services and Supply								10
11	Medical Records and Library								11
12	Prof. Educ. & Training(1)								12
13									13
14									14
	REIMBURSABLE COST CTRS.
	CORF
15	Skilled Nursing Care								15
16	Physical Therapy								16
17	Speech Pathology								17
18	Occupational Therapy								18
19	Respiratory Therapy								19
20	Medical Social Services								20
21	Psychological Services								21
22	Prosthetic and Orthotic Devices								22
23	Drugs and Biologicals								23
24	Supplies Charged to Patients								24
25	DME-Sold								25
26	DME-Rented								26
27									27
	CMHC
29	Drugs and Biologicals								29
30	Occupational Therapy								30
31	Psychiatric/Psychological Service								31
32	Individual Therapy								32
33	Group Therapy								33
34	Individualized Activity Therapies								34
35	Family Counseling								35
36	Diagnostic Services								36
37	Patient Training & Education								37
38									38
	OTHER PROVIDERS
40	Physical Therapy								40
41	Speech Pathology								41
42	Occupational Therapy								42
43									43
	NON-REIM. COST CENTERS
45	Sheltered Workshops								45
46	Recreational Programs								46
47	Resident Day Camps								47
48	Preschool Programs								48
49	Diagnostic Clinics								49
50	Home Employment Programs								50
51	Equipment Loan Service								51
52	Physicians' Private Office								52
53	Fundraising								53
54	Coffee Shops &Canteen								54
55	Research								55
56	Investment Property								56
57	Advertising								57
58	Franchise & Other Ass'mt								58
59	Prof. Ed. & Training(2)								59
60									60
	CMHC NON-REIMBURSABLE
61	Meals and Transportation								61
62	Activity Therapies								62
63	Psychosocial Programs								63
64	Vocational Training								64
65	Negative Cost Center								65
66	Cost to be Allocated								66
67	Unit Cost Multiplier								67
	(1) Approved Educational Activity		(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)
18-314									Rev. 7

---

Sheet 14: B-1_2

08-99			FORM CMS 2088-92					1890 (Cont.)
			PROVIDER NO:		PERIOD:		WORKSHEET B-1
	COST ALLOCATION				FROM ____________		Page 2 of 3
	(STATISTICAL BASIS)		___________		TO _____________
		Operation	Laundry			Medical	Medical
		of	and Linen	House-		Supplies	Records
	COST CENTERS	Plant	Services	keeping	Cafeteria		Library
		(Square	(Pounds of	(Hrs. of	Meals	(Costed	(Time
		Feet)	Laundry)	Service)	Served)	Requisitions)	Spent)
		6	7	8	9	10	11
	Gen. Service Cost Ctrs.
1	Cap. Rel. Costs--Bldg.&Fixt.							1
2	Cap. Rel. Costs--Movable Eqp.							2
3	Employee Benefits							3
4	Administrative and General							4
5	Maintenance and Repairs							5
6	Operation of Plant							6
7	Laundry and Linen Service							7
8	Housekeeping							8
9	Cafeteria							9
10	Central Services and Supply							10
11	Medical Records and Library							11
12	Prof. Educ. & Training(1)							12
13								13
14								14
	REIMBURSABLE COST CTRS.
	CORF
15	Skilled Nursing Care							15
16	Physical Therapy							16
17	Speech Pathology							17
18	Occupational Therapy							18
19	Respiratory Therapy							19
20	Medical Social Services							20
21	Psychological Services							21
22	Prosthetic and Orthotic Devices							22
23	Drugs and Biologicals							23
24	Supplies Charged to Patients							24
25	DME-Sold							25
26	DME-Rented							26
27								27
	CMHC
29	Drugs and Biologicals							29
30	Occupational Therapy							30
31	Psychiatric/Psychological Service							31
32	Individual Therapy							32
33	Group Therapy							33
34	Individualized Activity Therapies							34
35	Family Counseling							35
36	Diagnostic Services							36
37	Patient Training & Education							37
38								38
	OTHER PROVIDERS
40	Physical Therapy							40
41	Speech Pathology							41
42	Occupational Therapy							42
43								43
	NON-REIM. COST CENTERS
45	Sheltered Workshops							45
46	Recreational Programs							46
47	Resident Day Camps							47
48	Preschool Programs							48
49	Diagnostic Clinics							49
50	Home Employment Programs							50
51	Equipment Loan Service							51
52	Physicians' Private Office							52
53	Fundraising							53
54	Coffee Shops &Canteen							54
55	Research							55
56	Investment Property							56
57	Advertising							57
58	Franchise & Other Ass'mt							58
59	Prof. Ed. & Training(2)							59
60								60
	CMHC NON-REIMBURSABLE
61	Meals and Transportation							61
62	Activity Therapies							62
63	Psychosocial Programs							63
64	Vocational Training							64
65	Negative Cost Center							65
66	Cost to be Allocated							66
67	Unit Cost Multiplier							67
	(1) Approved Educational Activity		(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)
Rev. 3								18-315

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Sheet 15: B-1_3

1890 (Cont.)			FORM CMS 2088-92					08-99
			PROVIDER NO:		PERIOD:		WORKSHEET B-1
	COST ALLOCATION				FROM _____________		Page 3 of 3
	(STATISTICAL BASIS)		____________		TO ____________
		Prof.Educ.
		& Training
		(Assigned
	COST CENTERS	Time)
		12	13	14	15	16	17
	Gen. Service Cost Ctrs.
1	Cap. Rel. Costs--Bldg.&Fixt.							1
2	Cap. Rel. Costs--Movable Eqp.							2
3	Employee Benefits							3
4	Administrative and General							4
5	Maintenance and Repairs							5
6	Operation of Plant							6
7	Laundry and Linen Service							7
8	Housekeeping							8
9	Cafeteria							9
10	Central Services and Supply							10
11	Medical Records and Library							11
12	Prof. Educ. & Training(1)							12
13								13
14								14
	REIMBURSABLE COST CTRS.
	CORF
15	Skilled Nursing Care							15
16	Physical Therapy							16
17	Speech Pathology							17
18	Occupational Therapy							18
19	Respiratory Therapy							19
20	Medical Social Services							20
21	Psychological Services							21
22	Prosthetic and Orthotic Devices							22
23	Drugs and Biologicals							23
24	Supplies Charged to Patients							24
25	DME-Sold							25
26	DME-Rented							26
27								27
	CMHC
29	Drugs and Biologicals							29
30	Occupational Therapy							30
31	Psychiatric/Psychological Service							31
32	Individual Therapy							32
33	Group Therapy							33
34	Individualized Activity Therapies							34
35	Family Counseling							35
36	Diagnostic Services							36
37	Patient Training & Education							37
38								38
	OTHER PROVIDERS
40	Physical Therapy							40
41	Speech Pathology							41
42	Occupational Therapy							42
43								43
	NON-REIM. COST CENTERS
45	Sheltered Workshops							45
46	Recreational Programs							46
47	Resident Day Camps							47
48	Preschool Programs							48
49	Diagnostic Clinics							49
50	Home Employment Programs							50
51	Equipment Loan Service							51
52	Physicians' Private Office							52
53	Fundraising							53
54	Coffee Shops &Canteen							54
55	Research							55
56	Investment Property							56
57	Advertising							57
58	Franchise & Other Ass'mt							58
59	Prof. Ed. & Training(2)							59
60								60
	CMHC NON-REIMBURSABLE
61	Meals and Transportation							61
62	Activity Therapies							62
63	Psychosocial Programs							63
64	Vocational Training							64
65	Negative Cost Center							65
66	Cost to be Allocated							66
67	Unit Cost Multiplier							67
	(1) Approved Educational Activity		(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1808)
18-316								Rev. 3

---

Sheet 16: C

12-02					FORM CMS 2088-92						1890 (Cont.)
APPORTIONMENT OF PATIENT SERVICE COSTS						PROVIDER NO:		PERIOD:		WORKSHEET C
								FROM __________		Page 1 of 2
						_________		TO ___________
				RATIO OF COST						TITLE XVIII
				TO CHARGES			TITLE XVIII		REASONABLE	COST NET OF
				(Col. 1 line .01,			CHARGES	TITLE XVIII	COST	APPLICABLE
	CORF REIMBURSABLE SERVICE			divided by Col. 1,	TITLE XVIII	ALL OTHER	ON OR AFTER	COSTS ON	REDUCTION	REASONABLE
	COST CENTERS		TOTALS	line .02)	(See Instructions)	(See Instructions)	1/1/98	AFTER 1/1/98	AMOUNT	COST REDUCTION
			1	2	3	4	5	6	7	8
15	Skilled Nursing Care	.01									15
		.02
16	Physical Therapy	.01									16
		.02
17	Speech Pathology	.01									17
		.02
18	Occupational Therapy	.01									18
		.02
19	Respiratory Therapy	.01									19
		.02
20	Medical Social Services	.01									20
		.02
21	Psychological Services	.01									21
		.02
22	Prosthetic and Orthotic Devices	.01									22
		.02
23	Drugs and Biologicals	.01									23
		.02
24	Supplies Charged to Patients	.01									24
		.02
25	DME-Sold	.01									25
		.02
26	DME-Rented	.01									26
		.02
27		.01									27
		.02
28	TOTAL(Line 15 through 27)	.01									28
		.02
	CORF Providers--See instructions for amounts to transfer to Worksheet D, Part I.
FORM CMS-2088-92 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1809)
Rev. 6											18-317

---

Sheet 17: C_2

1890 (Cont.)					FORM CMS 2088-92						12-02
APPORTIONMENT OF PATIENT SERVICE COSTS						PROVIDER NO:		PERIOD:		WORKSHEET C
								FROM __________		Page 2 of 2
						_________		TO ___________
							TITLE XVIII	TITLE XVIII
				RATIO OF COST			CHARGES	COSTS ON OR		TITLE XVIII
				TO CHARGES			ON OR AFTER	AFTER 8/1/00,	REASONABLE	COSTS PRIOR
				(Col. 1 line a,			8/1/00, 1/1/02,	1/1/02, 1/1/03, or	COST	TO 8/1/00, 1/1/02,
	CMHC REIMBURSABLE SERVICE			divided by Col. 1,	TITLE XVIII	ALL OTHER	1/1/03, or 1/1/04	1/1/04	REDUCTION	1/1/03, or 1/1/04
	COST CENTERS		TOTALS	line b.	(See Instructions)	(See Instructions)	(See Instructions)	(See Instructions)	AMOUNT	(See Instructions)
			1	2	3	4	5	6	7	8
29	Drugs and Biologicals	.01									29
		.02
30	Occupational Therapy	.01									30
		.02
31	Psychiatric/Psychological Services	.01									31
		.02
32	Individual Therapy	.01									32
		.02
33	Group Therapy	.01									33
		.02
34	Individualized Activity Therapy	.01									34
		.02
35	Family Counseling	.01									35
		.02
36	Diagnostic Services	.01									36
		.02
37	Patient Training & Education	.01									37
		.02
38		.01									38
		.02
39	TOTAL (Lines 29 through 38)	.01									39
		.02
				RATIO OF COST						TITLE XVIII
				TO CHARGES			TITLE XVIII	TITLE XVIII	REASONABLE	COSTS NET OF
	OTHER OUTPATIENT THERAPY			(Col. 1 line .01,			CHARGES	COSTS	COST	APPLICABLE
	PROVIDERS			divided by Col. 1,	TITLE XVIII	ALL OTHER	ON OR AFTER	ON OR AFTER	REDUCTION	REASONABLE
			TOTALS	line .02)	(See Instructions)	(See Instructions)	1/1/1998	1/1/1998	AMOUNT	COST REDUCTION
			1	2	3	4	5	6	7	8
40	Physical Therapy	.01									40
		.02
41	Speech Pathology	.01									41
		.02
42	Occupational Therapy	.01									42
		.02
43		.01									43
		.02
44	TOTAL (Lines 40 through 43)	.01									44
		.02
	CMHC Providers--Transfer the amount entered in column 8, line 39 to Worksheet D, line 1.
	Other Outpatient Therapy Providers--Transfer the amount entered in column 8, line 44 to Worksheet D, line 1.
FORM CMS-2088-92 (12-2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.1809)
18-318											Rev. 6

---

Sheet 18: D^

12-04					FORM CMS 2088-92								1890 (Cont.)
CALCULATION OF REIMBURSEMENT					PROVIDER NO.:			PERIOD:				WORKSHEET D
SETTLEMENT FOR OUTPATIENT					______________			FROM ________
REHABILITATION SERVICES-TITLE XVIII								TO __________
		CORF			OPT						CMHC
PART I - COMPUTATION OF REIMBURSEMENT SETTLEMENT
	DESCRIPTION									1		1.01
1	Cost of provider services (see instructions)												1
1.01	CMHC PPS payments including outlier payments												1.01
1.02	1996 CMHC specific payment to cost ratio (obtain this ratio from your intermediary)												1.02
1.03	Line 1, column 1.01 times 1.02												1.03
1.04	Line 1.01 divided by line 1.03												1.04
1.05	CMHC transitional corridor payment												1.05
1.1	Cost of CORF services prior to 1/1/1998 (see instructions)												1.1
2	Adjustment for the cost of services covered by Workers' Compensation, and												2
	other primary payers (see instructions)
3	Subtotal (line 1 plus line 1.1 minus line 2) (For CMHCs see instructions)												3
4	Deductibles billed to program patients. (Do not include coinsurance)												4
5	Total amount reimbursable to provider prior to application of Lesser of												5
	reasonable cost or customary charges (line 3 minus line 4)
6	Excess of reasonable cost over customary charges (see instructions)												6
7	Subtotal (line 5 minus line 6)												7
8	80 percent of costs (line 7 x 80 percent)												8
9	Coinsurance billed to program patients (see instructions)												9
10	Net cost for comparison (line 7 minus line 9)												10
11	Reimbursable bad debts (see instructions)												11
11.01	Reimbursable bad debts for dual eligible beneficiaries (see instructions)												11.01
12	TOTAL COST-- (line 11 plus the lesser of line 8 or line 10 )												12
13	Recovery of unreimbursed cost under the lesser of cost or												13
	charges (from Worksheet D-1, Part I, line 3)
14	80% of recovery of unreimbursed cost under the lesser												14
	of cost or charges (line 13 X 80 percent)
15	Total cost (line 12 plus line 14 ) (see instructions)												15
16	Sequestration adjustment (see Instructions)												16
16.5	Other Adjustments (see instructions) (specify)												16.5
17	Adjusted total cost (line 15 minus the sum of lines 16 and 16.5) (see instructions)												17
18	Interim Payments												18
18.5	Tentative settlement (For intermediary use only)												18.5
19	Balance due Provider/Program (line 17 minus line 18) (Indicate overpayment in brackets)												19
	NOTE: FOR CORF SERVICES RENDERED PRIOR TO JANUARY 1, 1998 CORFS COMPLETE LINE 22.1 ONLY AS THESE
	SERVICES ARE NOT SUBJECT TO THE LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES,
	BUT ARE REIMBURSED BASED ON REASONABLE COSTS. FOR CORF RENDERED ON OR AFTER JANUARY 1,
	1998, COMPLETE LINE 21 THROUGH 29 AS THESE SERVICES AS SUBJECT TO LCC.
PART II -COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES												1
20	Reasonable cost of services												20
21	Cost of services (from Part I, line 1) (from Part I, line 1, column 1 for CMHCs) (see instructions)												21
21.1	Cost of services (from Part I, line 1.1 for CORFs) (see instructions)												21.1
22	TOTAL charges for medicare services												22
22.1	TOTAL CORF charges for medicare services prior to 1/1/1998												22.1
23	Customary Charges												23
24	Aggregate amount actually collected from patients liable for payment for services on a charge basis.												24
25	Amounts that would have been realized from patients liable for payment for services on a charge												25
	basis had such payment been made in accordance with 42 CFR 413.13(e)
26	Ratio of line 24 to line 25 (not to exceed 1.000000)												26
27	Total customary charges (line 22 x line 26)												27
27.1	Total customary CORF charges prior to 1/1/1998 (line 22.1 x line 26)												27.1
28	Excess of customary charges over reasonable cost (Complete												28
	only if line 27 exceeds line 21) (see instructions)
29	Excess of reasonable cost over customary charges (Complete												29
	only if line 21 exceeds line 27) (see instructions)
FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15 - II, SEC.
1810, 1810.1 AND 1810.2)
Rev. 7													18-319

---

Sheet 19: G^

1890 (Cont.)		FORM CMS 2088-92				12-04
	STATEMENT OF REVENUES	PROVIDER NO:	PERIOD:
	AND EXPENSES	____________	FROM ____________	WORKSHEET G
			TO ____________
1	Total patient revenues					1
2	Less: Allowances and discounts on patients' accounts					2
3	Net patient revenues (Line 1 minus line 2)					3
4	Less: total operating expenses					4
5	Net income from service to patients (Line 3 minus line 4)					5
	Other income:
6	Grants , gifts, and income designated by					6
	donor for specific expenses
7	Payments received from specialists					7
8	Investment income on unrestricted funds					8
9	Trade , quantity ,time and other discounts on purchases					9
10	Rebates and refunds of expenses					10
11	Income from laundry and linen service					11
12	Income from cafeteria - employees , guests, etc.					12
13	Sale of medical supplies to other than patients					13
14	Sale of workshop products or services					14
15	Coffee shops and canteen					15
16	Vending machines					16
17	Rental of building or office space to others					17
18	Sale of scrap, waste, etc.					18
19	Sale of medical records and abstracts					19
20	Other(Specify)					20
21	Other(Specify)					21
22	Other(Specify)					22
23	Total other income (Sum of lines 6-22)					23
24	Total (Line 5 plus line 23)					24
	Other expenses :
25	Fund raising					25
26	Gift, coffee shops, and canteen					26
27	Investment property					27
28	Other(Specify)					28
29	Other(Specify)					29
30	Other(Specify)					30
31	Total other expenses (Sum of lines 25 - 30)					31
32	Net income (or loss) for the period (line 24 minus line 31)					32
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15 - II, SEC. 1812)
18-320						Rev. 7

---

Sheet 20: A82

08-99

FORM CMS 2088-92

1890 (Cont.)

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. 0938-0037

PROVIDER NO:

PERIOD:

SUPPLEMENTAL

PROVIDER-BASED PHYSICIANS ADJUSTMENTS

FROM ___________

WORKSHEET A-8-2

____________

TO _____________

Cost Center/

Physician/

5 Percent of

Wkst A

Physician

Total

Professional

Provider

RCE

Provider

Unadjusted

Unadjusted

Line No.

Identifier

Remuneration

Component

Component

Amount

Component Hours

RCE Limit

RCE Limit

1

2

3

4

5

6

7

8

9

TOTAL

Cost of

Provider

Physician

Provider

Cost Center/

Memberships

Component

Cost of

Component

Wkst A

Physician

& Continuing

Share of

Malpractice

Share of

Adjusted

RCE

Line No.

Identifier

Education

Col 12

Insurance

Col 14

RCE Limit

Disallowance

Adjustment

10

11

12

13

14

15

16

17

18

TOTAL

FORM CMS-2088-92-A-8-2 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 1813)

Rev. 3

18-321

---

Sheet 21: A83

1890 (Cont.)						FORM CMS 2088-92							08-99
REASONABLE COST DETERMINATION FOR PHYSICAL					(COMPLETE THIS WORKSHEET		PROVIDER NO:		PERIOD:			WORKSHEET A-8-3
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS					FOR SERVICES PROVIDED				FROM: ___________			PARTS I, II & III
					PRIOR TO APRIL 10, 1998)		___________		TO: ___________
	PART I - GENERAL INFORMATION
1	Total number of weeks worked (During which outside suppliers (excluding aides) worked)												1
2	Line 1 multiplied by 15 hours per week												2
3	Number of unduplicated days on which supervisor or therapist was on provider site (See Instructions)												3
4	Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (See instructions)												4
5	Number of unduplicated offsite visits - supervisors or therapists (See Instructions)												5
6	Number of unduplicated offsite visits - therapy assistants (Include only visits made by therapy assistant and on which supervisor and/or												6
	therapist was not present during the visit(s)) (See Instructions)
7	Standard travel expense rate												7
8	Optional travel expense rate per mile												8
								Supervisors	Therapists	Assistants		Aides
								1	2	3		4
9	Total hours worked												9
10	A H S E A (See Instructions)												10
11	Standard Travel Allowance (Cols. 1 and 2, one-half of col. 2, line 10; col. 3, one-half of col 3, line 10)												11
12	Number of travel hours - Provider site - (see instructions)												12
12.01	Number of travel hours - Provider offsite - (see instructions)												12.01
13	Number of miles driven - Provider site - (see instructions)												13
13.01	Number of miles driven - Provider offsite - (see instructions)												13.01
	PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (Column 1, line 9 times column 1, line 10)												14
15	Therapists (Column 2, line 9 times column 2, line 10)												15
16	Assistants (Column 3, line9 times column 3, line10)												16
17	Subtotal Allowance Amount (Sum of lines 14-16)												17
18	Aides (Column 4, line 9 times column 4, line 10)												18
19	Total Allowance Amount (Sum of lines 17 and 18)												19
	If the sum of columns 1-3, line 9, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the
	amount from line 19. Otherwise complete lines 20 - 22.
20	Weighted average rate excluding aides (Line 17 divided by the sum of columns 1-3, line 9)												20
21	Weighted allowance excluding aides (Line 2 times line 20)												21
22	Total Salary Equivalency (Line 19 or sum of lines 18 plus 21)												22
	PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
	Standard Travel Allowance
23	Therapists (Line 3 times column 2, line 11)												23
24	Assistants (Line 4 times column3, line 11)												24
25	Subtotal (Sum of lines 23 and 24)												25
26	Standard Travel Expense (Line 7 times sum of lines 3 and 4)												26
27	Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (Sum of lines 25 and 26)												27
FORM CMS-2088-92-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1814 - 1814.3)
18-322													Rev. 3
08-99					FORM CMS 2088-92								1890 (Cont.)
REASONABLE COST DETERMINATION FOR PHYSICAL					(COMPLETE THIS WORKSHEET		PROVIDER NO.:		PERIOD:			WORKSHEET A-8-3
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS					FOR SERVICES PROVIDED				FROM: ___________			PARTS IV, V & VI
					PRIOR TO APRIL 10, 1998)		____________		TO: ___________
	PART IV - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
	Standard Travel Expense
28	Therapists (Line 5 times column 2, line 11)												28
29	Assistants (Line 6 times column 3, line 11)												29
30	Subtotal (Sum of lines 28 and 29)												30
31	Standard Travel Expense (Line 7 times the sum of lines 5 and 6)												31
	Optional Travel Allowance and Optional Travel Expense
32	Therapists (Sum of columns 1 and 2, line 12.01 times column 2, line 10)												32
33	Assistants (Column 3, line 12.01 times column 3, line 10)												33
34	Subtotal (Sum of lines 32 and 33)												34
35	Optional Travel Expense (Line 8 times the sum of columns 1-3, line 13.01)												35
	Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following three lines 36, 37, or 38, as appropriate.
36	Standard Travel Allowance and Standard Travel Expense (Sum of lines 30 and 31 - See Instructions)												36
37	Optional Travel Allowance and Standard Travel Expense (Sum of lines 34 and 31 - See Instructions)												37
38	Optional Travel Allowance and Optional Travel Expense (Sum of lines 34 and 35 - See Instructions)												38
	PART V - OVERTIME COMPUTATION
	Description							Therapists	Assistants	Aides		Total
								1	2	3		4
39	Overtime hours worked during cost reporting period (If column 4, line 39, is zero or equal to												39
	or greater than 2,080, do not complete lines 40-47 and enter zero in each column of line 48)
40	Overtime rate (Multiply the amounts in columns 2-4, line 10 ( A H S E A ) times 1.5)												40
41	Total overtime (Including base and overtime allowance) (Multiply line 39 times line 40)												41
	Calculation of Limit
42	Percentage of overtime hours by category (Divide the hours in each column on line 39 by the												42
	total overtime worked - column 4, line 39)
43	Allocation of provider's standard workyear for one full-time employee times the percentages												43
	on line 42. (See Instructions)
	Determination of Overtime Allowance
44	Adjusted hourly salary equivalency amount ( A H S E A ) (From Part I, Columns 2-4, line 10)												44
45	Overtime cost limitation (Line 43 times line 44)												45
46	Maximum overtime cost (Enter the lessor of line 41 or line 45)												46
47	Portion of overtime already included in hourly computation at the A H S E A												47
	(Multiply line 39 times line 44)
48	Overtime allowance (Line 46 minus 47 - if negative enter zero)(Column 4, sum of cols 1-3)												48
	PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
49	Salary equivalency amount (from Part II, line 22)												49
50	Travel allowance and expense - provider site (from Part III, line 27)												50
51	Travel allowance and expense - offsite services (from Part IV, lines 36, 37 or 38)												51
52	Overtime allowance (from Part V, col. 4, line 48)												52
53	Equipment cost (See Instructions)												53
54	Supplies (See Instructions)												54
55	Total allowance (Sum of lines 49-54)												55
56	Total cost of outside supplier services (from your records)												56
57	Excess over limitation (line 56 minus line 55 - if negative, enter zero -- See Instructions) (Transfer amount to Wkst. A-3, line 16)												57
FORM CMS-2088-92-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1814.4 - 1814.6)
Rev. 3													18-323

---

Sheet 22: A84

1890 (Cont.)			FORM CMS 2088-92							08-99
REASONABLE COST DETERMINATION FOR RESPIRATORY		(COMPLETE THIS WORKSHEET			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-4
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS		FOR SERVICES PROVIDED					FROM: ___________		PARTS I & II
		PRIOR TO APRIL 10, 1998)			___________		TO: ___________
	PART I - GENERAL INFORMATION
1	Total number of weeks worked (During which outside suppliers (excluding aides and trainees) worked)									1
2	Line 1 multiplied by 15 hours per week									2
	Number of unduplicated days on which the following category, as appropriate, has the highest A H S E A on the provider site ( See Instructions ):
3	Registered Therapist									3
4	Certified Therapist									4
5	Nonregistered, Noncertified Therapist									5
6	Standard travel expense rate									6
			Supervisors			Therapists
				Nonregistered			Nonregistered
	Description	Registered	Certified	Noncertified	Registered	Certified	Noncertified	Aides	Trainees
		1	2	3	4	5	6	7	8
7	Total Hours Worked									7
8	A H S E A (See Instructions)									8
9	Standard Travel Allowance (Enter in cols 1, 2, or 3, one-half of									9
	the amounts on line 8, columns 4, 5 or 6 respectively. Enter in
	cols. 4, 5 or 6 one-half of the amounts on line 8, columns 4, 5 or 6
	respectively.)
	PART II - SALARY EQUIVALENCY COMPUTATION
10	Supervisory Registered Therapist (Col 1, line 7 times col 1, line 8)									10
11	Supervisory Certified Therapist (Col 2, line 7 times col 2, Line 8)									11
12	Supervisory Non-Registered, Non-Certified Therapist (Col 3, line 7 times col 3, line 8)									12
13	Registered Therapists (Col 4, line 7 times col 4, line 8)									13
14	Certified Therapists (Col 5, line 7 times col 5, line 8)									14
15	Non-Registered, Non-Certified Therapists (Col 6, line 7 times col 6, line 8)									15
16	Subtotal Allowance Amount (Sum of lines 10-15)									16
17	Aides (Col 7, line 7 times col 7, line 8)									17
18	Trainees (Col 8, line 7 times col 8, line 8)									18
19	Total Allowance Amount (Sum of lines 16-18)									19
	If the sum of cols 1-6, line 7, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the amount from line 19.
	Otherwise, complete lines 20-22.
20	Weighted average rate excluding aides and trainees (Line 16 divided by the sum of cols 1-6, line 7)									20
21	Weighted allowance excluding aides and trainees (Line 2 times line 20)									21
22	Total Salary Equivalency (Line 19 or sum of lines 17, 18 and 21)									22
FORM CMS 2088-92-A-8-4 (11-1998) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1815 - 1815.2 )
18-324										Rev. 3
08-99			FORM CMS 2088-92							1890 (Cont.)
REASONABLE COST DETERMINATION FOR RESPIRATORY		(COMPLETE THIS WORKSHEET			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-4
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS		FOR SERVICES PROVIDED					FROM: ___________		PARTS III, IV & V
		PRIOR TO APRIL 10, 1998)			___________		TO: ___________
	PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION
23	Registered Therapists (Line 3 times col 4, line 9)									23
24	Certified Therapists (Line 4 times col 5, line 9)									24
25	Non-Registered, Non-Certified Therapists (Line 5 times col 6, line 9)									25
26	Subtotal (Sum of lines 23-25)									26
27	Standard Travel Expense (Line 6 times sum of lines 3-5)									27
28	Total Standard Travel Allowance and Standard Travel Expense (Sum of lines 26 and 27)									28
	PART IV - OVERTIME COMPUTATION
					Therapists
						Nonregistered
	Description			Registered	Certified	Noncertified	Aides	Trainees	Total
				1	2	3	4	5	6
29	Overtime hours worked during cost reporting period ( If col 6, line 29,									29
	is zero, or equal to or greater than 2,080, do not complete lines 30
	through 37 and enter zero in each column of line 38 )
30	Overtime rate ( Multiply the amounts in cols 4-8, line 8 (the AHSEA)									30
	times 1.5 )
31	Total overtime (Including base and overtime allowance)									31
	(Multiply line 29 times line 30)
	Calculation of Limitation
32	Percentage of overtime hours by category (Divide the hours in each								100%	32
	column on line 29 by the total overtime worked - column 6, line 29)
33	Allocation of provider's standard workyear for one full-time employee									33
	times the percentage on line 32. (See Instructions)
	Determination of Overtime Allowance
34	Adjusted hourly salary equivalency amount (AHSEA)									34
	(From Part I, cols. 4-8, line 8)
35	Overtime cost limitation (Line 33 times line 34)									35
36	Maximum overtime cost (Enter the lessor of line 31 or 35)									36
37	Portion of overtime already included in hourly computation at the									37
	A H S E A. (Multiply line 29 times line 34)
38	Overtime allowance (Line 36 minus line 37 - if negative enter zero)									38
	(Col. 6, sum of cols. 1 - 5)
	PART V - COMPUTATION OF RESPIRATORY THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
39	Salary equivalency amount (from Part II, line 22)									39
40	Travel allowance and expense (from Part III, line 28)									40
41	Overtime allowance (from Part IV, col 6, line 38)									41
42	Equipment cost (See Instructions)									42
43	Supplies (See Instructions)									43
44	Total allowance ( Sum of lines 39 - 43)									44
45	Total cost of outside supplier services (from your records)									45
46	Excess over limitation ( line 45 minus line 44, - if negative, enter zero - See Instructions) (Transfer to amount Wkst. A-3, line 15)									46
FORM CMS 2088-92-A-8-4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1815.3 - 1815.5 )
Rev. 3										18-325

---

Sheet 23: A85

1890 (Cont.)		FORM CMS 2088-92						08-99
REASONABLE COST DETERMINATION FOR THERAPY SERVICES			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998					FROM: ___________		PARTS I & II
			___________		TO: ___________
Check applicable box:		[ ] Respiratory [ ] Physical [ ] Occupational [ ] Speech Pathology
	PART I - GENERAL INFORMATION
1	Total number of weeks worked (during which outside (excluding aides worked)							1
2	Line 1 multiplied by 15 hours per week							2
3	Number of unduplicated days on which supervisor or therapist was on provider site (see instructions)							3
4	Number of unduplicated days on which therapy assistant was on provider site but neither supervisor nor therapist was							4
	on provider site (see instructions)
5	Number of unduplicated offsite visits - supervisors or therapists (see instructions)							5
6	Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which							6
	supervisor and/or therapist was not present during the visit(s)) (see instructions)
7	Standard travel expense rate							7
8	Optional travel expense rate per mile							8
			Supervisors	Therapists	Assistants	Aides	Trainees
			1	2	3	4	5
9	Total hours worked							9
10	AHSEA (see instructions)							10
11	Standard Travel Allowance (columns 1 and 2, one-half of column 2,							11
	line 10; column 3, one-half of column 3, line 10)
12	Number of travel hours - Provider on site - (see instructions)							12
12.01	Number of travel hours - Provider offsite - (see instructions)							12.01
13	Number of miles driven - Provider on site - (see instructions)							13
13.01	Number of miles driven - Provider offsite - (see instructions)							13.01
	PART II - SALARY EQUIVALENCY COMPUTATION
14	Supervisors (column 1, line 9 times column 1, line 10)							14
15	Therapists (column 2, line 9 times column 2, line 10)							15
16	Assistants (column 3, line 9 times column 3, line10)							16
17	Subtotal Allowance Amount (sum of lines 14-16)							17
18	Aides (column 4, line 9 times column 4, line 10)							18
19	Trainees (column 5, line 9 times column 5, line 10)							19
20	Total Allowance Amount (see instructions)							20
	If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2,
	make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21-23.
21	Weighted average rate excluding aides and trainees (see instructions)							21
22	Weighted allowance excluding aides and trainees (see instructions)							22
23	Total salary equivalency (see instructions)							23
FORM CMS-2088-92-A-8-5 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816 - 1816.2)
18-326								Rev. 3
08-99		FORM CMS 2088-92						1890 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY SERVICES			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998					FROM: ___________		PARTS III & IV
			____________		TO: ___________
Check applicable box:		[ ] Respiratory [ ] Physical [ ] Occupational [ ] Speech Pathology
	PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24	Therapists (line 3 times column 2, line 11)							24
25	Assistants (line 4 times column 3, line 11)							25
26	Subtotal (sum of lines 24 and 25)							26
27	Standard Travel Expense (line 7 times sum of lines 3 and 4)							27
28	Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (sum of lines 26 and 27)							28
Optional Travel Allowance and Optional Travel Expense
29	Therapists (sum of columns 1 and 2, line 12 times column 2, line 10)							29
30	Assistants (column 3, line 10 times column 3, line 12)							30
31	Subtotal (sum of lines 29 and 30)							31
32	Optional travel expense (line 8 times the sum of columns 1-3, line 13)							32
33	Standard travel allowance and standard travel expense (line 28)							33
34	Optional travel allowance and standard travel expense (sum of lines 27 and 30)							34
35	Optional travel allowance and optional travel expense (sum of lines 31 and 32)							35
	PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36	Therapists (line 5 times column 2, line 11)							36
37	Assistants (line 6 times column 3, line 11)							37
38	Subtotal (sum of lines 36 and 37)							38
39	Standard Travel Expense (line 7 times the sum of lines 5 and 6)							39
Optional Travel Allowance and Optional Travel Expense
40	Therapists (sum of columns 1 and 2, line 12.01 times column 2, line 10)							40
41	Assistants (column 3, line 12.01 times column 3, line 10)							41
42	Subtotal (sum of lines 40 and 41)							42
43	Optional Travel Expense (line 8 times the sum of columns 1-3, line 13.01)							43
Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following
three lines 44, 45, or 46, as appropriate.
44	Standard Travel Allowance and Standard Travel Expense (sum of lines 38 and 39 - see instructions)							44
45	Optional Travel Allowance and Standard Travel Expense (sum of lines 39 and 42 - see instructions)							45
46	Optional Travel Allowance and Optional Travel Expense (sum of lines 42 and 43 - see instructions)							46
FORM CMS-2088-92-A-8-5 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816.3 - 1816.4)
Rev. 3								18-327
1890 (Cont.)		FORM CMS 2088-92						08-99
REASONABLE COST DETERMINATION FOR THERAPY SERVICES			PROVIDER NO.:		PERIOD:		WORKSHEET A-8-5
FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998					FROM: ___________		PARTS V & VI
			___________		TO: ___________
Check applicable box:		[ ] Respiratory [ ] Physical [ ] Occupational [ ] Speech Pathology
	PART V - OVERTIME COMPUTATION
			Therapists	Assistants	Aides	Trainees	Total
			1	2	3	4	5
47	Overtime hours worked during reporting period (if column 5,							47
	line 47, is zero or equal to or greater than 2,080, do not complete
	lines 48-55 and enter zero in each column of line 56)
48	Overtime rate (see instructions)							48
49	Total overtime (including base and overtime allowance) (multiply							49
	line 47 times line 48)
CALCULATION OF LIMIT
50	Percentage of overtime hours by category (divide the hours in each							50
	column on line 47 by the total overtime worked - column 5, line 47)
51	Allocation of provider's standard workyear for one full-time							51
	employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52	Adjusted hourly salary equivalency amount (see instructions)							52
53	Overtime cost limitation (line 51 times line 52)							53
54	Maximum overtime cost (enter the lessor of line 49 or line 53)							54
55	Portion of overtime already included in hourly computation at the AHSEA (multiply line 47 times line 52)							55
56	Overtime allowance (line 54 minus line 55 - if negative enter zero) (column 5, sum of columns 1-4)							56
	PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57	Salary equivalency amount (from Part II, line 23)							57
58	Travel allowance and expense - provider site (from Part III, lines 33, 34, or 35))							58
59	Travel allowance and expense - provider offsite services (from Part IV, lines 44, 45, or 46)							59
60	Overtime allowance (from Part V, column 5, line 56)							60
61	Equipment cost (see instructions)							61
62	Supplies (see instructions)							62
63	Total allowance (sum of lines 57-62)							63
64	Total cost of outside supplier services (from your records)							64
65	Excess over limitation (line 64 minus line 63 - if negative, enter zero -- See Instructions) (Transfer amount to Wkst. A-3, line 17, 17.1, 17.2 or 17.3 as applicable)							65
FORM CMS-2088-92-A-8-5 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816.5 - 1816.6)
18-328								Rev. 3