Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)

CHAPTER 33

ORGAN PROCUREMENT ORGANIZATION

AND TISSUE TYPING LABORATORY

COST REPORT

FORM CMS-216-94

Section

General 3300

Recommended Sequence for Completing OPO/LAB Cost Report 3301

Worksheet S - Organ Procurement Organization/

Histocompatibility Laboratory General Data and

Certification Statement 3302

Part I - General 3302.1

Part II - Certification By Officer or Administrator 3302.2

Part III – Settlement Summary 3302.3

Worksheet S-1 - Organ Procurement Organization/

Histocompatibility Laboratory Identification Data 3303

Part I - OPO Statistics 3303.1

Part II - Lab Statistics 3303.2

Part III - Full Time Equivalent Employees (FTEs) 3303.3

Worksheet A - Reclassification and Adjustment of Trial

Balance of Expenses 3304

Worksheet A-1 - Administrative and General Expenses 3305

Worksheet A-2 - Organ Acquisition Costs 3306

Worksheet A-3 - Tissue Typing Laboratory Costs 3307

Worksheet A-4 - Reclassifications 3308

Worksheet A-5 - Adjustments to Expenses 3309

Worksheet A-6 - Capital Expenditures and Depreciation

Reconciliation 3310

Worksheet B - Cost Allocation - General Service Costs and

Worksheet B-1 - Cost Allocation - Statistical

Basis 3311

Worksheet C - Computation of Medicare Cost 3312

Worksheet D - Calculation of Reimbursement Settlement 3313

Worksheet E - Balance Sheet 3314

Worksheet E-1 - Statement of Operating Expenses and

Revenues 3315

Worksheet E-2 - Statement of Revenues and Expenses 3316

Supplemental Worksheet A-5-1 - Statement of Costs of

Services From Related Organizations 3317

Kidney Placement Efforts - Documentation Requirements 3318

Exhibit 1 - Form CMS-216-94 Worksheets 3390

Electronic Reporting Specifications for Form CMS-216-94 3395

Rev. 4 33-1