CMS-222-92 Independent Rural Health Clinic and Freestanding Federal

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Overview

WS-S part I
WS-S part III
A,p1
A,p2
A-1
A-2
A-2-1
B-Part I&II
C-Part 1
C-Part II
Sup. B-1

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Sheet 1: WS-S part I

03-10			Form CMS 222-92				2990 (Cont.)
This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can result						FORM APPROVED
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).						OMB NO: 0938-0107
INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING				PROVIDER NO:	PERIOD:	WORKSHEET
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET					FROM: __________	S
STATISTICAL DATA AND CERTIFICATION STATEMENT				_______________	TO: ____________	PART I
Intermediary Use Only:
		[ ] Audited	Date Received ________________		[ ] Initial	[ ] Re-opened
		[ ] Desk Reviewed	Intermediary No. ______________		[ ] Final
PART I - STATISTICAL DATA			[ ] Projected Cost Report		[ ] Actual/Final Cost Report
Check			[ ] Electronic filed cost report		Date:
applicable box			[ ] Manually submitted cost report		Time:
1	Name:						1
1.01	Street:				P.O. Box:		1.01
1.02	City:		State:		Zip Code:		1.02
1.03	County:						1.03
2	Provider Number:						2
3	Designation:						3
4	Reporting Period: From To						4
		Type of Control		Type of Provider
		(see instructions)		(see instructions)	Date Certified
	1	2		3	4
5							5
		Source of Federal Funds		Grant Award Number
		(see instructions)		(see instructions)		Date
	1	2		3		4
6							6
7	Names of Physicians Furnishing Services At The Health Facility or Under Agreement						7
	(As Described in Instructions) and Medicare Billing Numbers (Include all Part B Billing Numbers)
		Name				Billing Number
		1				2
7.01							7.01
7.02							7.02
7.03							7.03
7.04							7.04
7.05							7.05
8		Supervisory Physicians					8
					Hours of Supervision
		Name			For Reporting Period
		1			2
8.01							8.01
8.02							8.02
8.03							8.03
8.04							8.04
8.05							8.05
FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903 and 2903.1)
Rev. 9							29-303
	2990 (Cont.)		Form CMS 222-92				03-10
INDEPENDENT RURAL HEALTH CLINIC/				PROVIDER NO:	PERIOD:	WORKSHEET S
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET					From:	PART I (Cont.) &
STATISTICAL DATA AND CERTIFICATION STATEMENT					To:	PART II
PART I (CONTINUED)-STATISTICAL DATA
9	Does the facility operate as other than a RHC or FQHC? Enter "Y" for yes or "N" for no.						9
10	If yes, specify what type of operation. (i.e., physicians office, independent laboratory, etc.)						10
11	Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day						11
		Days			Hours of Operation
					From	To
11.01		Sunday					11.01
11.02		Monday					11.02
11.03		Tuesday					11.03
11.04		Wednesday					11.04
11.05		Thursday					11.05
11.06		Friday					11.06
11.07		Saturday					11.07
12	Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.						12
		Days			Hours of Operation
					From	To
12.01		Sunday					12.01
12.02		Monday					12.02
12.03		Tuesday					12.03
12.04		Wednesday					12.04
12.05		Thursday					12.05
12.06		Friday					12.06
12.07		Saturday					12.07
13	If this is a low or no Medicare Utilization cost report, enter "L" for low or "N" for No Medicare Utilization.						13
14	Is this facility filing a consolidated cost report under CMS Pub. 100-4, chapter 9, section						14
	30.8? Enter "Y" for yes or "N" for no. If yes, see instructions.
PART II - CERTIFICATION BY OFFICER OR ADMINISTRATOR
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 WHERE OTHERWISE ILLEGAL,
CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
			CERTIFICATION BY OFFICER OR ADMINISTRATOR
		I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report prepared by
		______________________________________ (Provider Name and Number) for the cost report period beginning
		________________ and ending ______________ and that 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 the laws and regulations regarding
		the Provider in accordance 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 Administrator of Facility				Title		Date
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 0938-0107. The time required to complete this
information collection is estimated to average 50 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: Centers for Medicare & Medicaid Services, 7500
Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.
FORM CMS-222-92 (3-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903 and 2903.2)
29-304							Rev. 9

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Sheet 2: WS-S part III

01-05			Form CMS 222-92				2990 (Cont.)
INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING				PROVIDER NO.:	PERIOD:	WORKSHEET
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET				_______________	FROM: __________	S
STATISTICAL DATA AND CERTIFICATION STATEMENT				CLINIC NO.:	TO: ____________	PART III
				_______________
PART III - STATISTICAL DATA FOR CLINICS FILING UNDER CONSOLIDATED COST REPORTING
1	Name:						1
2	Street:				P.O. Box:		2
3	City:		State:		Zip Code:		3
4	County:						4
5	Provider Number:						5
6	Designation:			Date Certified:			6
7	Names of Physicians Furnishing Services At The Health Facility or Under Agreement						7
	(As Described in Instructions) and Medicare Billing Numbers (Include all Part B Billing Numbers)
		Name				Billing Number
		1				2
7.01							7.01
7.02							7.02
7.03							7.03
7.04							7.04
7.05							7.05
8		Supervisory Physicians					8
					Hours of Supervision
		Name			For Reporting Period
		1			2
8.01							8.01
8.02							8.02
8.03							8.03
8.04							8.04
8.05							8.05
9	Does the facility operate as other than a RHC or FQHC? Enter "Y" for yes or "N" for no.						9
10	If yes, specify what type of operation. (i.e., physicians office, independent laboratory, etc.)						10
11	Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day						11
		Days			Hours of Operation
					From	To
11.01		Sunday					11.01
11.02		Monday					11.02
11.03		Tuesday					11.03
11.04		Wednesday					11.04
11.05		Thursday					11.05
11.06		Friday					11.06
11.07		Saturday					11.07
12	Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.						12
		Days			Hours of Operation
					From	To
12.01		Sunday					12.01
12.02		Monday					12.02
12.03		Tuesday					12.03
12.04		Wednesday					12.04
12.05		Thursday					12.05
12.06		Friday					12.06
12.07		Saturday					12.07
FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903.2)
Rev. 7							29-304.1
Rev. 7							29-303

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Sheet 3: A,p1

03-10			Form CMS 222-92							2990 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL				Facility No.		Reporting Period		WORKSHEET A
BALANCE OF EXPENSES						From		Page 1
						To
							Reclassified	Adjustments	Net
		COST CENTER	Compen-	Other	Total	Reclassi-	Trial Balance	Increases	Expenses
			sation		(Col. 1 + 2)	fications	(Col. 3 +/- 4)	(Decreases)	(Col. 5 +/- 6)
			1	2	3	4	5	6	7
		FACILITY HEALTH CARE STAFF COSTS
1	0100	Physician								1
2	0200	Physician Assistant								2
3	0300	Nurse Practitioner								3
4	0400	Visiting Nurse								4
5	0500	Other Nurse								5
6	0600	Clinical Psychologist								6
7	0700	Clinical Social Worker								7
8	0800	Laboratory Technician								8
9	0900	Other (Specify)								9
10	1000									10
11	1100									11
12		Subtotal-Facility Health Care Staff Costs								12
		COSTS UNDER AGREEMENT
13	1300	Physician Services Under Agreement								13
14	1400	Physician Supervision Under Agreement								14
15	1500									15
16		Subtotal Under Agreement (Lines 13-15)								16
		OTHER HEALTH CARE COSTS
17	1700	Medical Supplies								17
18	1800	Transportation (Health Care Staff)								18
19	1900	Depreciation-Medical Equipment								19
20	2000	Professional Liability Insurance								20
21	2100	Other (Specify)								21
22	2200									22
23	2300									23
24		Subtotal-Other Health Care Costs (Lines 17-23)								24
25		Total Cost of Services (Other Than								25
		Overhead And Other RHC/FQHC Services)
		Sum of Lines 12, 16, And 24
		FACILITY OVERHEAD-FACILITY COST
26	2600	Rent								26
27	2700	Insurance								27
28	2800	Interest On Mortgage Or Loans								28
29	2900	Utilities								29
FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2904)
Rev. 9										29-305

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Sheet 4: A,p2

2990 (Cont.)			Form CMS 222-92							03-10
RECLASSIFICATION AND ADJUSTMENT OF TRIAL				Facility No.		Reporting Period		WORKSHEET A
BALANCE OF EXPENSES						From		Page 2
						To
							Reclassified	Adjustments	Net
		COST CENTER	Compen-	Other	Total	Reclassi-	Trial Balance	Increases	Expenses
			sation		(Col. 1 + 2)	fications	(Col. 3 +/- 4)	(Decreases)	(Col. 5 +/- 6)
			1	2	3	4	5	6	7
30	3000	Depreciation-Buildings And Fixtures								30
31	3100	Depreciation-Equipment								31
32	3200	Housekeeping And Maintenance								32
33	3300	Property Tax								33
34	3400	Other(Specify)								34
35	3500									35
36	3600									36
37		Subtotal-Facility Costs (Lines 26-36)								37
		FACILITY OVERHEAD-ADMINISTRATIVE COSTS
38	3800	Office Salaries								38
39	3900	Depreciation-Office Equipment								39
40	4000	Office Supplies								40
41	4100	Legal								41
42	4200	Accounting								42
43	4300	Insurance								43
44	4400	Telephone								44
45	4500	Fringe Benefits And Payroll Taxes								45
46	4600	Other (Specify)								46
47	4700									47
48	4800									48
49		Subtotal-Administrative Cost (Lines 38-48)								49
50		Total Overhead (Lines 37 And 49)								50
		COST OTHER THAN RHC/FQHC SERVICES
51	5100	Pharmacy								51
52	5200	Dental								52
53	5300	Optometry								53
54	5400	Other (Specify)								54
55	5500									55
56	5600									56
57		Subtotal-Cost Other Than RHC/FQHC (Lines 51-56)								57
		NON-REIMBURSABLE COSTS (Specify)
58	5800									58
59	5900									59
60	6000									60
61		Subtotal Non-Reimbursable Costs (Lines 58-60)								61
62		TOTAL COSTS (Sum Of Lines 25, 50, 57, And 61)				-0-				62
FORM CMS-222-92 (3-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2904)
29-306										Rev. 9

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Sheet 5: A-1

03-02			Form CMS 222-92						2990 (Cont.)
RECLASSIFICATIONS		Facility No.			Reporting Period		WORKSHEET A-1
					From
					To
		CODE	INCREASE			DECREASE
			COST	LINE		COST	LINE
	EXPLANATION OF ENTRY	(1)	CENTER	NO.	AMOUNT (2)	CENTER	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									30
31									31
32									32
33									33
34									34
35									35
36	TOTAL RECLASSIFICATIONS (Sum of Column 4								36
	must equal sum of Column 7)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A, Col 4, line as appropriate.
FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2905)
Rev. 5									29-307

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Sheet 6: A-2

2990 (Cont.)		Form CMS 222-92					03-02
ADJUSTMENTS TO EXPENSES	Facility No.			Reporting Period		WORKSHEET A-2
				From
				To
	Basis for			Expense Classification on Worksheet A
	Adjust-			from which amount is to be deducted
Description (1)	ment			or to which the amount is to be added
	(2)		Amount	Cost Center			Line No.
	1		2	3			4
1 Investment income on commingled
restricted and unrestricted funds
(chapter 2)
2 Trade, quantity and time discounts
on purchases (chapter 8)		B
3 Rebates and refunds of
expenses (chapter 8)		B
4 Rental of building or office
space to others
5 Home office costs
(chapter 21)
6 Adjustment resulting from transactions	From
with related organizations	Supp. Wkst.
(chapter 10)	A-2-1
7 Vending machines
8 Practitioner Assigned by National
Health Service Corps
9 Depreciation - Buildings and Fixtures					Depreciation		30
10 Depreciation - Equipment					Depreciation		31
11 Other (Specify)
12 Total							62
(1) Description - all line references in this column pertain to CMS Pub. PRM 15-I.
(2) Basis for adjustment (SEE INSTRUCTIONS)
A. Costs - if cost, including applicable overhead, can be determined.
B. Amount Received - if cost cannot be determined.
FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB 15-II, SECTION 2906)
29-308							Rev. 5

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Sheet 7: A-2-1

2990 ( Cont. )

Form CMS 222-92

01-10

STATEMENT OF COSTS OF SERVICES

Facility No.

Reporting Period

SUPPLEMENTAL

FROM RELATED ORGANIZATIONS

From

WORKSHEET A-2-1

To

PARTS I-III

Part I.

Introduction. Are there any costs included on Worksheet A which resulted from transactions with related organizations as

defined in the Provider Reimbursement Manual, Part I, Chapter 10?

[ ] Yes

[ ] No (If "Yes", complete Parts II and III )

Part II.

Costs incurred and adjustments required (as result of transactions with related organizations):

AMOUNT

NET

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6

ALLOWABLE

ADJUSTMENT

IN COST

(COL.4 MINUS

Line No.

Cost Center

Expense Items

AMOUNT

COL. 5)

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1-4) Transfer col. 6, line 1-4 to Wkst. A,col.6 as appropriate)

5

(Transfer col.6, line 5 to Wkst. A-2, col.2, line 6, Adjustment to Expenses)

Part III.

Interrelationship of facility to related organization (s):

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the

provider to furnish the information requested on Part III of this worksheet.

This information is used by the Centers for Medicare & 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 the provider does 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

of

of

Type of

(1)

Name

Ownership

Name

Ownership

Business

1

2

3

4

5

6

1

1

2

2

3

3

4

4

(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 the provider;

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

C. Provider has financial interest in corporation, partnership, or other organization(s);

D. Director, officer, administrator, or key person of the provider or relative of such person has financial interest

in related organization;

E. Individual is director, officer, administrator, or key person of the provider and related organization;

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

financial interest in the provider;

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

FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 2909)

29-312

Rev. 8

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Sheet 8: B-Part I&II

01-05	Form CMS 222-92				2990 (Cont.)
VISITS AND OVERHEAD COST FOR	Facility No.		Reporting Period		WORKSHEET B
RHC/FQHC SERVICES			From		PARTS I & II
			To
PART I - VISITS AND PRODUCTIVITY		Part A - Visits And Productivity
	1	2	3	4	5
	Number of			Minimum	Greater of
	FTE	Total	Productivity	Visits	Col. 2 or
Positions	Personnel	Visits	Standard	(Col. 1 x Col. 3)	Col. 4
1. Physicians			4200
2. Physician Assistants			2100
3. Nurse Practitioners			2100
4. Subtotal (Sum of lines 1-3)
5. Visiting Nurse
6. Clinical Psychologist
7. Clinical Social Worker
8. Total Staff
9. Physician Services
Under Agreement
PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
					Amount
10. Cost of RHC/FQHC Services - excluding overhead - (W/S A,Col. 7, Line 25)
11. Cost of Other Than RHC/FQHC Services - Excluding overhead (W/S A, Col. 7, Sum of
Lines 57 and 61)
12. Cost of All Services - excluding overhead - (Sum of Lines 10 and 11)
13. Ratio of RHC/FQHC Services (Line 10 Divided by Line 12)
14. Total Overhead - (W/S A, Col. 7, Line 50)
15. Overhead Applicable to RHC/FQHC Services (Line 13 x Line 14)
16. Total Allowable Cost of RHC/FQHC Services (Sum of Lines 10 and 15)
FORM CMS-222-92 (1-2005) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB. 15-II SECTIONS 2907 THRU 2907.2)
Rev. 7					29-309

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Sheet 9: C-Part 1

2990 (Cont. )		Form CMS 222-92				01-05
DETERMINATION OF MEDICARE		Facility No.	Reporting Period		WORKSHEET C
PAYMENT			From		PART 1
			To
PART I- DETERMINATION OF RATE FOR RHC/FQHC SERVICES					AMOUNT
1	Total Allowable Costs(Worksheet B, Part II, Line 16)					1
2	Cost of Pneumococcal and Influenza Vaccine and Its ( Their) Administration					2
	(From Supplemental Worksheet B-1, Line 15)
3	Total Allowable Cost Excluding Pneumococcal and Influenza Vaccine					3
	(Line 1 - Line 2)
4	Greater of Minimum Visits or Actual Visits by Health Care Staff					4
	(Worksheet B, Part 1, Column 5, Line 8
5	Physicians Visits Under Agreements					5
	(Worksheet B, Part 1, Column 5, Line 9)
6	Total Adjusted Visits					6
	(Line 4 + Line 5)
7	Adjusted Cost Per Visit					7
	(Line 3 divided by Line 6)
		1	2	2.01	3
		Rate Period 1	Rate Period 2	Rate Period 3
8	Maximum Rate Per Visit (See Instructions)					8
9	Rate For Medicare Covered Visits					9
	(Lessor of Line 7 or Line 8)
FORM CMS-222-93 (8-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,
SECTIONS 2908 AND 2908.1)
29-310						Rev. 7

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Sheet 10: C-Part II

01-10		Form CMS 222-92				2990 ( Cont. )
DETERMINATION OF MEDICARE		Facility No.	Reporting Period		WORKSHEET C
PAYMENT			From		PART II
			To
PART II - DETERMINATION OF TOTAL PAYMENT		1	2	2.01	3
		Rate period 1	Rate Period 2	Rate Period 3
10	Rate for Medicare Covered Visits (Part I, Line 9)					10
11	Medicare Covered Visits Excluding Mental Health					11
	Services (From Intermediary Records)
12	Medicare Cost Excluding Costs for Mental Health					12
	Services (Line 10 multiplied by Line 11)
13	Medicare Covered Visits for Mental Health					13
	Services (From Intermediary Records)
14	Medicare Covered Cost for Mental Health					14
	Services (Line 10 multiplied by Line 13)
15	Limit Adjustment					15
	(Line 14 times the applicable percentage) (see instructions)
16	Total Medicare Cost					16
	(Line 12 plus line 15)
17	Less: Beneficiary Deductible					17
	(From Intermediary Records)
18	Net Medicare Cost Excluding Pneumococcal					18
	and Influenza Vaccine and Its (Their) Administration
	(Line 16 minus line 17)
19	Reimbursable Cost of RHC/FQHC Services, Other Than Pneumococcal					19
	and Influenza Vaccine (80% multiplied by line 18, Column 3)
20	Medicare Cost of Pneumococcal and Influenza Vaccine and					20
	Its (Their) Administration (From Supp. Worksheet B-1, Line 16)
21	Total Reimbursable Medicare Cost (Line 19 plus Line 20)					21
22	Less Payments to RHC/FQHC During Reporting Period					22
23	Balance Due To/From The Medicare Program					23
	Exclusive of Bad Debts (Line 21 less Line 22)
24	Total Reimbursable Bad Debts, Net of Bad Debt
	Recoveries (From Provider Records)					24
24.01	Total Gross Reimbursable Bad Debts for Dual Eligible Beneficiaries					24.01
	(From Provider Records)
25	Total Amount Due To/From The Medicare Program (Line 23 plus Line 24)					25
FORM CMS-222-92 (1-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
PUB 15-II,SECTIONS 2908 AND 2908.2)
Rev. 8					29-311

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Sheet 11: Sup. B-1

01-10			Form CMS 222-92				2990 ( Cont.)
COMPUTATION OF				Facility No.	Reporting Period	SUPPLEMENTAL
PNEUMOCOCCAL AND INFLUENZA					From	WORKSHEET B-1
VACCINE COST					To
			1	2	2.01	2.02
						INFLUENZA
				SEASONAL		& H1N1
	PART 1 - CALCULATION OF COST		PNEUMOCOCCAL	INFLUENZA	H1N1	(See instructions)
1	Health Care Staff Cost						1
	(Worksheet A, Column 7, Line 12)
2	Ratio of Pneumococcal and Influenza Vaccine						2
	Staff Time to Total Health Care Staff Time
3	Pneumococcal and Influenza Vaccine						3
	Health Care Staff Cost (Line 1 x Line 2)
4	Medical Supplies Cost - Pneumococcal and Influenza						4
	Vaccine (From Your Records)
5	Direct Cost of Pneumococcal and Influenza						5
	Vaccine (Sum of Lines 3 & 4)
6	Total Direct Cost of the Facility						6
	(Worksheet A, Column 7, Line 25 )
7	Total Facility Overhead						7
	(Worksheet A, Column 7, Line 50)
8	Ratio of Pneumococcal and Influenza Vaccine						8
	Direct Cost to Total Direct Cost (Line 5 divided by Line 6)
9	Overhead Cost - Pneumococcal and Influenza						9
	Vaccine (Line 7 x Line 8)
10	Total Pneumococcal and Influenza Vaccine Cost and						10
	Its (Their) Administration (Sum of Lines 5 & 9)
11	Total Number of Pneumococcal and Influenza						11
	Vaccine Injections (From Provider Records)
12	Cost Per Pneumococcal and Influenza						12
	Vaccine Injection (Line 10 divided by Line 11)
13	Number of Pneumococcal and Influenza Vaccine						13
	Injections Administered to Medicare Beneficiaries
14	Medicare Cost of Pneumococcal and Influenza Vaccine						14
	and Its (Their) Administration (Line 12 Multiplied by Line 13)
15	Total Cost of Pneumococcal and Influenza Vaccine and Its (Their) Administration						15
	(Sum of Line 10, Columns 1, 2, 2.01, and 2.02) Transfer to Wkst. C, Part I, Line 2
16	Total Medicare Cost of Pneumococcal and Influenza Vaccine and Its (Their) Administration						16
	(Sum of Line 14, Columns 1, 2, 2.01, and 2.02) Transfer to Wkst. C, Part II, Line 20
FORM CMS-222-92 (1-2010) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15-II, SECTION 2910)
Rev. 8							29-313