CMS-2540-10 Crosswalk [Added Worksheet]

CMS-2540 Crosswalk.xlsx

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

CMS-2540-10 Crosswalk [Added Worksheet]

OMB: 0938-0463

Document [xlsx]
Download: xlsx | pdf

Overview

S
S2
SII
S3
S-3II
S-3IV
S-3V
S4
S5
S6
S7a
S8
A
A6
A7
A8
A81
A82
B
B-1
B-II
B-2
C
D
DII
D-1
E-I
E-II
E1
G
GII
G-1
G-2
G-3
H
H1-1
H1-II
H2-1
H2-II
H3-I
H4
H5
I1
I2
I3
I4
I-5
J-1-I
J-1-II
J-2
J-3
J-4
K
K-1
K-2
K-3
K-4-1
K-4-2
K-5-1
K-5-II
K-5-III
K6


Sheet 1: S

2/11





FORM CMS-2540-10




4190 (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. 0938-0463
SKILLED NURSING FACILITY AND





PROVIDER NO.:

PERIOD:


SKILLED NURSING FACILITY HEALTH








FROM ___________________
WORKSHEET S
CARE COMPLEX COST REPORT





______________________



PARTS I II & III
CERTIFICATION AND








TO _________________


SETTLEMENT SUMMARY


























PART I - COST REPORT STATUS












Provider
[ ] Electronic filed cost report




Date:____________

Time:____________
use only
[ ] Manually submitted cost report









Contractor
[ ] Cost Report Status



If # 3 or 4:

Date Received _____________


use only:
[ 1 ] As Submitted:


[ ] Desk Reviewed

Contractor No. _____________




[ 2 ] Amended:


[ ] Audited

[ ] First Cost Report Processed by Contractor




[ 3 ] Settled:










[ 4 ] Reopened: If number 4, Enter





[ ] Last Cost Report to be Processed by Contractor





Number of times reopened [ ]























PART II - CERTIFICATION


























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












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












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









































CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDERS)


























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












Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Names) and Numbers)} for the cost reporting period












beginning _______________ and ending _______________ and to the best of my knowledge and belief, it is a true, correct and complete statement prepared from












the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations












regarding the provision of health care services identified in this cost report were provided in compliance with such laws and regulations.








































OFFICER OR ADMINISTRATOR OF PROVIDER


























Printed Name
___________________________________________




Signed________________________________________________


















Title _____________________________________________





Date _______________






























PART III - SETTLEMENT SUMMARY





















TITLE XVIII










TITLE V
A
B TITLE XIX







1
2
3 4
1 SKILLED NURSING FACILITY










1
2 NURSING FACILITY










2
3 I C F / M R










3
4 SNF - BASED HHA










4
5 SNF - BASED RHC










5
6 SNF - BASED FQHC










6
7 SNF - BASED CMHC










7
8 SNF - BASED O.L.T.C.










8
100 TOTAL










100
The above amounts represent "due to" or "due from" the applicable Program for the element of the above complex indicated.












(Indicate Overpayments in Brackets.)


























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












number for this information collection is 0938-0463. The time required to complete this information collection is estimated 202 hours per response, including the time to review instructions,












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












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


























FORM CMS-2540-10 ( 12/2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS












PUB. 15-II, SECTIONS 4103 )












Rev. 1











41-303















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1


Sheet 2: S2

4190 (Cont.)

FORM CMS-2540-10






2/11



SKILLED NURSING FACILITY AND SKILLED NURSING


PROVIDER NO.:
PERIOD

WORKSHEET



FACILITY HEALTH CARE COMPLEX




FROM_____________

S - 2



IDENTIFICATION DATA


_______________ ____________________ TO_____________


Part I




Skilled Nursing Facility and Skilled Nursing Facility Complex Address:














1 Street:


P.O. Box:




1



2 City:


State:
Zip Code:


2



3 County:


CBSA Code:
Urban / Rural:


3



SNF and SNF-Based Component Identification:






















Payment System






Component Name

Provider No. Date (P, O, or N)





Component



Certified V XVIII XIX





0 1

2 3 4 5 6




4 S N F








4



5 Nursing Facility








5



6 I C F / M R








6



7 SNF-Based H.H.A.








7



8 SNF-Based RHC








8



9 SNF-Based FQHC








9



10 SNF-Based CMHC








10



11 SNF-Based O.L.T.C.








11



12 SNF-Based HOSPICE








12



13 Cost Reporting Period (mm/dd/yyyy)

From:
To:



13



14 Type of Control (See Instructions)








14



Type of Freestanding Skilled Nursing Facility








Y / N



15 Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?








15



16 Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5?








16



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








17




organizations as defined in CMS Pub. 15-I, chapter 10? If yes, complete Worksheet A-8-1.













Miscellaneous Cost Reporting information














18 If this is a low or no Medicare utilization cost report, enter "L" for low Medicare Utilization, or








18




enter "N" for No Medicare Utilization.













19 Other








19



Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on Lines 22 - 24.














20 Straight Line








20



21 Declining Balance








21



22 Sum of the Year's Digits








22



23 Sum of line 20 through 22








23



24 If depreciation is funded, enter the balance as of the end of the period.








24



25 Were there any disposal of capital assets during the cost reporting period? (Y/N)








25


CMS2540-10
26 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)








26



27 Did you cease to participate in the Medicare program at end of the period to which this cost report applies








27



28 Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports








28



FORM ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4104)









EFG



41-304









Rev. 1



















2/11
FORM CMS-2540-10






4190 (Cont.)



SKILLED NURSING FACILITY AND SKILLED NURSING


PROVIDER NO.:
PERIOD

WORKSHEET



FACILITY HEALTH CARE COMPLEX




FROM_____________

S - 2 Part I



IDENTIFICATION DATA


_______________ ____________________ TO__________

(Continued)



If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of














costs or charges enter "Y" for each component and type of service that qualifies for the exemption.






Part A Part B Other




29 Skilled Nursing Facility








29



30 Nursing Facility








30



31 I C F / M R








31



32 SNF-Based H.H.A.








32



33 SNF-Based RHC








33



34 SNF-Based FQHC








34



35 SNF-Based CMHC








35



SNF-Based OLTC








36













Y / N




37 Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients.








37



38 Are you legally-required to carry malpractice insurance?








38



39 Is the malpractice a "claims-made:", or "occurence" policy? If the policy is "claims-maid" enter 1. If policy is "occurence", enter 2.








39



40 What is the liability limit for the malpractice policy? Enter in column 1 the monetary








40




limit per lawsuit. Enter in column 2 the monetary limit per policy year.

















Premiums
Paid Losses
Self insurance






41 List malpractice premiums and paid losses:








41



42 Are malpractice premiums and paid losses reported in other than the Administrative and General cost center?







Y / N





Enter Y or N. If yes, check box, and submit supporting schedule listing cost centers and amounts.








42



43 Are there any related organizations or home office costs as defined in CMS Pub. 15-1, chapter 10?








43



44 If yes, and there are costs, for the home office, enter the applicable provider number



Provider #



44




If this facility is part of a chain organization, enter the name and address of the home office on the lines below













45 Name:
Contractor name

Contractor Number



45



46 Street:



PO Box



46



47 City



State
Zip

47


































































































































































































































FORM ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4104)














Rev.1









41-305














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1




Sheet 3: SII

4190 (Cont.)

FORM CMS-2540-10


2/11

SKILLED NURSING FACILITY AND SKILLED NURSING

PROVIDER NO.:
PERIOD:
WORKSHEET S-2



FACILITY HEALTH CARE COMPLEX



FROM
Part II



IDENTIFICATION DATA



TO





General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No












For all the dates responses the format will be (mm/dd/yyyy)








Completed by All Skilled Nursing Facilities























Provider Organization and Operation



1 2









Y/N Date



1 Has the Provider changed ownership immediately prior to the beginning of the cost reporting period?






1


If column 1 is "Y", enter the date of the change in column 2. (see instructions)















1 2 3








Y/N Date V/I


2 Has the provider terminated participation in the Medicare Program? If column 1 is yes,






2


enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary









3 Is the provider involved in business transactions, including management contracts, with individuals or






3


entities (e.g., chain home offices, drug or medical supply companies) that are related to the provider or










its officers, medical staff, management personnel, or members of the board of directors through










ownership, control, or family and other similar relationships? (see instructions)





















Financial Data and Reports
















1 2 3








Y/N Type Date


4 Were the financial statements prepared by a Certified Public Accountant? If column 1 is "Y" enter "A"






4


for Audited, "C" for Compiled, or "R" for Reviewed in column 2. Submit a complete copy or enter










date available in column 3. (see instructions) If column 1 is "N" see instructions.









5 Are the cost report total expenses and total revenues different from those on the filed financial






5


statements? If column 1 is "Y", submit reconciliation.




























1 2


Approved Educational Activities





Y/N Legal Oper.


6 Were costs claimed for Nursing School? If column 1 is "Y", enter "Y" or "N" in column 2 to indicate whether the






6


provider is the legal operator of the program









7 Were costs claimed for Allied Health Programs? If "Y" see instructions.






7

8 Were approvals and/or renewals obtained during the cost reporting period for Nursing School and/or






8


Allied Health Program? If "Y", see instructions.





















Bad Debts


















1










Y/N


9 Is the provider seeking reimbursement for bad debts? If "Y", see instructions.






9

10 If line 9 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy.






10

11 If line 9 is "Y", are patient deductibles and/or coinsurance waived? If "Y", see instructions.






11













Bed Complement










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






12


















1 2 3 4







Y/N Date Y/N Date


PS&R Data



Part A Part A Part B Part B


13 Was the cost report prepared using the PS&R only?






13


If either col. 1 or 3 is "Y", enter the paid through date of the PS&R used










to prepare this cost report in cols. 2 and 4 .(see Instructions.)









14 Was the cost report prepared using the PS&R for total and the provider's records






14


for allocation? If either col. 1 or 3 is "Y" enter the paid through date of the PS&R










used to prepare this cost report in columns 2 and 4.









15 If line 13 or 14 is "Y", were adjustments made to PS&R data for additional claims that






15


have been billed but are not included on the PS&R used to file this cost report?









If "Y", see Instructions.









16 If line 13 or 14 is "Y", then were adjustments made to PS&R data for corrections of other






16


PS&R information? If "Y", see Instructions.









17 If line 13 or 14 is "Y", then were adjustments made to PS&R data for Other?






17


Describe the other adjustments:
_________________________________







18 Was the cost report prepared only using the provider's records? If "Y" see Instructions.






18





































































































































41-306







Rev. 1
















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 4: S3

2/11




FORM CMS-2540-10





4190 (Cont.)
SKILLED NURSING FACILITY AND
PROVIDER NO.:

PERIOD

WORKSHEET S-3
SKILLED NURSING FACILITY HEALTH CARE COMPLEX


FROM____________________

PART I
STATISTICAL DATA










Number Bed I n p a t i e n t D a y s D i s c h a r g e s


of Days Title Title Title
Total Title Title Title
Total

Component Beds Available V XVIII XIX Other
V XVIII XIX Other



1 2 3 4 5 6 7 8 9 10 11 12
1 Skilled Nursing Facility











1
2 Nursing Facility











2
3 ICF/MR











3
4 Home Health Agency











4
5 Other Long Term Care











5
6 SNF-Based CMHC











6
7 Hospice











7
8 Total (Sum of lines 1-7)











8



























Full Time


Average Length of Stay A d m i s s i o n s Equivalent



Title Title Title Total Title Title Title
Total Employees Nonpaid



V XVIII XIX
V XVIII XIX Other
on Payroll Workers



13 14 15 16 17 18 19 20 21 22 23
1 Skilled Nursing Facility











1
2 Nursing Facility











2
3 ICF/MR











3
4 Home Health Agency











4
5 Other Long Term Care











5
6 SNF-Based CMHC











6
7 Hospice











7
8 Total (Sum of lines 1-7)











8






















































































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4105.




























Rev. 1












41-307





































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1



Sheet 5: S-3II

4190(Cont.)
FORM CMS-2540-10



2/11





PROVIDER NO.:
PERIOD:
WORKSHEET S-3




SNF WAGE INDEX INFORMATION


FROM __________
PARTS II & III






______________
TO _____________









Reclass. Adjusted Paid Hours Average







of Salaries Salaries Related Hourly Wage




PART II DIRECT SALARIES
Amount from Wkst. (col. 1 ± to Salary (col. 3 ÷






Reported A-6 col. 2) in col. 3 col. 4)






1 2 3 4 5





SALARIES









1 Total salary (See Instructions)




1



2 Physician salaries-Part A




2



3 Physician salaries-Part B




3



4 Interns & Residents (approved)




4



5 Home office personnel




5



6 Sum of lines 2 thru 5




6



7 Revised wages (line 1 minus line 6)




7



8 Other Long Term Care




8



9 H.H.A.




9



10 CMHC




10



11 Hospice




11



12 Non-reimbursable




12



13 Total Excluded salary




13




(Sum of lines 8 through 12)









14 Subtotal (line 7 minus line 13)




14




OTHER WAGES AND RELATED COSTS









15 Contract Labor: Patient Related & Mgmt









16 Contract Labor: Physician services-Part A




16



17 Home office salaries & wage related costs




17




WAGE RELATED COSTS









18 Wage related costs core. (See Part IV)




18



19 Wage related costs other (See Part IV)




19



20 Wage related costs (excluded units)




20



21 Physicians Part A - WRC




21



22 Physicians Part B - WRC




22



23 Subtotal (see instructions)




23



PART III - OVERHEAD COST - DIRECT SALARIES













Reclass. Adjusted Paid Hours Average







of Salaries Salaries Related Hourly Wage






Amount from (col. 1 ± to Salary (col. 3 ÷






Reported Wkst. A-6 col. 2) in col. 3 col. 4)






1 2 3 4 5




1 Employee Benefits




1



2 Administrative & General




2



3 Plant Operation, Maintenance & Repairs




3



4 Laundry & Linen Service




4



5 Housekeeping




5



6 Dietary




6



7 Nursing Administration




7



8 Central Services and Supply




8



9 Pharmacy




9



10 Medical Records & Medical Records Library




10



11 Social Service




11



12 Interns & Records (Apprvd Tching Prog)




12



13 Other General Service (specify)




13



14 Total (sum lines 1 thru 13)




14



FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II,










SECTION 4105.1 - 4105.2)






















41-308





Rev. 1









































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 6: S-3IV

2/11
FORM CMS-2540-10



4190 (Cont.)






PROVIDER NO.:
PERIOD:
WORKSHEET



SNF WAGE RELATED COSTS



FROM __________
S-3






______________
TO _____________
PART IV



PART IV - Wage Related Cost






















Part A - Core List









































Amount










Reported
















RETIREMENT COST









1 401K Employer Contributions





1


2 Tax Sheltered Annuity (TSA) Employer Contribution





2


3 Qualified and Non-Qualified Pension Plan Cost





3


4 Prior Year Pension Service Cost





4



PLAN ADMINISTRATIVE COSTS (Paid to External Organization):









5 401K/TSA Plan Administration fees





5


6 Legal/Accounting/Management Fees-Pension Plan





6


7 Employee Managed Care Program Administration Fees





7



HEALTH AND INSURANCE COST









8 Health Insurance (Purchased or Self Funded)





8


9 Prescription Drug Plan





9


10 Dental, Hearing and Vision Plan





10


11 Life Insurance (If employee is owner or beneficiary)





11


12 Accidental Insurance (If employee is owner or beneficiary)





12


13 Disability Insurance (If employee is owner or beneficiary)





13


14 Long-Term Care Insurance (If employee is owner or beneficiary)





14


15 Workers' Compensation Insurance





15


16 Retirement Health Care Cost (Only current year, not the extraordinary





16



accrual required by FASB 106 Non cumulative portion)









TAXES








17 FICA-Employers Portion Only





17


18 Medicare Taxes - Employers Portion Only





18


19 Unemployment Insurance





19


20 State or Federal Unemployment Taxes





20



OTHER









21 Executive Deferred Compensation





21


22 Day Care Cost and Allowances





22


23 Tuition Reimbursement





23


24 Total Wage Related cost (Sum of lines 1 -23)





24














Part B Other than Core Related Cost










25 Other Wage Related Costs (specify)_________________________________________





25














































































































FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4105)






















Rev. 1






41-309
































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 7: S-3V

DRAFT
FORM CMS-2540-10



4190 (Cont.)





PROVIDER NO.:
PERIOD:
WORKSHEET





SNF REPORTING OF

FROM ________
S-3





DIRECT CARE EXPENDITURES ________________
TO ___________
PART V








Adjusted Paid Hours Average








Salaries Related Hourly Wage






Amount Fringe (col. 1 + to Salary (col. 3 ÷






Reported Benefits col. 2) in col. 3 col. 4)




Occupational Category
1 2 3 4 5





Direct Salaries










Nursing Occupations









1 Registered Nurses (RNs)




1



2 Licensed Practical Nurses (LPNs)




2



3 Nursing Assistants/Aides




3




Total Nursing









4 Physical Therapists




4



5 Physical Therapy Assistants




5



6 Physical Therapy Aides




6



7 Occupational Therapists




7



8 Occupational Therapy Assistants




8



9 Occupational Therapy Aides




9



10 Speech Therapists




10



11 Respiratory Therapists




11



12 Other Medical Staff




12




Contract Labor










Nursing Occupations









13 Registered Nurses (RNs)




13



14 Licensed Practical Nurses (LPNs)




14



15 Nursing Assistants/Aides




15




Total Nursing









16 Physical Therapists




16



17 Physical Therapy Assistants




17



18 Physical Therapy Aides




18



19 Occupational Therapists




19



20 Occupational Therapy Assistants




20



21 Occupational Therapy Aides




21



22 Speech Therapists




22



23 Respiratory Therapists




23



24 Other Medical Staff




24



















































































































































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






















41-308





Rev. ___





































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 8: S4

4190 (Cont.)



FORM CMS-2540-10



2/11


















PROVIDER NO.:
PERIOD:

















{APP4}IALLWAYS~/PCOPB1~Q/PGQ/1
S.N.F. -BASED HOME HEALTH AGENCY




FROM ____________

WORKSHEET S-4















STATISTICAL DATA


HHA NO.:
TO _______________












































HOME HEALTH AGENCY STATISTICAL DATA
























1 County








1



















Title Title Title

















DESCRIPTION



V XVIII XIX Other Total




















1 2 3 4 5














2 Home Health Aide Hours








2













3 Unduplicated Census Count (see instructions)








3













HOME HEALTH AGENCY - NUMBER OF EMPLOYEES

























(FULL TIME EQUIVALENT)





Staff Contract Total






















1 2 3














4 Enter the number of hours in your normal work week








4













5 Administrator and Assistant Administrator(s)








5













6 Directors and Assistant Director(s)








6













7 Other Administrative Personnel








7













8 Direct Nursing Service








8













9 Nursing Supervisor








9













10 Physical Therapy Service








10













11 Physical Therapy Supervisor








11













12 Occupational Therapy Service








12













13 Occupational Therapy Supervisor








13













14 Speech Pathology Service








14













15 Speech Pathology Supervisor








15













16 Medical Social Service








16













17 Medical Social Service Supervisor








17













18 Home Health Aide








18













19 Home Health Aide Supervisor








19













20 Other (specify)








20













HOME HEALTH AGENCY CBSA CODES
























21 Enter the number of hours in your normal work week








21













22 How many CBSAs in column 1 did you provide services to during this cost reporting period.








22













23 List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code).








23







































PPS ACTIVITY DATA - Applicable for Medicare Services Rendered on or after October 1, 2000






























Full Episodes LUPA PEP TOTAL




















Without With
only





















Outliers Outliers Episodes Episodes (cols. 1-4)




















1 2 3 4 5














24 Skilled Nursing Visits








24













25 Skilled Nursing Visit Charges








25













26 Physical Therapy Visits








26













27 Physical Therapy Visit Charges








27













28 Occupational Therapy Visits








28













29 Occupational Therapy Visit Charges








29













30 Speech Pathology Visits








30













31 Speech Pathology Visit Charges








31













32 Medical Social Service Visits








32













33 Medical Social Service Visit Charges








33













34 Home Health Aide Visits








34













35 Home Health Aide Visit Charges








35













36 Total visits (sum of lines 24, 25, 28, 29, 31 and 34)








36













37 Other Charges








37













38 Total Charges (sum of lines 25, 27, 29, 31, 33, 35 and 37)








38













39 Total Number of Episodes (standard/non outlier)








39













40 Total Number of Outlier Episodes








40













Total Non-Routine Medical Supply Charges








41







































FORM CMS-2540-10 (12.10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4106)
























41-310








Rev. 1



















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1














Sheet 9: S5

4190 (Cont.)





FORM CMS-2540-10








2/11
SNF - BASED RURAL HEALTH CLINIC PROVIDER NO:


PERIOD:






FEDERALLY QUALIFIED HEALTH _______________________________


FROM____________________



WORKSHEET
CENTER STATISTICAL DATA COMPONENT NO:


TO_______________________



S - 5






________________________










Check applicable box:



[ ] RHC
[ ] FQHC









PART I - STATISTICAL DATA
















1 Street:










County:


1
2 City:






State:


Zip Code:


2
3 Designation (for FQHC's only) - Enter "R" for rural or "U" for urban














3
Source of Federal funds:











Grant Award Date
4 Community Health Center (Section 330(d), PHS Act)














4
5 Migrant Health Center (Section 329(d), PHS Act)














5
6 Health Services for the Homeless (Section 340(d), PHS Act)














6
7 Appalachian Regional Commission














7
8 Look - Alikes














8
9 Other (specify)














9
10 Does the facility operate as other than an RHC or FQHC? If yes, indicate the number of other operations in column 2.












1 2

(Enter in subscripts of line 10 the type of other operation(s) and the operating hours.)














10

NOTE: Line 11 (Clinic) is to be completed regardless of the response to line 10.
















Facility hours of operations (1)


















Sunday Monday Tuesday Wednesday Thursday Friday Saturday



from to from to from to from to from to from to from to

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
11 Clinic














11

(1) List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.















12 Have you received an approval for an exception to the productivity standard?














12
13 Is this a consolidated cost report in accordance with CMS Pub 27, section 508D. If yes, enter in column 2 the number of














13

providers included in this report. List the names of all providers and numbers on subscripted lines below.















14 Provider Name








NPI Number




14
15 Have you provided all or substantially all GME cost. If yes, enter in column 2 the number of program visits performed as














15

Nursing and Allied Health Education Activities.





































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4107)















41-311















Rev. 1

































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1






Sheet 10: S6


2/11



FORM CMS-2540-10
4190 (Cont.)








PROVIDER NO.: PERIOD:

SKILLED NURSING FACILITY BASED
FROM ____________ WORKSHEET S-6
C.M.H.C. STATISTICAL DATA C.M.H.C. NO.: _______________ TO _______________














NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)










Employment Category: Enter the number of hours





Staff Contract Total

in your normal work week ( ).





1 2 3
1 Administrator and Assistant Administrators








1
2 Directors and Assistant Directors








2
3 Other Administrative Personnel








3
4 Directing Nursing Service








4
5 Nursing Supervisor








5
6 Physical Therapy Service








6
7 Physical Therapy Supervisor








7
8 Occupational Therapy Service








8
9 Occupational Therapy Supervisor








9
10 Speech Pathology Service








10
11 Speech Pathology Supervisor








11
12 Medical Social Service








12
13 Medical Social Service Supervisor








13
14 Respiratory Therapy Service








14
15 Respiratory Therapy Supervisor








15
16 Psychological Service








16
17 Psychological Service Supervisor








17
18









18
19









19
































































































FORM CMS - 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4108 )










Rev. 1









41-312














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 11: S7a

4190 (Cont.)

FORM CMS-2540-10

2/11


PROSPECTIVE PAYMENT

PROVIDER NO.:
PERIOD:
WORKSHEET S-7



FOR SNF



FROM:





STATISTICAL DATA



TO:






GROUP





Days



1





2


1 RUX






1

2 RUL






2

3 RVX






3

4 RVL






4

5 RHX






5

6 RHL






6

7 RMX






7

8 RML






8

9 RLX






9

10 RUC






10

11 RUB






11

12 RUA






12

13 RVC






13

14 RVB






14

15 RVA






15

16 RHC






16

17 RHB






17

18 RHA






18

19 RMC






19

20 RMB






20

21 RMA






21

22 RLB






22

23 RLA






23

24 ES3






24

25 ES2






25

26 ES1






26

27 HE2






27

28 HE1






28

29 HD2






29

30 HD1






30

31 HC2






31

32 HC1






32

33 HB2






33
34 HB1






34

35 LE2






35

36 LE1






36

37 LD2






37

38 LD1






38

39 LC2






39

40 LC1






40

41 LB2






41

42 LB1






42

43 CE2






43

44 CE1






44

45 CD2






45

46 CD1






46

47 CC2






47

48 CC1






48

49 CB2






49

50 CB1






50













FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4109)


















Rev.1

02/11

FORM CMS-2540-10


4190 (Cont.)

PROSPECTIVE PAYMENT FOR SNF


PROVIDER NO.:
PERIOD:
WORKSHEET


STATISTICAL DATA




FROM:
S-7








TO:





GROUP





Days



1





2


51 CA2






51

52 CA1






52

53 SE3






53

54 SE2






54

55 SE1






55

56 SSC






56

57 SSB






57

58 SSA






58

59 IB2






59

60 IB1






60

61 IA2






61

62 IA1






62

63 BB2






63

64 BB1






64

65 BA2






65

66 BA1






66

67 PE2






67

68 PE1






68

69 PD2






69

70 PD1






70

71 PC2






71

72 PC1






72

73 PB2






73

74 PB1






74

75 PA2






75

76 PA1






76

99 AAA






99

100 Total






100














Enter in column 1 the expense for each category. Enter in column 2 the percentage of total expense for each










category to total SNF revenue from Worksheet G-2, Part I, line 6, column 3. Indicate in column 3 "Y" for yes or "N"










for no if the spending reflects increases associated with direct patient care and related expenses for each category.










(See instructions)















Expenses Percentage Y/N








1 2 3


101 Staffing






101

102 Recruitment






102

103 Retention of employees






103

104 Training






104

105 Other (Specify)






105













































































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4109)










Rev. 1







41-314




































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 12: S8

4190 (Cont.)

FORM CMS-2540-10



2/11














PROVIDER NO.:
PERIOD:
















HOSPICE IDENTIFICATION DATA


FROM _____________
WORKSHEET S - 8















HOSPICE NO.:




















_____________
TO ________________






































PART I Enrollment Days Based on Level of Care






















Title XVIII Title XIX Title XVIII Title XIX



















Unduplicated Unduplicated Other Total















Unduplicated Unduplicated Skilled Nursing Nursing Unduplicated Unduplicated














Enrollment Days Medicare Days Medicaid Days Facility Days Facility Days Days Days















1 2 3 4 5 6













1 Continuous Home Care





1












2 Routine Home Care





2












3 Inpatient Respite Care





3












4 General Inpatient Care





4





HCFA Software Control:






5 Total Hospice Days





5


































PART II Census Data
























Title XVIII Title XIX



















Skilled


















Title XVIII Title XIX Nursing facility Nursing Facility Other Total















1 2 3 4 5 6













6 Number of Patients Receiving Hospice Care





6












7 Total Number of Unduplicated Continuous




















Care Hours Billable to Medicare





7












8 Average Length of Stay





8












9 Unduplicated Census Count





9




































































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 4110 )










































41-315






Rev. 1




















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1










Sheet 13: A

02/11


FORM CMS-2540-10




4190 (Cont.)





PROVIDER NO.:
PERIOD:



.
RECLASSIFICATION AND ADJUSTMENT

FROM ________________
WORKSHEET A



OF TRIAL BALANCE OF EXPENSES _________________
TO ________________











RECLASSI- RECLASSIFIED ADJUSTMENTS NET EXPENSES








FICATIONS TRIAL TO EXPENSES FOR COST




COST CENTER SALARIES OTHER TOTAL Increase/Decrease BALANCE Increase/Decrease ALLOCATION




(Omit Cents)

( Col 1 + Col 2 ) ( Fr Wkst A-6 ) ( Col 3 +/- Col 4 ) ( Fr Wkst A-8 ) ( Col 5 +/- Col 6 )


A B D 1 2 3 4 5 6 7 A

GENERAL SERVICE COST CENTERS











1 00100 Capital-Related Costs - Building & Fixture






1

2 00200 Capital-Related Costs - Moveable Equipment






2

3 00300 Employee Benefits






3

4 00400 Administrative and General






4

5 00500 Plant Operation, Maintenance and Repairs






5

6 00600 Laundry and Linen Service






6

7 00700 Housekeeping






7

8 00800 Dietary






8

9 00900 Nursing Administration






9

10 01000 Central Services and Supply






10

11 01100 Pharmacy






11

12 01200 Medical Records and Library






12

13 01300 Social Service






13

14 01400 Nursing and Allied Health Education Activities






14

15
Other General Service Cost






15

DIRECT CARE EXPENDITURES

LINES 16 THROUGH 29 ARE RESERVED FOR FUTURE USE








INPATIENT ROUTINE SERVICE COST CENTERS











30 03000 Skilled Nursing Facility






30

31 03100 Nursing Facility






31

32 03200 Intermediate Care Facility - Mentally Challenged






32

33
Other Long Term Care






33

ANCILLARY SERVICE COST CENTERS











40 04000 Radiology






40

41 04100 Laboratory






41

42 04200 Intravenous Therapy






42

43 04300 Oxygen (Inhalation) Therapy






43

44 04400 Physical Therapy






44

45 04500 Occupational Therapy






45

46 04600 Speech Pathology






46

47 04700 Electro cardiology






47









































































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4113 )











Rev. 1








41-316



























4190 (Cont.)


FORM CMS-2540-10




02/11





PROVIDER NO.:
PERIOD:



.
RECLASSIFICATION AND ADJUSTMENT


FROM ________________
WORKSHEET A



OF TRIAL BALANCE OF EXPENSES
_________________
TO ________________







COST CENTER


RECLASSI- RECLASSIFIED ADJUSTMENTS NET EXPENSES





SALARIES OTHER TOTAL FICATIONS TRIAL TO EXPENSES FOR COST




(Omit Cents)


Increase/Decrease BALANCE Increase /Decrease ALLOCATION






( Col 1 + Col 2 ) ( Fr Wkst A-6 ) ( Col 3 +/- Col 4 ) ( Fr Wkst A-8 ) ( Col 5 +/- Col 6 )


A B D 1 2 3 4 5 6 7


48 04800 Medical Supplies Charged to Patients






48

49 04900 Drugs Charged to Patients






49

50 05000 Dental Care - Title XIX only






50

51 05100 Support Surfaces






51

52
Other Ancillary Service Cost Center






52

OUTPATIENT SERVICE COST CENTERS











60 06000 Clinic






60

61 06100 Rural Health Clinic (RHC)






61

62 6200 FQHC






62

63 6300 Other Outpatient Service Cost






63

OTHER REIMBURSABLE COST CENTERS











70 07000 Home Health Agency Cost






70

71 07100 Ambulance






71

72 07200 Nursing and Allied Health Education Activities






72

73 07300 C.M.H.C.






73

74 07400 Other Reimbursable Cost






74

SPECIAL PURPOSE COST CENTERS











80 08000 Malpractice Premiums & Paid Losses





-0- 80

81 08100 Interest Expense





- 0 - 81

82 08200 Utilization Review -- SNF





- 0 - 82

83 08300 Hospice






83

84
Other Special Purpose Cost






84

NON REIMBURSABLE COST CENTERS











90 09000 Gift, Flower, Coffee Shops and Canteen






90

91 09100 Barber and Beauty Shop






91

92 09200 Physicians' Private Offices






92

93 09300 Nonpaid Workers






93

94 09400 Patients Laundry






94

95
Other Non Reimbursable Cost






95

100
TOTAL






100



























































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4113 )











41-317








Rev. 1
























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 14: A6

2/11



FORM CMS-2540-10




4190 (Cont.)





PROVIDER NO:
PERIOD:




RECLASSIFICATIONS




FROM _________________________
WORKSHEET A-6






__________________________________
TO __________________




EXPLANATION OF CODE
I N C R E A S E


D E C R E A S E



RECLASSIFICATION ENTRY (1) COST CENTER LN NO. SALARY NON SALARY COST CENTER LN NO. SALARY NON SALARY


1 2 3 4 5 6 7 8 9
1









1
2









2
3









3
4









4
5









5
6









6
7









7
8









8
9









9
10









10
11









11
12









12
13









13
14









14
15









15
16









16
17









17
18









18
19









19
20









20
21









21
22









22
23









23
24









24
25









25
26









26
27









27
28









28
29









29
30









30
31









31
32









32
33









33
34









34
35









35
36 TOTAL RECLASSIFICATIONS (Sum of column 4 and 5 must








36

equal total line - sum of column 8 and 9

(2)






(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.




(2) Transfer to Worksheet A, column 4, line as appropriate.




FORM CMS-2540-10 ( 10/12 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4114 )










Rev. 1









41-318






















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 15: A7

4190 (Cont.)

FORM CMS-2540-10




2/11






PROVIDER NO.:
PERIOD:




RECONCILIATION OF CAPITAL COSTS CENTERS




FROM _________
WORKSHEET A-7






_____________
TO __________



ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES















Acquisitions
Disposals
Fully




Beginning


and Ending Depreciated


Description
Balances Purchases Donation Total Retirements Balance Assets




1 2 3 4 5 6 7

1 Land







1
2 Land Improvements







2
3 Buildings and Fixtures







3
4 Building Improvements







4
5 Fixed Equipment







5
6 Movable Equipment







6
7 Subtotal (sum of lines 1-6)







7
8 Reconciling Items







8
9 Total (line 6 minus line 8)







9












































































































































































































































































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4015)










41-319








Rev. 1














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 16: A8


2/11 FORM CMS-2540-10




4190 (Cont.)




PROVIDER NO.
PERIOD:







ADJUSTMENTS TO EXPENSES

FROM ____________
WORKSHEET A-8






________________
TO _____________








(2)
EXPENSE CLASSIFICATION ON







(1) BASIS FOR
WORKSHEET A, TO / FROM WHICH







DESCRIPTION ADJUST- AMOUNT THE AMOUNT IS TO BE ADJUSTED\








MENT

COST CENTER
LINE NO.




1 2 3
4
5



1 Investment income on restricted funds





1



(Chapter 2)









2 Trade, quantity and time discounts





2



on purchases (Chapter 8)









3 Refunds and rebates of expenses





3



Chapter 8)









4 Rental of provider space by suppliers





4



Chapter 8)









5 Telephone services (pay stations





5



excluded) (Chapter 21)









6 Television and radio service





6



(Chapter 21)









7 Parking lot (chapter 21)





7














8 Remuneration applicable to provider- Worksheet




8



based physician adjustment A-8-2








9 Home office costs (chapter 21)





9














10 Sale of scrap, waste, etc.





10



(Chapter23)









11 Nonallowable costs related to certain





11



Capital expenditures (chapter 24)









12 Adjustment resulting from transactions Worksheet




12



with related organizations (chapter 10) A-8-1








13 Laundry and Linen service





13














14 Revenue - Employee meals





14














15 Cost of meals - Guests





15














16 Sale of medical supplies to other than patients





16














17 Sale of drugs to other than patients





17














18 Sale of medical records and abstracts





18














19 Vending machines





19














20 Income from imposition of interest,





20


finance or penalty charges (chapter 21)








21 Interest expense on Medicare overpayments





21



and borrowings to repay Medicare overpayments









22 Depreciation--buildings and fixtures


Capital Related Cost- Building
1 22














23 Depreciation--movable equipment


Capital Related Cost-Movable

23







Equipment
2



24 Other Adjustment





24














100 TOTAL (Sum of lines 1 through 24)





100



(Transfer to Worksheet A, col. 6, line 100)




















(2) Basis for adjustment
A. Costs--if costs, including applicable overhead, can be determined.










B. Amount Received--if cost cannot be determined.








FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,










SECTION 4116 )










Rev. 1






41-320

































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 17: A81

4190 (Cont.)


FORM CMS-2540-10



2/11

STATEMENT OF COSTS PROVIDER NO:
PERIOD:




OF SERVICES FROM

FROM _____________
WORKSHEET A-8-1


RELATED ORGANIZATIONS ___________________
TO ___________




Part I Costs incurred and adjustments required as a result of transactions with related












organizations. Location and amount included on Worksheet A, Column 5



Amount
Adjustments








Allowable
(Col 4 minus


Line No. Cost Center Expense Items Amount In Cost
Col 5)


1 2 3 4 5 6

1








1
2








2
3








3
4








4
5








5
6








6
7








7
8








8
9








9
100 TOTALS (Sum of lines 1-9)







100

Transfer column 6, line 100 to Worksheet A-8, column 3, line 12)









Part II Interrelationship to related organization(s):























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


furnish the information requested under Part II of this worksheet.














This information is used by the Centers for Medicare and Medicaid Services and its contractors in determining that the costs applicable










to services, facilities and supplies furnished by organizations related to you by common ownership or control, represent reasonable










costs as determined under section 1861 of the Social Security Act. If you do not provide all or any part of the requested information,










the cost report is considered incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.














Related Organization(s)

(1)
Percentage

Percentage



Symbol
Name of Name of
Type of




Ownership

Ownership
Business


1 2 3

4 5
6

1








1
2








2
3








3
4








4
5








5
6








6
7








7
8








8
9








9
10








10
(1) Use the following symbols to indicate interrelationship to related organizations:











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


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






in both related organization and in provider.


and related organization.






B. Corporation, partnership or other organization has financial


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






interest in provider.


or relative of such person has financial interest in provider.






C. Provider has financial interest in corporation, partnership,


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






or other organization.


_____________________________________________________






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










relative of such person has financial interest in related










organization.









FORM CMS - 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II SECTION 4117 )






















41-321








Rev. 1


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 18: A82


2/11

FORM CMS-2540-10



4139 (CONT.)





PROVIDER NO:
PERIOD:




PROVIDER-BASED PHYSICIANS ADJUSTMENTS

FROM ______________________
WORKSHEET A-8-2






________________________
TO _________________






Cost Center /



Physician /
5 Percent of


Wkst A Physician Total Professional Provider R C E Provider Unadjusted Unadjusted


Line No. Identifier Remuneration Component Component Amount Component R C E Limit R C E Limit








Hours




1 2 3 4 5 6 7 8 9

1








1
2








2
3








3
4








4
5








5
6








6
7








7
8








8
9








9
10








10
11








11
100
TOTAL






100















Cost of Provider Physician Provider






Cost Center / Memberships Component Cost of Component Adjusted R C E



Wkst A Physician & Continuing Share of Malpractice Share of R C E Limit Disallowance Adjustment


Line No. Identifier Education Col 12 Insurance Column 14





10 11 12 13 14 15 16 17 18

1








1
2








2
3








3
4








4
5








5
6








6
7








7
8








8
9








9
10








10
11








11
100
TOTAL






100
FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4118 )






















Rev. 1








41-322


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 19: B

4190 (Cont.)




FORM CMS-2540-10




2/11









PROVIDER NO.:
PERIOD:







COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B











_________________
TO ________________
PART I











NET EXPENSES CAP. REL. CAP. REL. EMPLOYEE
ADMINIS-










FOR COST BUILDINGS MOVABLE BENEFITS SUBTOTAL TRATIVE






COST CENTER


ALLOCATION & FIXTURES EQUIPMENT
( Sum of & GENERAL






(Omit Cents)


Fr. Wkst A, Col 7


Columns 0 - 3 )











0 1 2 3 3 A 4




GENERAL SERVICE COST CENTERS















1 Capital-Related Costs - Building & Fixture









1



2 Capital-Related Costs - Moveable Equipment









2



3 Employee Benefits









3



4 Administrative and General









4



5 Plant Operation, Maintenance and Repairs









5



6 Laundry and Linen Service









6



7 Housekeeping









7



8 Dietary









8



9 Nursing Administration









9



10 Central Services and Supply









10



11 Pharmacy









11



12 Medical Records and Library









12



13 Social Service









13



14 Nursing and Allied Health Education Activities









14



15 Other General Service Cost









15



INPATIENT ROUTINE SERVICE COST CENTERS















30 Skilled Nursing Facility









30



31 Nursing Facility









31



32 Intermediate Care Facility - Mentally Retarded









32



33 Other Long Term Care









33



ANCILLARY SERVICE COST CENTERS















40 Radiology









40



41 Laboratory









41



42 Intravenous Therapy









42



43 Oxygen (Inhalation) Therapy









43



44 Physical Therapy









44



45 Occupational Therapy









45



46 Speech Pathology









46



47 Electro cardiology









47



48 Medical Supplies Charged to Patients









48



49 Drugs Charged to Patients









49



50 Dental Care - Title XIX only









50



51 Support Surfaces









51



52 Other Ancillary Service Cost Center









52
























































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )
































41-323










Rev. 1



2/11




FORM CMS-2540-10




4190 (Cont.)









PROVIDER NO.:
PERIOD:







COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B











_________________
TO ________________
PART I











NET EXPENSES CAP. REL. CAP. REL. EMPLOYEE
ADMINIS-










FOR COST BUILDINGS MOVABLE BENEFITS SUBTOTAL TRATIVE






COST CENTER


ALLOCATION & FIXTURES EQUIPMENT
( Sum of & GENERAL





(Omit Cents)


Fr. Wkst A, Col 7


Columns 0 - 3 )











0 1 2 3 3 A 4




OUTPATIENT SERVICE COST CENTERS















60 Clinic









60



61 Rural Health Clinic (RHC)









61



62 FQHC









62



63 Other Outpatient Service Cost









63



OTHER REIMBURSABLE COST CENTERS















70 Home Health Agency Cost









70



71 Ambulance









71



72 Nursing and Allied Health Education Activities









72



73 C.M.H.C.









73



74 Other Reimbursable Cost









74



SPECIAL PURPOSE COST CENTERS















83 Hospice









83



84 Other Special Purpose Cost









84



89 Subtotals









89



NON REIMBURSABLE COST CENTERS















90 Gift, Flower, Coffee Shops and Canteen









90



91 Barber and Beauty Shop









91



92 Physicians' Private Offices









92



93 Nonpaid Workers









93



94 Patients Laundry









94



95 Other Non Reimbursable Cost









95



98 Cross Foot Adjustments









98



99 Negative Cost Center









99



100 Total









100






























































































































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )
































Rev. 1










41-324





































4190 (Cont.)




FORM CMS-2540-10




2/11









PROVIDER NO.:
PERIOD:







COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B











_________________
TO ________________
PART I










PLANT OPER. LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY









MAINTENANCE & LINEN KEEPING
ADMINIS- SERVICES







COST CENTER

& REPAIRS SERVICE

TRATION & SUPPLY







(Omit Cents)


















5 6 7 8 9 10 11




GENERAL SERVICE COST CENTERS















1 Capital-Related Costs - Building & Fixture









1



2 Capital-Related Costs - Moveable Equipment









2



3 Employee Benefits









3



4 Administrative and General









4



5 Plant Operation, Maintenance and Repairs









5



6 Laundry and Linen Service









6



7 Housekeeping









7



8 Dietary









8



9 Nursing Administration









9



10 Central Services and Supply









10



11 Pharmacy









11



12 Medical Records and Library









12



13 Social Service









13



14 Nursing and Allied Health Education Activities









14



15 Other General Service Cost









15



INPATIENT ROUTINE SERVICE COST CENTERS















30 Skilled Nursing Facility









30



31 Nursing Facility









31



32 Intermediate Care Facility - Mentally Retarded









32



33 Other Long Term Care









33



ANCILLARY SERVICE COST CENTERS















40 Radiology









40



41 Laboratory









41



42 Intravenous Therapy









42



43 Oxygen (Inhalation) Therapy









43



44 Physical Therapy









44



45 Occupational Therapy









45



46 Speech Pathology









46



47 Electro cardiology









47



48 Medical Supplies Charged to Patients









48



49 Drugs Charged to Patients









49



50 Dental Care - Title XIX only









50



51 Support Surfaces









51



52 Other Ancillary Service Cost Center









52
























































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )

















































41-325










Rev. 1




















2/11




FORM CMS-2540-10




4190 (Cont.)









PROVIDER NO.:
PERIOD:







COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B











_________________
TO ________________
PART I










PLANT OPER. LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY









MAINTENANCE & LINEN KEEPING
ADMINIS- SERVICES







COST CENTER

& REPAIRS SERVICE

TRATION & SUPPLY







(Omit Cents)


















5 6 7 8 9 10 11




OUTPATIENT SERVICE COST CENTERS















60 Clinic









60



61 Rural Health Clinic (RHC)









61



62 FQHC









62



63 Other Outpatient Service Cost









63



OTHER REIMBURSABLE COST CENTERS















70 Home Health Agency Cost









70



71 Ambulance









71



72 Nursing and Allied Health Education Activities









72



73 C.M.H.C.









73



74 Other Reimbursable Cost









74



SPECIAL PURPOSE COST CENTERS















83 Hospice









83



84 Other Special Purpose Cost









84



89 Subtotals









89



NON REIMBURSABLE COST CENTERS















90 Gift, Flower, Coffee Shops and Canteen









90



91 Barber and Beauty Shop









91



92 Physicians' Private Offices









92



93 Nonpaid Workers









93



94 Patients Laundry









94



95 Other Non Reimbursable Cost









95



98 Cross Foot Adjustments









98



99 Negative Cost Center









99



100 Total









100






























































































































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )
































Rev. 1










41-326






















































4190 (Cont.)




FORM CMS-2540-10




2/11









PROVIDER NO.:
PERIOD:







COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B











_________________
TO ________________
PART I










MEDICAL SOCIAL NURSING & OTHER
POST







COST CENTER

RECORDS SERVICE ALLIED GENERAL SUBTOTAL STEP-DOWN TOTAL






(Omit Cents)

& LIBRARY
HEALTH SERVICE
ADJUSTMENTS












EDUCATION COST












12 13 14 15 16 17 18




GENERAL SERVICE COST CENTERS















1 Capital-Related Costs - Building & Fixture









1



2 Capital-Related Costs - Moveable Equipment









2



3 Employee Benefits









3



4 Administrative and General









4



5 Plant Operation, Maintenance and Repairs









5



6 Laundry and Linen Service









6



7 Housekeeping









7



8 Dietary









8



9 Nursing Administration









9



10 Central Services and Supply









10



11 Pharmacy









11



12 Medical Records and Library









12



13 Social Service









13



14 Nursing and Allied Health Education Activities









14



15 Other General Service Cost









15



INPATIENT ROUTINE SERVICE COST CENTERS















30 Skilled Nursing Facility









30



31 Nursing Facility









31



32 Intermediate Care Facility - Mentally Retarded









32



33 Other Long Term Care









33



ANCILLARY SERVICE COST CENTERS















40 Radiology









40



41 Laboratory









41



42 Intravenous Therapy









42



43 Oxygen (Inhalation) Therapy









43



44 Physical Therapy









44



45 Occupational Therapy









45



46 Speech Pathology









46



47 Electro cardiology









47



48 Medical Supplies Charged to Patients









48



49 Drugs Charged to Patients









49



50 Dental Care - Title XIX only









50



51 Support Surfaces









51



52 Other Ancillary Service Cost Center









52






















































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )
































41-327









Rev. 1





















4190 (Cont.)




FORM CMS-2540-10




2/11









PROVIDER NO.:
PERIOD:







COST ALLOCATION - GENERAL SERVICE COSTS






FROM ________________
WORKSHEET B











_________________
TO ________________
PART I










MEDICAL SOCIAL NURSING & OTHER
POST










RECORDS SERVICE ALLIED GENERAL SUBTOTAL STEP-DOWN TOTAL






COST CENTER

& LIBRARY
HEALTH SERVICE
ADJUSTMENTS







(Omit Cents)



EDUCATION COST












12 13 14 15 16 17 18




OUTPATIENT SERVICE COST CENTERS















60 Clinic









60



61 Rural Health Clinic (RHC)









61



62 FQHC









62



63 Other Outpatient Service Cost









63



OTHER REIMBURSABLE COST CENTERS















70 Home Health Agency Cost









70



71 Ambulance









71



72 Nursing and Allied Health Education Activities









72



73 C.M.H.C.









73



74 Other Reimbursable Cost









74



SPECIAL PURPOSE COST CENTERS















83 Hospice









83



84 Other Special Purpose Cost









84



89 Subtotals









89



NON REIMBURSABLE COST CENTERS















90 Gift, Flower, Coffee Shops and Canteen









90



91 Barber and Beauty Shop









91



92 Physicians' Private Offices









92



93 Nonpaid Workers









93



94 Patients Laundry









94



95 Other Non Reimbursable Cost









95



98 Cross Foot Adjustments









98



99 Negative Cost Center









99



100 Total









100




















FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120 )
































Rev. 1










41-328



































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Sheet 20: B-1

4190 (Cont.)




FORM CMS-2540-10




2/11






PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B - 1






_________________
TO ________________








CAP. REL. CAP. REL. EMPLOYEE RECONCIL- ADMINIS-







BUILDINGS MOVABLE BENEFITS IATION TRATIVE


COST CENTER



& FIXTURES EQUIPMENT

& GENERAL


(Omit Cents)



( Square ( Square (Gross
(Accumulated







Feet) Feet) Salaries)
Cost)






0 1 2 3 4 A 4
GENERAL SERVICE COST CENTERS











1 Capital-Related Costs - Building & Fixture









1
2 Capital-Related Costs - Moveable Equipment









2
3 Employee Benefits









3
4 Administrative and General









4
5 Plant Operation, Maintenance and Repairs









5
6 Laundry and Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Central Services and Supply









10
11 Pharmacy









11
12 Medical Records and Library









12
13 Social Service









13
14 Nursing and Allied Health Education Activities









14
15 Other General Service Cost









15
INPATIENT ROUTINE SERVICE COST CENTERS











30 Skilled Nursing Facility









30
31 Nursing Facility









31
32 Intermediate Care Facility - Mentally Retarded









32
33 Other Long Term care









33
ANCILLARY SERVICE COST CENTERS











40 Radiology









40
41 Laboratory









41
42 Intravenous Therapy









42
43 Oxygen (Inhalation) Therapy









43
44 Physical Therapy









44
45 Occupational Therapy









45
46 Speech Pathology









46
47 Electro cardiology









47
48 Medical Supplies Charged to Patients









48
49 Drugs Charged to Patients









49
50 Dental Care - Title XIX only









50
51 Support Surfaces









51
52 Other Ancillary Service Cost Center









52




















































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)











41-329










Rev. 1


























2/11




FORM CMS-2540-10




4190 (Cont.)






PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B - 1






_________________
TO ________________








CAP. REL. CAP. REL. EMPLOYEE
ADMINIS-







BUILDINGS MOVABLE BENEFITS RECONCIL- TRATIVE

COST CENTER



& FIXTURES EQUIPMENT
IATION & GENERAL


(Omit Cents)



( Square ( Square (Gross
(Accumulated







Feet) Feet) Salaries)
Cost)






0 1 2 3 4 A 4
OUTPATIENT SERVICE COST CENTERS











60 Clinic









60
61 Rural Health Clinic (RHC)









61
62 FQHC









62
63 Other Outpatient Service Cost









63
OTHER REIMBURSABLE COST CENTERS











70 Home Health Agency Cost









70
71 Ambulance









71
72 Nursing and Allied Health Education Activities









72
73 C.M.H.C.









73
74 Other Reimbursable Cost









74
SPECIAL PURPOSE COST CENTERS











83 Hospice









83
84 Other Special Purpose Cost









84
89 Subtotals









89
NON REIMBURSABLE COST CENTERS











90 Gift, Flower, Coffee Shops and Canteen









90
91 Barber and Beauty Shop









91
92 Physicians' Private Offices









92
93 Nonpaid Workers









93
94 Patients Laundry









94
95 Other Non Reimbursable Cost









95
98 Cross Foot Adjustment









98
99 Negative Cost Center









99
102 Cost to Be Allocated (Per Worksheet B, Part I)









102
103 Unit Cost Multiplier (Worksheet B, Part I)









103
104 Cost to Be Allocated (Per Worksheet B, Part II)









104
105 Unit Cost Multiplier (Worksheet B, Part II)









105








































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)











Rev. 1










41-330




















































4190 (Cont.)




FORM CMS-2540-10




2/11






PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B - 1






_________________
TO ________________






PLANT OPER. LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY





MAINTENANCE & LINEN KEEPING
ADMINIS- SERVICES



COST CENTER

& REPAIRS SERVICE

TRATION & SUPPLY



(Omit Cents)

(Square (Pounds of (Hours of (Meals (Direct (Costed (Costed





Feet) Laundry) Service) Served) Nrsing Hrs.) Requisitions) Requisitions)





5 6 7 8 9 10 11
GENERAL SERVICE COST CENTERS











1 Captial-Related Costs - Building & Fixture









1
2 Capital-Related Costs - Moveable Equipment









2
3 Employee Benefits









3
4 Administrative and General









4
5 Plant Operation, Maintenance and Repairs









5
6 Laundry and Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Central Services and Supply









10
11 Pharmacy









11
12 Medical Records and Library









12
13 Social Service









13
14 Nursing and Allied Health Education Activities









14
15 Other General Service Cost









15
INPATIENT ROUTINE SERVICE COST CENTERS











30 Skilled Nursing Facility









30
31 Nursing Facility









31
32 Intermediate Care Facility - Mentally Retarded









32
33 Other Long Term care









33
ANCILLARY SERVICE COST CENTERS











40 Radiology









40
41 Laboratory









41
42 Intravenous Therapy









42
43 Oxygen (Inhalation) Therapy









43
44 Physical Therapy









44
45 Occupational Therapy









45
46 Speech Pathology









46
47 Electro cardiology









47
48 Medical Supplies Charged to Patients









48
49 Drugs Charged to Patients









49
50 Dental Care - Title XIX only









50
51 Support Surfaces









51
52 Other Ancillary Service Cost Center









52

































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)











41-331










Rev. 1


























2/11




FORM CMS-2540-10




4190 (Cont.)






PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B - 1






_________________
TO ________________






PLANT OPER. LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY





MAINTENANCE & LINEN KEEPING
ADMINIS- SERVICES



COST CENTER

& REPAIRS SERVICE

TRATION & SUPPLY



(Omit Cents)

(Square (Pounds of (Hours of (Meals (Direct (Costed (Costed





Feet) Laundry) Service) Served) Nrsing Hrs.) Requisitions) Requisitions)





5 6 7 8 9 10 11
OUTPATIENT SERVICE COST CENTERS











60 Clinic









60
61 Rural Health Clinic (RHC)









61
62 FQHC









62
63 Other Outpatient Service Cost









63
OTHER REIMBURSABLE COST CENTERS











70 Home Health Agency Cost









70
71 Ambulance









71
72 Nursing and Allied Health Education Activities









72
73 C.M.H.C.









73
74 Other Reimbursable Cost









74
SPECIAL PURPOSE COST CENTERS











83 Hospice









83
84 Other Special Purpose Cost









84
89 Subtotals









89
NON REIMBURSABLE COST CENTERS











90 Gift, Flower, Coffee Shops and Canteen









90
91 Barber and Beauty Shop









91
92 Physicians' Private Offices









92
93 Nonpaid Workers









93
94 Patients Laundry









94
95 Other Non Reimbursable Cost









95
98 Cross Foot Adjustment









98
99 Negative Cost Center









99
102 Cost to Be Allocated (Per Worksheet B, Part I)









102
103 Unit Cost Multiplier (Worksheet B, Part I)









103
104 Cost to Be Allocated (Per Worksheet B, Part II)









104
105 Unit Cost Multiplier (Worksheet B, Part II)









105








































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)











Rev. 1










41-332




















































4190 (Cont.)




FORM CMS-2540-10




2/11






PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COSTS

FROM ________________
WORKSHEET B - 1






_________________
TO ________________






MEDICAL SOCIAL NURSING & OTHER
POST



COST CENTER

RECORDS SERVICE ALLIED GENERAL SUBTOTAL STEP-DOWN TOTAL


(Omit Cents)

& LIBRARY
HEALTH EDUCATION SERVICE
ADJUSTMENTS






(Time (Time (Assigned COST








Spent) Spent) Time)









12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS











1 Captial-Related Costs - Building & Fixture









1
2 Capital-Related Costs - Moveable Equipment









2
3 Employee Benefits









3
4 Administrative and General









4
5 Plant Operation, Maintenance and Repairs









5
6 Laundry and Linen Service









6
7 Housekeeping









7
8 Dietary









8
9 Nursing Administration









9
10 Central Services and Supply









10
11 Pharmacy









11
12 Medical Records and Library









12
13 Social Service









13
14 Nursing and Allied Health Education Activities









14
15 Other General Service Cost









15
INPATIENT ROUTINE SERVICE COST CENTERS











30 Skilled Nursing Facility









30
31 Nursing Facility









31
32 Intermediate Care Facility - Mentally Retarded









32
33 Other Long Term care









33
ANCILLARY SERVICE COST CENTERS











40 Radiology









40
41 Laboratory









41
42 Intravenous Therapy









42
43 Oxygen (Inhalation) Therapy









43
44 Physical Therapy









44
45 Occupational Therapy









45
46 Speech Pathology









46
47 Electro cardiology









47
48 Medical Supplies Charged to Patients









48
50 Dental Care - Title XIX only









50
52 Other Ancillary Service Cost Center









52


























FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)









Rev. 1













41-333










Rev. 1


























2/11




FORM CMS-2540-10




4190 (Cont.)






PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COSTS






FROM ________________
WORKSHEET B - 1






_________________
TO ________________






MEDICAL SOCIAL NURSING & OTHER
POST






RECORDS SERVICE ALLIED GENERAL SUBTOTAL STEP-DOWN TOTAL


COST CENTER

& LIBRARY
HEALTH EDU SERVICE
ADJUSTMENTS



(Omit Cents)

(Time (Time (Assigned COST








Spent) Spent) Time)









12 13 14 15 16 17 18
OUTPATIENT SERVICE COST CENTERS











60 Clinic









60
61 Rural Health Clinic (RHC)









61
62 FQHC









62
63 Other Outpatient Service Cost









63
OTHER REIMBURSABLE COST CENTERS











70 Home Health Agency Cost









70
71 Ambulance









71
72 Nursing and Allied Health Education Activities









72
73 C.M.H.C.









73
74 Other Reimbursable Cost









74
SPECIAL PURPOSE COST CENTERS











83 Hospice









83
84 Other Special Purpose Cost









84
89 Subtotals









89
NON REIMBURSABLE COST CENTERS











90 Gift, Flower, Coffee Shops and Canteen









90
91 Barber and Beauty Shop









91
92 Physicians' Private Offices









92
93 Nonpaid Workers









93
94 Patients Laundry









94
95 Other Non Reimbursable Cost









95
98 Cross Foot Adjustment









98
99 Negative Cost Center









99
102 Cost to Be Allocated (Per Worksheet B, Part I)









102
103 Unit Cost Multiplier (Worksheet B, Part I)









103
104 Cost to Be Allocated (Per Worksheet B, Part II)









104
105 Unit Cost Multiplier (Worksheet B, Part II)









105

































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4120)











Rev. 1










41-334
































































































































































































































































































































































































































































































































































































































































































































































































































































Sheet 21: B-II

4190 (Cont.)


FORM CMS-2540-10




2/11




PROVIDER NO.:
PERIOD:



.

ALLOCATION OF CAPITAL - RELATED COSTS



FROM ________________
WORKSHEET B






_________________
TO ________________
PART II





DIRECTLY CAP. REL. CAP. REL.
EMPLOYEE ADMINIS- PLANT OPER.




ASSIGNED BUILDINGS MOVABLE SUBTOTAL BENEFITS TRATIVE MAINTENANCE


COST CENTER
CAPITAL & FIXTURES EQUIPMENT

& GENERAL & REPAIRS


(Omit Cents)
RELATED COSTS










0 1 2 2 A 3 4 5

GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Building & Fixture







1
2 Capital-Related Costs - Moveable Equipment







2
3 Employee Benefits







3
4 Administrative and General







4
5 Plant Operation, Maintenance and Repairs







5
6 Laundry and Linen Service







6
7 Housekeeping







7
8 Dietary







8
9 Nursing Administration







9
10 Central Services and Supply







10
11 Pharmacy







11
12 Medical Records and Library







12
13 Social Service







13
14 Nursing and Allied Health Education Activities







14
15 Other General Service Cost







15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility







30
31 Nursing Facility







31
32 Intermediate Care Facility - Mentally Retarded







32
33 Other Long Term care







33
ANCILLARY SERVICE COST CENTERS










40 Radiology







40
41 Laboratory







41
42 Intravenous Therapy







42
43 Oxygen (Inhalation) Therapy







43
44 Physical Therapy







44
45 Occupational Therapy







45
46 Speech Pathology







46
47 Electro cardiology







47
48 Medical Supplies Charged to Patients







48
49 Drugs Charged to Patients







49
50 Dental Care - Title XIX only







50
51 Support Surfaces







51
52 Other Ancillary Service Cost Center







52




























































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )






















41-335








Rev. 1












2/11


FORM CMS-2540-10




4190 (Cont.)




PROVIDER NO.:
PERIOD:



.

ALLOCATION OF CAPITAL - RELATED COSTS



FROM ________________
WORKSHEET B






_________________
TO ________________
PART II





DIRECTLY CAP. REL. CAP. REL.
EMPLOYEE ADMINIS- PLANT OPER.




ASSIGNED BUILDINGS MOVABLE SUBTOTAL BENEFITS TRATIVE MAINTENANCE

COST CENTER
CAPITAL & FIXTURES EQUIPMENT

& GENERAL & REPAIRS


(Omit Cents)
RELATED COSTS










0 1 2 2 A 3 4 5

OUTPATIENT SERVICE COST CENTERS










60 Clinic







60
61 Rural Health Clinic (RHC)







61
62 FQHC







62
63 Other Outpatient Service Cost







63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost







70
71 Ambulance







71
72 Nursing and Allied Health Education Activities







72
73 C.M.H.C.







73
74 Other Reimbursable Cost







74
SPECIAL PURPOSE COST CENTERS










83 Hospice







83
84 Other Special Purpose Cost







84
89 Subtotals







89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen







90
91 Barber and Beauty Shop







91
92 Physicians' Private Offices







92
93 Nonpaid Workers







93
94 Patients Laundry







94
95 Other Non Reimbursable Cost







95
98 Cross Foot Adjustments







98
99 Negative Cost Center







99
100 Total







100
















































































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )






















Rev. 1








41-336
























4190 (Cont.)


FORM CMS-2540-10




2/11




PROVIDER NO.:
PERIOD:



.

ALLOCATION OF CAPITAL - RELATED COSTS



FROM ________________
WORKSHEET B






_________________
TO ________________
PART II






LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY





& LINEN KEEPING
ADMINIS- SERVICES



COST CENTER

SERVICE

TRATION & SUPPLY



(Omit Cents)













6 7 8 9 10 11

GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Building & Fixture







1
2 Capital-Related Costs - Movable Equipment







2
3 Employee Benefits







3
4 Administrative and General







4
5 Plant Operation, Maintenance and Repairs







5
6 Laundry and Linen Service







6
7 Housekeeping







7
8 Dietary







8
9 Nursing Administration







9
10 Central Services and Supply







10
11 Pharmacy







11
12 Medical Records and Library







12
13 Social Service







13
14 Nursing and Allied Health Education Activities







14
15 Other General Service Cost







15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility







30
31 Nursing Facility







31
32 Intermediate Care Facility - Mentally Retarded







32
33 Other Long Term care







33
ANCILLARY SERVICE COST CENTERS










40 Radiology







40
41 Laboratory







41
42 Intravenous Therapy







42
43 Oxygen (Inhalation) Therapy







43
44 Physical Therapy







44
45 Occupational Therapy







45
46 Speech Pathology







46
47 Electro cardiology







47
48 Medical Supplies Charged to Patients







48
49 Drugs Charged to Patients







49
50 Dental Care - Title XIX only







50
51 Support Surfaces







51
52 Other Ancillary Service Cost Center







52
















































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )






















41-337








Rev. 1












2/11


FORM CMS-2540-10




4190 (Cont.)




PROVIDER NO.:
PERIOD:





ALLOCATION OF CAPITAL - RELATED COSTS



FROM ________________
WORKSHEET B






_________________
TO ________________
PART II






LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY





& LINEN KEEPING
ADMINIS- SERVICES



COST CENTER

SERVICE

TRATION & SUPPLY



(Omit Cents)













6 7 8 9 10 11

OUTPATIENT SERVICE COST CENTERS










60 Clinic







60
61 Rural Health Clinic (RHC)







61
62 FQHC







62
63 Other Outpatient Service Cost







63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost







70
71 Ambulance







71
72 Nursing and Allied Health Education Activities







72
73 C.M.H.C.







73
74 Other Reimbursable Cost







74
SPECIAL PURPOSE COST CENTERS










83 Hospice







83
84 Other Special Purpose Cost







84
89 Subtotals







89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen







90
91 Barber and Beauty Shop







91
92 Physicians' Private Offices







92
93 Nonpaid Workers







93
94 Patients Laundry







94
95 Other Non Reimbursable Cost







95
98 Cross Foot Adjustments







98
99 Negative Cost Center







99
100 Total







100
















































































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4121 )






















Rev. 1








41-338
























2/11


FORM CMS-2540-10




4190 (Cont.)




PROVIDER NO.:
PERIOD:





ALLOCATION OF CAPITAL - RELATED COSTS



FROM ________________
WORKSHEET B






_________________
TO ________________
PART II





MEDICAL SOCIAL NURSING & OTHER
POST



COST CENTER
RECORDS SERVICE ALLIED GENERAL SUBTOTAL STEP-DOWN TOTAL


(Omit Cents)
& LIBRARY
HEALTH SERVICE
ADJUSTMENTS







EDUCATION COST







12 13 14 15 16 17 18

GENERAL SERVICE COST CENTERS










1 Capital-Related Costs - Building & Fixture







1
2 Capital-Related Costs - Movable Equipment







2
3 Employee Benefits







3
4 Administrative and General







4
5 Plant Operation, Maintenance and Repairs







5
6 Laundry and Linen Service







6
7 Housekeeping







7
8 Dietary







8
9 Nursing Administration







9
10 Central Services and Supply







10
11 Pharmacy







11
12 Medical Records and Library







12
13 Social Service







13
14 Nursing and Allied Health Education Activities







14
15 Other General Service Cost







15
INPATIENT ROUTINE SERVICE COST CENTERS










30 Skilled Nursing Facility







30
31 Nursing Facility







31
32 Intermediate Care Facility - Mentally Retarded







32
33 Other Long Term care







33
ANCILLARY SERVICE COST CENTERS










40 Radiology







40
41 Laboratory







41
42 Intravenous Therapy







42
43 Oxygen (Inhalation) Therapy







43
44 Physical Therapy







44
45 Occupational Therapy







45
46 Speech Pathology







46
47 Electro cardiology







47
48 Medical Supplies Charged to Patients







48
49 Drugs Charged to Patients







49
50 Dental Care - Title XIX only







50
51 Support Surfaces







51
52 Other Ancillary Service Cost Center







52
















































41-339








Rev. 1
























2/11


FORM CMS-2540-10




4190 (Cont.)




PROVIDER NO.:
PERIOD:





ALLOCATION OF CAPITAL - RELATED COSTS



FROM ________________
WORKSHEET B






_________________
TO ________________
PART II





MEDICAL SOCIAL NURSING & OTHER
POST





RECORDS SERVICE ALLIED GENERAL SUBTOTAL STEP-DOWN TOTAL


COST CENTER
& LIBRARY
HEALTH SERVICE
ADJUSTMENTS



(Omit Cents)


EDUCATION COST







12 13 14 15 16 17 18

OUTPATIENT SERVICE COST CENTERS










60 Clinic







60
61 Rural Health Clinic (RHC)







61
62 FQHC







62
63 Other Outpatient Service Cost







63
OTHER REIMBURSABLE COST CENTERS










70 Home Health Agency Cost







70
71 Ambulance







71
72 Nursing and Allied Health Education Activities







72
73 C.M.H.C.







73
74 Other Reimbursable Cost







74
SPECIAL PURPOSE COST CENTERS










83 Hospice







83
84 Other Special Purpose Cost







84
89 Subtotals







89
NON REIMBURSABLE COST CENTERS










90 Gift, Flower, Coffee Shops and Canteen







90
91 Barber and Beauty Shop







91
92 Physicians' Private Offices







92
93 Nonpaid Workers







93
94 Patients Laundry







94
95 Other Non Reimbursable Cost







95
98 Cross Foot Adjustments







98
99 Negative Cost Center







99
100 Total







100




























































#REF!






















Rev. 1








41-340

Sheet 22: B-2

4190 ( Cont.)
FORM CMS-2540-10


2/11





















PROVIDER NO.: PERIOD





















.
POST STEP DOWN ADJUSTMENTS
FROM_______________
WORKSHEET B-2






















____________________ TO____________

























WORKSHEET B -






















DESCRIPTION PART NO. LINE NO. AMOUNT





















1 2 3 4




















1




1



















2




2



















3




3



















4




4



















5




5



















6




6



















7




7



















8




8



















9




9



















10




10



















11




11



















12




12



















13




13



















14




14



















15




15



















16




16



















17




17



















18




18



















19




19



















20




20



















21




21



















22




22



















23




23



















24




24



















25




25



















26




26



















27




27



















28




28



















29




29



















30




30



















31




31



















32




32



















33




33



















34




34



















35




35



















36




36



















37




37



















38




38



















39




39



















40




40



















41




41



















42




42



















43




43



















44




44



















45




45



















46




46



















47




47



















48




48



















49




49



















50




50



















FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN

























CMS PUB. 15-II SECTION 4122 )









































































































41-341




Rev. 1

























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1















Sheet 23: C

2/11
FORM CMS-2540-10

4190 ( Cont.)





RATIO OF COST TO CHARGES PROVIDER NO. : PERIOD :







FOR ANCILLARY AND OUTPATIENT
FROM _________________ WORKSHEET C






COST CENTERS ______________________ TO ___________

























































TOTAL Total Ratio







Cost Center (From Wkst B, Charges (col. 1 divided








Pt. I, Col. 18)
by col. 2)








1 2 3






ANCILLARY SERVICE COST CENTERS










40 Radiology


40





41 Laboratory


41





42 Intravenous Therapy


42





43 Oxygen ( Inhalation ) Therapy


43





44 Physical Therapy


44





45 Occupational Therapy


45





46 Speech Pathology


46





47 Electro cardiology


47





48 Medical Supplies Charged


48





49 Drugs Charged to Patients


49





50 Dental Care - Title XIX only


50





51 Support Surfaces


51





52 Other Ancillary Service Cost


52





OUTPATIENT SERVICE COST CENTERS










60 Clinic


60





61 R H C


61





62 FQHC


62





63 Other Outpatient Service Cost


63





71 Ambulance


71





100 Total


100









































































































































































































































FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15 II, SECTION 4123 )






















Rev. 1



41-342















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 24: D

4190 (Cont.)




FORM CMS-2540-10




2/11
APPORTIONMENT OF ANCILLARY AND
PROVIDER NO. :
PERIOD :
WORKSHEET D

OUTPATIENT COST


FROM ______________
PART I







______________________
TO ________________



PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST











Check
[ ] Title V ( 1 ) Check One: [ ] SNF [ ] NF [ ] ICF/MR
[ ] Other __________________


One:
[ ] Title XVIII

[ ] PPS - Must also complete Part II








[ ] Title XIX ( 1 )











RATIO OF HEALTH CARE HEALTH CARE



COST TO PROGRAM CHARGES PROGRAM COST
Cost Center

CHARGES











( Fr. Wkst. C Part A
Part B
Part A
Part B




Column 3 )



(Col. 1 X Col. 2)
(Col. 1 X Col. 3)




1 2
3
4
5

ANCILLARY SERVICE COST CENTERS











40 Radiology









40
41 Laboratory









41
42 Intravenous Therapy









42
43 Oxygen ( Inhalation )









43

Therapy










44 Physical Therapy









44
45 Occupational Therapy









45
46 Speech Pathology









46
47 Electro cardiology









47
48 Medical Supplies









48

Charged To Patients










49 Drugs Charged to Patients









49
50 Dental Care - Title XIX









50
51 Support Surfaces









51
52 Other Ancillary Services









52
OUTPATIENT COST CENTERS











60 Clinic









60
61 R H C









61
62 FQHC









62
63 Other Outpatient Services









63
71 Ambulance (2)









71
100 Total (Sum of lines 40 - 71)









100
( 1 ) For titles V and XIX use columns 1, 2 and 4 only.











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











FORM CMS- 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 4124)
























41-343










Rev. 1








































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 25: DII

2/11


FORM CMS-2540-10




4190 (Cont.)

APPORTIONMENT OF ANCILLARY AND PROVIDER NO. :
PERIOD :

WORKSHEET D

OUTPATIENT COST

FROM ______________

PARTS II & III





______________________
TO ________________






Check One:
[ ] SNF [ ] NF [ ] ICF/MR



















PART II - APPORTIONMENT OF VACCINE COST


























1 Drugs charged to patients - ratio of cost to charges ( From Worksheet C, column 3, line 49)








1

2 Program vaccine charges ( From your records, or the P S & R.)








2

3 Program costs ( Line 1 X line 2) ( Title XVIII, PPS providers,








3


transfer this amount to Worksheet E, Part I, line 24)

























PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH






























Total Cost Nursing & Ratio of Nursing Program Part A Program Part B






(From Allied Health & Allied Health Part A Cost Nursing & Allied Part B Cost Nursing & Allied



Cost Centers

Worksheet B, (From Wkst. B, Costs To Total (From Wkst. D. Health Costs for (From Wkst. D. Health Costs for






Part I, Col 18) Part I, Column 14) Costs - Part A Part 1, Col. 4) Pass Through Part 1, Col. 5) Pass Through








(Col. 2 / Col.. 1)
(Col. 3 X Col. 4)
(Col. 3 X Col. 6)






1 2 3 4 5 6 7


ANCILLARY SERVICE COST CENTERS












40 Radiology








40

41 Laboratory








41

42 Intravenous Therapy








42

43 Oxygen ( Inhalation ) Therapy








43

44 Physical Therapy








44

45 Occupational Therapy








45

46 Speech Pathology








46

47 Electro cardiology








47

48 Medical Supplies








48

49 Drugs Charged to Patients








49

50 Dental Care - Title XIX only








50

51 Support Surfaces








51

52 Other Ancillary Service Costs








52

100 Total ( Sum of lines 40 - 52)








100







































































FORM CMS- 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 4124)












Rev. 1









41-344



















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 26: D-1

4190 (Cont.)

FORM CMS-2540-10

2/11





PROVIDER NO. : PERIOD :






COMPUTATION OF INPATIENT


FROM ______________
WORKSHEET D-1


ROUTINE COSTS

______________________ TO ____________
PARTS I & II


Check One:
[ ] Title V [ ] Title XVIII [ ] Title XIX






Check One:
[ ] SNF [ ] NF [ ] ICF/MR






PART I CALCULATION OF INPATIENT ROUTINE COSTS























INPATIENT DAYS









1 Inpatient days including private room days





1


2 Private room days





2


3 Inpatient days including private room days applicable to the Program





3


4 Medically necessary private room days applicable to the Program





4


5 Total general inpatient routine service cost





5



PRIVATE ROOM DIFFERENTIAL ADJUSTMENT









6 General inpatient routine service charges





6


7 General inpatient routine service cost/charge ratio (Line 5 divided by line 6)





7


8 Enter private room charges from your records





8


9 Average private room per diem charge (Private room charges





9



line 8 divided by private room days, line 2)









10 Enter semi-private room charges from your records





10


11 Average semi-private room per diem charge (Semi-private room charges





11



line 10, divided by semi-private room days)









12 Average per diem private room charge differential ( Line 9 minus line 11 )





12


13 Average per diem private room cost differential ( Line 7 times line 12 )





13


14 Private room cost differential adjustment ( Line 2 times line 13 )





14


15 General inpatient routine service cost net of private room cost differential





15



( Line 5 minus line 14 )










PROGRAM INPATIENT ROUTINE SERVICE COSTS









16 Adjusted general inpatient service cost per diem





16



( Line 15 divided by line 1 )









17 Program routine service cost ( Line 3 times line 16 )





17


18 Medically necessary private room cost applicable to program ( line 4 times line 13 )





18


19 Total program general inpatient routine service cost ( Line 17 plus line 18 )





19


20 Capital related cost allocated to inpatient routine service costs ( From Wkst. B,





20



Part II column 18, - line 30 for SNF; line 31 for NF,or line 32 for ICF/MR )









21 Per diem capital related costs ( Line 20 divided by line 1 )





21


22 Program capital related cost ( Line 3 times line 21 )





22


23 Inpatient routine service cost ( Line 19 minus line 22 )





23


24 Aggregate charges to beneficiaries for excess costs ( From provider records )





24


25 Total program routine service costs for comparison to the cost limitation





25



( Line 23 minus line 24 )









26 Enter the per diem limitation (1)





26


27 Inpatientroutine service cost limitation (Line 3 times the per diem limitation line 26) (1)





27


28 Reimbursable inpatient routine service costs ( Line 22 plus the lesser of line 25 or line 27 )





28



( Transfer to Worksheet E, Part II, line 4) ( See instructions )










(1) Lines 26 and 27 are not applicable for title XVIII, but may be used for title V and or title XIX





















PART II CALCULATION OF INPATIENT NURSING & ALLIED HEALTH COSTS FOR PPS PASS-THROUGH










1 Total inpatient days





1


2 Program inpatient days. ( From Worksheet S-3, Part I, cols. 3, or 5, line 1 as applicable)





2


3 Total Nursing & Allied Health costs. ( From Worksheet B, Part I, column 14, line 14)





3


4 Nursing & Allied Health ratio. ( Line 2 divided by line 1)





4


5 Program Nursing & Allied Health costs for pass-through. (Line 3 times line 4)





5


FORM CMS-2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4125 )






















41-345






Rev. 1




















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 27: E-I

2/11

FORM CMS-2540-10

4190 ( Cont.)







































CALCULATION OF
PROVIDER NO.: PERIOD:







.






























.

REIMBURSEMENT SETTLEMENT

FROM _____________ WORKSHEET E








































TITLE XVIII
_________________ TO ______________ PART I





















































































PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES












































1 Inpatient ancillary services - Part A - ( See Instructions )



1






































2 Nursing and Allied Health Education Activities



2






































3 Total cost ( Sum of lines 1 and 2)



3






































4 Inpatient PPS amount (see instructions)



4






































5 Primary payor amounts



5






































6 Coinsurance



6






































7 Reimbursable bad debts (From your records)



7






































8 Reimbursable bad debts for dual eligible beneficiaries (See instructions)



8






































9 Adjusted reimbursable bad debts for periods ending on and after 10/01/2005 (See instructions)



9






































10 Recovery of bad debts - for statistical records only



10






































11 Utilization review



11






































12 Subtotal (See instructions)



12






































13 Interim payments (See instructions)



13






































14 Tentative adjustment



14






































15 OTHER adjustment (See instructions)



15






































16 Balance due provider/program (Line 12 minus line 13 and 14, plus or minus line 15)



16







































(Indicate overpayment in brackets) (See Instructions)











































17 Protested amounts (Nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2)



17




















































































PART B - ANCILLARY SERVICES COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES - TITLE XVIII ONLY












































18 Ancillary services Part B



18






































19 Vaccine cost (From Wkst D, Part II, line 3)



19






































20 Nursing & Allied Health Education Activities (from Wkst D, part III, col. 7, line 100)



20






































21 Total reasonable costs (Sum of lines 18, 19, and 20)



21






































22 Medicare Part B ancillary charges (See instructions)



22






































23 Cost of covered services (Lesser of line 21 or line 22)



23






































24 Primary payor amounts



24






































25 Coinsurance and deductibles



25






































26 Reimbursable bad debts (From your records)



26






































27 Other Adjustments (See instructions) Specify



27






































28 Subtotal (Sum of lines 23 and 26, minus lines 24 and 25, plus or minus line 27)



28






































29 Interim payments (See instructions)



29






































30 Tentative adjustment



30






































31 OTHER adjustments (See instructions)



31






































32 Balance due provider/program (Line 28 minus line 29, 30 and line 31)



32







































(Indicate overpayments in brackets) (See Instructions)











































33 Protested amounts (Nonallowable cost report items) in accordance with CMS Pub.15-II, section 115.2



33






































FORM CMS 2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II SECTION 4130)






















































































































































































Rev. 1




41-346


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1


































Sheet 28: E-II

4190 (Cont.)

FORM CMS-2540-10

2/11









































CALCULATION OF
PROVIDER NO.: PERIOD:








































.

REIMBURSEMENT SETTLEMENT

FROM __________ WORKSHEET E










































FOR TITLE V and TITLE XIX ONLY
_________________ TO ______________ PART II









































Check one:

[ ] Title V [ ] Title XIX










































Check one:
[ ] SNF [ ] NF [ ] ICF/MR











































COMPUTATION OF NET COST OF COVERED SERVICES













































1 Inpatient ancillary services (See Instructions)



1








































2 Intern and Resident Cost (From Worksheet D-2)



2








































3 Outpatient services



3








































4 Inpatient routine services (See instructions)



4

















Total reasonable costs (sum of lines 1, 2 and 3)





















5 Utilization review--physicians' compensation (From provider records)



5

















Cost of covered services (lesser of lines 4 or 5)





















6 Cost of covered services (Sum of lines 1 - 5)



6

















Inpatient routine PPS amount (see instructions)





















7 Differential in charges between semiprivate accommodations and less



7









































than semiprivate accommodations













































8 SUBTOTAL (Line 6 minus line 7)



8

















Reimbursable bad debts





















9 Primary payor amounts



9

















Utilization review





















10 Total Reasonable Cost (Line 8 minus line 9)



10

















Recovery of unreimbursed cost under the lesser of reasonable cost or customary charges






















REASONABLE CHARGES













































11 Inpatient ancillary service charges



11

















Subtotal (Sum of lines 6 through 14)





















12 Intern and Resident Charges (From Provider Records)



12

















Sequestration adjustment





















13 Outpatient service charges



13

















Interim payments (See instructions)





















14 Inpatient routine service charges



14

















Balance due provider/program (Line 15 minus the sum of lines 16 and 17)





















15 Differential in charges between semiprivate accommodations and less



15

















(Indicate overpayments in brackets)






















than semiprivate accommodations






















Protested amounts (Nonallowable cost report items in accordance with





















16 Total reasonable charges



16

















CMS Pub. 15-II, section 115.2)






















CUSTOMARY CHARGES






















Balance due provider/program (Line 18 plus or minus line 19)





















17 Aggregate amount actually collected from patients liable for payment for



17









































services on a charge basis













































18 Amounts that would have been realized from patients liable for payment for services



18









































on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)













































19 Ratio of line 17 to line 18 (not to exceed 1.000000)



19








































20 Total customary charges (See instructions)



20









































COMPUTATION OF REIMBURSEMENT SETTLEMENT













































21 Cost of covered services (See Instructions)



21








































22 Deductibles



22








































23 Subtotal (Line 21 minus line 22)



23








































24 Coinsurance



24








































25 Subtotal (Line 23 minus line 24)



25








































26 Reimbursable bad debts ( From your records)



26








































27 Subtotal (Sum of lines 25 and 26)



27








































28 Unrefunded charges to beneficiaries for excess costs erroneously collected



28









































based on correction of cost limit













































29 Recovery of excess depreciation resulting from provider termination or a decrease



29









































in program utilization













































30 Other Adjustments (See instructions) Specify



30








































31 Amounts applicable to prior cost reporting periods resulting from disposition of



31









































depreciable assets ( If minus, enter amount in brackets)













































32 Subtotal (Line 27 plus or minus lines 30, and 31, minus lines 28 and 29)



32








































33 Interim payments



33








































34 Balance due provider/program (Line 32 minus line 33)



34









































(Indicate overpayments in brackets) (See Instructions)





























































































FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,














































SECTIONS 4130.2 )






























































































41-347




Rev. 1


































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1




































Sheet 29: E1

2/11

FORM CMS-2540-10



4190 ( Cont.)


ANALYSIS OF PAYMENTS TO PROVIDERS

PROVIDER NO.:
PERIOD:





FOR SERVICES RENDERED



FROM ________________
WORKSHEET E - 1






________________
TO ________________









Inpatient Part A
Part B








mm/dd/yyyy Amount mm/dd/yyyy Amount




Description

1 2 3 4



1 Total interim payments paid to provider





1


2 Interim payments payable on individual bills, either submitted





2



or to be submitted to the intermediary/contractor for services










rendered in the cost reporting period. If none, enter zero









3 List separately each retroactive lump sum
.01



3.01



adjustment amount based on subsequent revision of
.02



3.02



the interim rate for the cost reporting period Program to .03



3.03



Also show date of each payment. Provider .04



3.04





.05



3.05



If none, write "NONE," or enter a zero (1)
.50



3.50





.51



3.51




Provider to .52



3.52




Program .53



3.53





.54



3.54



SUBTOTAL (Sum of lines 3.01 - 3.05 minus sum of lines 3.50 - 3.54)
.99



3.99


4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99) Transfer to Wkst E, Part I





4



line 18 for Part A, and line 35 for Part B. or Transfer to Wkst E, Part II, line 33)










TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR









5 List separately each tentative settlement Program to .01



5.01



payment after desk review. Also show Provider .02



5.02



date of each payment.
.03



5.03



If none, write "NONE," or enter a zero.(1)
.50



5.50




Provider to .51



5.51




Program .52



5.52



SUBTOTAL (Sum of lines 5.01 - 5.03 minus sum of lines 5.50 - 5.52)
.99



5.99


6 Determined net settlement amount (balance Program to provider .01



6.01



due) based on the cost report. (1) Provider to program .50



6.50


7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)





7


8 Name of Intermediary/Contractor

Intermediary/Contractor Number


8














9 Signature of Authorized Person

Date: (mm/dd/yyyy)


9














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










FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4131 )










Rev. 1






41-348




















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 30: G

4190 ( Cont.)

FORM CMS-2540-10

2/11







PROVIDER NO.: PERIOD:







BALANCE SHEET

FROM ________ WORKSHEET G





(If you are nonproprietary and do not maintain fund-type


TO ___________






accounting records, complete the "General Fund" column only)













Specific








Assets General Purpose Endowment Plant






(Omit cents) Fund Fund Fund Fund







1 2 3 4






CURRENT ASSETS









1 Cash on hand and in banks



1




2 Temporary investments



2




3 Notes receivable



3




4 Accounts receivable



4




5 Other receivables



5




6 Less: allowances for uncollectible notes ( ) ( ) ( ) ( ) 6





and accounts receivable









7 Inventory



7




8 Prepaid expenses



8




9 Other current assets



9




10 Due from other funds



10




11 TOTAL CURRENT ASSETS



11





(Sum of lines 1 - 10)










FIXED ASSETS









12 Land



12




13 Land improvements



13




14 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 14




15 Buildings



15




16 Less Accumulated depreciation ( ) ( ) ( ) ( ) 16




17 Leasehold improvements



17




18 Less: Accumulated Amortization ( ) ( ) ( ) ( ) 18




19 Fixed equipment



19




20 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 20




21 Automobiles and trucks



21




22 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 22




23 Major movable equipment



23




24 Less: Accumulated depreciation ( ) ( ) ( ) ( ) 24




25 Minor equipment - Depreeciable



25




26 Minor equipment nondepreciable



26




27 Other fixed assets



27




28 TOTAL FIXED ASSETS



28





(Sum of lines 12 - 27)










OTHER ASSETS









29 Investments



29




30 Deposits on leases



30




31 Due from owners/officers



31




32 Other assets



32




33 TOTAL OTHER ASSETS



33





(Sum of lines 29 - 34)









34 TOTAL ASSETS



34





(Sum of lines 11, 28 and 33)










( ) = contra amount





















FORM CMS 2540 10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4140 )






















41-349




Rev. 1


































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 31: GII

2/11

FORM CMS-2540-10

4190 ( Cont.)







PROVIDER NO.: PERIOD:






BALANCE SHEET
FROM ________ WORKSHEET G





(If you are nonproprietary and do not maintain fund-type


TO ___________ (Cont.)





accounting records, complete the "General Fund" column only)











Liabilities and Fund
Specific








Balances General Purpose Endowment Plant






(Omit cents) Fund Fund Fund Fund







1 2 3 4






CURRENT LIABILITIES









35 Accounts payable



35




36 Salaries, wages & fees payable



36




37 Payroll taxes payable



37




38 Notes & loans payable (Short term)



38




39 Deferred income



39




40 Accelerated payments



40




41 Due to other funds



41




42 Other current liabilities



42




43 TOTAL CURRENT LIABILITIES



43





(Sum of lines 35 - 42)










LONG TERM LIABILITIES









44 Mortgage payable



44




45 Notes payable



45




46 Unsecured loans



46




47 Loans from owners:



47




48 Other long term liabilities



48




49




49




50 TOTAL LONG TERM LIABILITIES



50





(Sum of lines 44 - 49)









51 TOTAL LIABILITIES



51





(Sum of lines 43 and 50)










CAPITAL ACCOUNTS









52 General fund balance



52




53 Specific purpose fund



53




54 Donor created - endowment fund



54





balance - restricted









55 Donor created - endowment fund



55





balance - unrestricted









56 Governing body created - endowment



56





fund balance









57 Plant fund balance - invested in plant



57




58 Plant fund balance - reserve for



58





plant improvement, replacement and










expansion









59 TOTAL FUND BALANCES



59





(Sum of lines 50 thru 56)









60 TOTAL LIABILITIES AND



60





FUND BALANCES










(Sum of lines 51 and 59)










( ) = contra amount

































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4140 )






















Rev. 1




41-350














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 32: G-1

4190 (Cont.)


FORM CMS-2540-10



2/11





PROVIDER NO:
PERIOD:





STATEMENT OF CHANGES IN FUND BALANCES



FROM ___________________
WORKSHEET G - 1






________________________
TO ________________










































GENERAL FUND SPECIFIC PURPOSE FUND ENDOWMENT FUND PLANT FUND


1 2 3 4 5 6 7 8

1 Fund balances at beginning of







1

period









2 Net income (loss)







2

(From Wkst. G-3, line 32)









3 Total (Sum of line 1 and line 2)







3
4 Additions (Credit adjustments)







4
5








5
6








6
7








7
8








8
9








9
10 Total additions (Sum of lines 4 - 9)







10
11 Subtotal (Line 3 plus line 10)







11
12 Deductions (Debit adjustments)







12
13








13
14








14
15








15
16








16
17








17
18 Total deductions







18

(Sum of lines 12 - 17)









19 Fund balance at end of period per







19

balance sheet (Line 11 - line 18)









































































































FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4140)










41-351








Rev. 1


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 33: G-2

2/11
FORM CMS-2540-10

4190 ( Cont.)







PROVIDER NO: PERIOD:








STATEMENT OF PATIENT REVENUES ______________ FROM _________ WORKSHEET G - 2







AND OPERATING EXPENSES
TO ___________ PARTS I & II







PART I - PATIENT REVENUES










Revenue Center INPATIENT OUTPATIENT TOTAL








1 2 3







GENERAL INPATIENT ROUTINE CARE SERVICES









1 Skilled Nursing Facility


1





2 Nursing facility


2





3 ICF/MR


3





4 Other long term care


4





5 Total general inpatient care services


5






(Sum of lines 1 - 4)










All Other Care Service









6 Ancillary services


6





7 Clinic


7





8 Home Health Agency


8





9 Ambulance


9





10 RHC


10





11 FQHC & CMHC


11





12 SNF Based Hospice


12





13 Total Patient Revenues ( Sum of lines 5 - 12 )


13






( Transfer column 3 to Worksheet G-3, Line 1 )










PART II - OPERATING EXPENSES









1 Operating Expenses ( Per Worksheet A, Col. 3, Line 100 )


1

















2 Add ( Specify )


2

















3



3

















4



4

















5



5

















6



6

















7



7

















8 Total Additions ( Sum of lines 2 - 7 )


8

















9 Deduct ( Specify )


9

















10



10

















11



11

















12



12

















13



13

















14 Total Deductions ( Sum of lines 9 - 13 )


14

















15 Total Operating Expenses ( Sum of lines 1 and 8, minus line 14 )


15






( Transfer to Worksheet G-3, Line 4 )









FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4140 )






















Rev. 1



41-352











































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 34: G-3

4190 ( Cont.)
FORM CMS-2540-10
2/11







STATEMENT OF REVENUES PROVIDER NO: PERIOD:








AND EXPENSES ______________ FROM _________ WORKSHEET G - 3









TO ___________



















1 Total patient revenues (From Wkst. G - 2, Part I, col. 3, line 13)


1





2 Less: contractual allowances and discounts on patients accounts


2





3 Net patient revenues (Line 1 minus line 2)


3





4 Less: total operating expenses (From Worksheet G-2, Part II, line 15)


4





5 Net income from service to patients (Line 3 minus 4)


5





6 Other income:


6





7 Contributions, donations, bequests, etc


7





8 Income from investments


8





9 Revenues from communications ( Telephone and Internet service)


9





10 Revenue from television and radio service


10





11 Purchase discounts


11





12 Rebates and refunds of expenses


12





13 Parking lot receipts


13





14 Revenue from laundry and linen service


14





15 Revenue from meals sold to employees and guests


15





16 Revenue from rental of living quarters


16





17 Revenue from sale of medical and surgical supplies to other than patients


17





18 Revenue from sale of drugs to other than patients


18





19 Revenue from sale of medical records and abstracts


19





20 Tuition (fees, sale of textbooks, uniforms, etc.)


20





21 Revenue from gifts, flower, coffee shops, canteen


21





22 Rental of vending machines


22





23 Rental of skilled nursing space


23





24 Governmental appropriations


24





25 Other (specify)


25





26 Total other income (Sum of lines 7 - 25)


26





27 Total (Line 5 plus line 26)


27





28 Other expenses (specify)


28





29



29





30



30





31 Total other expenses (Sum of lines 28 - 30)


31





32 Net income (or loss) for the period (Line 27 minus line 31)


32





































































































































































































FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN










CMS PUB. 15-II, SECTION 4140)










41-353



Rev. 1















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 35: H


2/11


FORM CMS-2540-10





4190 (Cont.)
ANALYSIS OF PROVIDER-BASED





PROVIDER NO.: __________
PERIOD:
WORKSHEET
HOME HEALTH AGENCY COSTS







FROM __________
H







HHA NO.: ________________
TO _____________






TRANSPOR- CONTRACTED/ OTHER TOTAL RECLASSIFI- RECLASSIFIED ADJUST- NET


SALARIES EMPLOYEE TATION PURCHASED COSTS (sum of cols. CATIONS TRIAL BALANCE MENTS EXPENSES FOR

COST CENTER DESCRIPTIONS
BENEFITS (see SERVICES
1 thru 5)
(col. 6 + col. 7)
ALLOCATION

(omit cents)

instructions)





(col. 8 + col. 9)


1 2 3 4 5 6 7 8 9 10
GENERAL SERVICE COST CENTERS











1 Capital Related-Bldgs. and Fixtures









1
2 Capital Related-Movable Equipment









2
3 Plant Operation & Maintenance









3
4 Transportation (see instructions)









4
5 Administrative and General









5
HHA REIMBURSABLE SERVICES










6 Skilled Nursing Care









6
7 Physical Therapy









7
8 Occupational Therapy









8
9 Speech Pathology









9
10 Medical Social Services









10
11 Home Health Aide









11
12 Supplies (see instructions)









12
13 Drugs









13
14 DME









14
15 Telemedicine









15
HHA NONREIMBURSABLE SERVICES










16 Home Dialysis Aide Service









16
17 Respiratory Therapy









17
18 Private Duty Nursing









18
19 Clinic









19
20 Health Promotion Activities









20
21 Day Care Program









21
22 Home Delivered Meals Program









22
23 Homemaker Service









23
24 All Others









24
25 Total (sum of lines 1-24)









25
Column, 6 line 25 should agree with the Worksheet A, column 3, line 70, or subscript as applicable.






































































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 4141)





































Rev. 1










41-354













































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 36: H1-1

4190 (Cont.)

FORM CMS-2540-10




2/11






PROVIDER NO.: ___________
PERIOD:
WORKSHEET H-1

COST ALLOCATION - HHA GENERAL SERVICE COST





FROM ________________
PART I






HHA NO.: ________________
TO ___________________





NET EXPENSES CAPITAL








FOR COST RELATED COSTS








ALLOCATION

PLANT

ADMINIS-




(from Wkst. BLDGS. & MOVABLE OPERATION & TRANS- SUBTOTAL TRATIVE TOTAL



H, col. 10) FIXTURES EQUIPMENT MAINTENANCE PORTATION (cols. 0-4) & GENERAL (cols. 4a + 5)



0 1 2 3 4 4a 5 6

GENERAL SERVICE COST CENTERS










1 Capital Related-Bldgs. and Fixtures







1
2 Capital Related-Movable Equipment







2
3 Plant Operation & Maintenance







3
4 Transportation (see instructions)







4
5 Administrative and General







5
HHA REIMBURSABLE SERVICES










6 Skilled Nursing Care







6
7 Physical Therapy







7
8 Occupational Therapy







8
9 Speech Pathology







9
10 Medical Social Services







10
11 Home Health Aide







11
12 Supplies (see instructions)







12
13 Drugs







13
14 DME







14
15 Telemedicine







15
HHA NONREIMBURSABLE SERVICES










16 Home Dialysis Aide Services







16
17 Respiratory Therapy







17
18 Private Duty Nursing







18
19 Clinic







19
20 Health Promotion Activities







20
21 Day Care Program







21
22 Home Delivered Meals Program







22
23 Homemaker Service







23
24 All Others







24
25 Totals (sum of lines 1-24)







25




























































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






















41-355







Rev. 1



































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 37: H1-II


2/11 FORM CMS-2540-10





4190 (Cont.)





PROVIDER NO.: __________
PERIOD:
WORKSHEET H-1,


COST ALLOCATION - HHA STATISTICAL BASIS




FROM _________________
PART II






HHA NO.: ________________
TO ___________________







CAPITAL









RELATED COSTS PLANT

ADMINIS-





BLDGS. & MOVABLE OPERATION &

TRATIVE





FIXTURES EQUIPMENT MAINTENANCE TRANS-
& GENERAL





(SQUARE (DOLLAR (SQUARE PORTATION RECONCIL- (ACCUM.





FEET) VALUE) FEET) (MILEAGE) IATION COST)





1 2 3 4 5a 5


GENERAL SERVICE COST CENTERS










1 Capital Related-Bldgs. and Fixtures






1

2 Capital Related-Movable Equipment






2

3 Plant Operation & Maintenance






3

4 Transportation (see instructions)






4

5 Administrative and General






5

HHA REIMBURSABLE SERVICES










6 Skilled Nursing Care






6

7 Physical Therapy






7

8 Occupational Therapy






8

9 Speech Pathology






9

10 Medical Social Services






10

11 Home Health Aide






11

12 Supplies (see instructions)






12

13 Drugs






13

14 DME






14

15 Telemedicine






15

HHA NONREIMBURSABLE SERVICES










16 Home Dialysis Aide Services






16

17 Respiratory Therapy






17

18 Private Duty Nursing






18

19 Clinic






19

20 Health Promotion Activities






20

21 Day Care Program






21

22 Home Delivered Meals Program






22

23 Homemaker Service






23

24 All Others






24

25 Total (sum of lines 1-24)






25

26 Cost To Be Allocated






26

27 Unit Cost Multiplier






27













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






















Rev. 1







41-356















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 38: H2-1

4190 (Cont.)


FORM CMS-2540-10




2/11

2/11

FORM CMS-2540-10



4190 (Cont.)

4190 (Cont.)
FORM CMS-2540-10




2/11
ALLOCATION OF GENERAL SERVICE



PROVIDER NO.: ______________

PERIOD:
WORKSHEET H-2,
ALLOCATION OF GENERAL SERVICE

PROVIDER NO.: ______________

PERIOD:
WORKSHEET H-2,

ALLOCATION OF GENERAL SERVICE

PROVIDER NO.: ______________

PERIOD:
WORKSHEET H-2,

COSTS TO HHA COST CENTERS



HHA NO.: _____________

FROM__________________
PART I
COSTS TO HHA COST CENTERS

HHA NO.: _____________

FROM__________________
PART I (CONT.)

COSTS TO HHA COST CENTERS

HHA NO.: _____________

FROM ______________
PART I (CONT.)









TO ___________________








TO ___________________









TO _________________





From
NEW CAPITAL
















INTERN &





Wkst HHA RELATED COSTS






















RESIDENT
ALLOCATED


HHA COST CENTER H-1 TRIAL

ADMINIS-
LAUNDRY

CORF COST CENTER

NURSING CENTRAL
MEDICAL



HHA COST CENTER INTERNS & RESIDENTS OTHER SUBTOTAL COST & POST
HHA


(omit cents) Part I, BALANCE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & OPERATION & LINEN

(omit cents) HOUSE ADMINIS- SERVICES &
RECORDS & SOCIAL


(omit cents) SALARY AND PROGRAM GENERAL (sum of cols. STEPDOWN SUBTOTAL A&G (see TOTAL


col. 6, (1) FIXTURES EQUIPMENT BENEFITS (cols. 0-3) GENERAL OF PLANT SERVICE


KEEPING DIETARY TRATION SUPPLY PHARMACY LIBRARY SERVICE



FRINGES COSTS SERVICE 3a-16) ADJUSTMENTS (cols. 17 ± 18) Part II) HHA COSTS


line 0 1 2 3 3A 4 5 6


7 8 9 10 11 12 13



14 15 16 17 18 19 20 21
1 Administrative and General 5







1 1 Administrative and General






1
1 Administrative and General







1
2 Skilled Nursing Care 6







2 2 Skilled Nursing Care






2
2 Skilled Nursing Care







2
3 Physical Therapy 7







3 3 Physical Therapy






3
3 Physical Therapy







3
4 Occupational Therapy 8







4 4 Occupational Therapy






4
4 Occupational Therapy







4
5 Speech Pathology 9







5 5 Speech Pathology






5
5 Speech Pathology







5
6 Medical Social Services 10







6 6 Medical Social Services






6
6 Medical Social Services







6
7 Home Health Aide 11







7 7 Home Health Aide






7
7 Home Health Aide







7
8 Supplies 12







8 8 Supplies






8
8 Supplies







8
9 Drugs 13







9 9 Drugs






9
9 Drugs







9
10 DME 14







10 10 DME






10
10 DME







10
11 Telemedicine 15







11 11 Telemedicine






11
11 Telemedicine







11
12 Home Dialysis Aide Services 16







12 12 Home Dialysis Aide Services






12
12 Home Dialysis Aide Services







12
13 Respiratory Therapy 17







13 13 Respiratory Therapy






13
13 Respiratory Therapy







13
14 Private Duty Nursing 18







14 14 Private Duty Nursing






14
14 Private Duty Nursing







14
15 Clinic 19







15 15 Clinic






15
15 Clinic







15
16 Health Promotion Activities 20







16 16 Health Promotion Activities






16
16 Health Promotion Activities







16
17 Day Care Program 21







17 17 Day Care Program






17
17 Day Care Program







17
18 Home Delivered Meals Program 22







18 18 Home Delivered Meals Program






18
18 Home Delivered Meals Program







18
19 Homemaker Service 23







19 19 Homemaker Service






19
19 Homemaker Service







19
20 All Others 24







20 20 All Others






20
20 All Others







20
21 Totals (sum of lines 1-20) (2)








21 21 Totals (sum of lines 1-20) (2)






21
21 Totals (sum of lines 1-20) (2)







21
22 Unit Cost Multiplier: column 19, line 1








22 22 Unit Cost Multiplier: column 19, line 1






22
22 Unit Cost Multiplier: column 19, line 1







22

divided by the sum of column 19,










divided by the sum of column 19,









divided by the sum of column 19,









line 21, minus column 19, line 1,










line 21, minus column 19, line 1,









line 21, minus column 19, line 1,









rounded to 6 decimal places.










rounded to 6 decimal places.









rounded to 6 decimal places.










































(1) Column 0, line 21 must agree with Wkst. A, column 7, line 70.










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









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









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








































































































































































FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)










FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)









FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)











































41-357









Rev. 1 Rev. 1







41-358

41-359







Rev. 1
















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1






















Sheet 39: H2-II

4190 (Cont.)


FORM CMS-2540-10



2/11

2/11

FORM CMS-2540-10


4190 (Cont.) 4190 (Cont.)

FORM CMS-2540-10


2/11
ALLOCATION OF GENERAL SERVICE
PROVIDER NO.: ___________

PERIOD:

WORKSHEET H-2,

ALLOCATION OF GENERAL SERVICE
PROVIDER NO.: ______________
PERIOD:
WORKSHEET H-2,

ALLOCATION OF GENERAL SERVICE
PROVIDER NO.: __________
PERIOD:
WORKSHEET H-2,

COSTS TO HHA COST CENTERS
HHA NO.: _____________

FROM__________________

PART II

COSTS TO HHA COST CENTERS
HHA NO.: _____________
FROM__________________
PART II (CONT.)

COSTS TO HHA COST CENTERS
HHA NO.: _____________
FROM__________________
PART II (CONT.)

STATISTICAL BASIS



TO ___________________




STATISTICAL BASIS


TO ___________________



STATISTICAL BASIS


TO ___________________







CAPITAL























RELATED COST

ADMINIS-



LAUNDRY

NURSING CENTRAL




MEDICAL
INTERNS & RESIDENTS





BLDGS. & MOVABLE EMPLOYEE
TRATIVE & OPERATION


& LINEN HOUSE- ADMINIS- SERVICES &




RECORDS & SOCIAL SALARY & PROGRAM OTHER

HHA COST CENTER

FIXTURES EQUIPMENT BENEFITS
GENERAL OF PLANT

HHA COST CENTER SERVICE KEEPING DIETARY TRATION SUPPLY PHARMACY

HHA COST CENTER
LIBRARY SERVICE FRINGES COSTS GENERAL




(SQUARE (DOLLAR (GROSS RECONCIL- (ACCUM. (SQUARE


(POUNDS OF (HOURS OF (MEALS (DIRECT (COSTED (COSTED



(TIME (TIME (ASSIGNED (ASSIGNED SERVICE




FEET) VALUE) SALARIES) IATION COST) FEET)


LAUNDRY) SERVICE) SERVED) NURS. HRS) REQUIS.) REQUIS.)



SPENT) SPENT) TIME) TIME) (SPECIFY)




1 2 3 3A 4 5


6 7 8 9 10 11



12 13 14 15 16
1 Administrative and General







1 1 Administrative and General





1 1 Administrative and General





1
2 Skilled Nursing Care







2 2 Skilled Nursing Care





2 2 Skilled Nursing Care





2
3 Physical Therapy







3 3 Physical Therapy





3 3 Physical Therapy





3
4 Occupational Therapy







4 4 Occupational Therapy





4 4 Occupational Therapy





4
5 Speech Pathology







5 5 Speech Pathology





5 5 Speech Pathology





5
6 Medical Social Services







6 6 Medical Social Services





6 6 Medical Social Services





6
7 Home Health Aide







7 7 Home Health Aide





7 7 Home Health Aide





7
8 Supplies







8 8 Supplies





8 8 Supplies





8
9 Drugs







9 9 Drugs





9 9 Drugs





9
10 DME







10 10 DME





10 10 DME





10
11 Telemedicine







11 11 Telemedicine





11 11 Telemedicine





11
12 Home Dialysis Aide Services







12 12 Home Dialysis Aide Services





12 12 Home Dialysis Aide Services





12
13 Respiratory Therapy







13 13 Respiratory Therapy





13 13 Respiratory Therapy





13
14 Private Duty Nursing







14 14 Private Duty Nursing





14 14 Private Duty Nursing





14
15 Clinic







15 15 Clinic





15 15 Clinic





15
16 Health Promotion Activities







16 16 Health Promotion Activities





16 16 Health Promotion Activities





16
17 Day Care Program







17 17 Day Care Program





17 17 Day Care Program





17
18 Home Delivered Meals Program







18 18 Home Delivered Meals Program





18 18 Home Delivered Meals Program





18
19 Homemaker Service







19 19 Homemaker Service





19 19 Homemaker Service





19
20 All Others







20 20 All Others





20 20 All Others





20
21 Totals (sum of lines 1-20)







21 21 Totals (sum of lines 1-20)





21 21 Totals (sum of lines 1-20)





21
22 Total cost to be allocated







22 22 Total cost to be allocated





22 22 Total cost to be allocated





22
23 Unit Cost Multiplier







23 23 Unit Cost Multiplier





23 23 Unit Cost Multiplier





23


























































FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)









FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)







FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4143)




































41-360








Rev. 1 Rev. 1






41-361 41-362






Rev. 1































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

















Sheet 40: H3-I


2/11



FORM CMS-2540-10







4190 (Cont.)







PROVIDER NO.:_____________

PERIOD:

WORKSHEET H-3,

APPORTIONMENT OF PATIENT SERVICE COSTS








FROM ______________

Parts I & II








HHA NO.:________________

TO ________________




Check applicable box

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











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














Cost Per Visit Computation
From, Facility Shared

Average
Program Visits

Cost of Services




Wkst. Costs Ancillary

Cost
Part B

Part B
Total


H-2, (From Costs Total HHA
Per Visit
Not Subject Subject
Not Subject Subject Program Cost

Patient Services Part I, Wkst. H-2, (From Costs Total (col. 3
to Deductibles to Deductibles
to Deductibles to Deductibles (sum of


col. 21, Part I) Part II) (cols. 1 + 2) Visits ÷ col. 4) Part A & Coinsurance & Coinsurance Part A & Coinsurance & Coinsurance cols. 9-10)


line - 1 2 3 4 5 6 7 8 9 10 11 12
1 Skilled Nursing Care 2











1
2 Physical Therapy 3











2
3 Occupational Therapy 4











3
4 Speech Pathology 5











4
5 Medical Social Services 6











5
6 Home Health Aide 7











6
7 Total (sum of lines 1-6)












7
















Supplies and Drugs Cost







Program Covered Charges


Cost of Services

Computations

From Facility Shared
Total

Part B

Part B




Wkst. H-2, Costs Ancillary Total Charges

Not Subject Subject
Not Subject Subject

Other Patient Services
Part I, (From Costs HHA (from Ratio
to to
to to




Wkst. H-2, (From Cost HHA (col. 3
Deductibles Deductibles
Deductibles Deductibles



col. 21, Part I) Part II) (cols. 1 + 2) Record) ÷ col. 4) Part A & Coinsurance & Coinsurance Part A Coinsurance Coinsurance



line - 1 2 3 4 5 6 7 8 9 10 11
8 Cost of Medical Supplies
8










8
9 Cost of Drugs
9










9
















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























Total














HHA Charge
HHA Shared
Transfer to






From Wkst. C,
Cost to Charge
(From Provider
Ancillary Cost
Part I






col. 3
Ratio
records)
(Col.1 X Col 2)
as indicated






line -
1
2
3
4

1 Physical Therapy


44






col. 2, line 2
1
2 Occupational Therapy


45






col. 2, line 3
2
3 Speech Pathology


46






col. 2, line 4
3
4 Cost of Medical Supplies


48






col. 2, line 8
4
5 Cost of Drugs


49






col. 2, line 9
5
































FORM CMS-2540-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4144






























Rev. 1













41-363










































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1




Sheet 41: H4

4190 (Cont.)
FORM CMS-2540-10


2/11







PROVIDER NO.: PERIOD: WORKSHEET H-4,





CALCULATION OF HHA

______________ FROM___________ Parts I & II





REIMBURSEMENT SETTLEMENT

HHA NO.: TO______________









______________







Check Applicable Box
[ ] Title V [ ] Title XVIII [ ] Title XIX






PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES














Part B









Not Subject to Subject to









Deductibles Deductibles








Part A & Coinsurance & Coinsurance






Description
1 2 3






Reasonable Cost of Part A & Part B Services









1 Reasonable cost of services (see instructions)



1




2 Total charges



2





Customary Charges









3 Amount actually collected from patients liable for payment



3





for services on a charge basis (from your records)









4 Amount that would have been realized from patients liable



4





for payment for services on a charge basis had such










payment been made in accordance with 42 CFR 413.13(b)









5 Ratio of line 3 to line 4 (not to exceed 1.000000)



5




6 Total customary charges (see instructions)



6




7 Excess of total customary charges over total reasonable



7





cost (complete only if line 6 exceeds line 1)









8 Excess of reasonable cost over customary charges



8





(complete only if line 1 exceeds line 6)









9 Primary payer amounts



9




PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT














Part A Services Part B Services






Description

1 2





10 Total reasonable cost (see instructions)



10




11 Total PPS Reimbursement - Full Episodes without Outliers



11




12 Total PPS Reimbursement - Full Episodes with Outliers



12




13 Total PPS Reimbursement - LUPA Episodes



13




14 Total PPS Reimbursement - PEP Episodes



14




15 Total PPS Outlier Reimbursement - Full Episodes with Outliers



15




16 Total PPS Outlier Reimbursement - PEP Episodes



16




17 Total Other Payments



17




18 DME Payments



18




19 Oxygen Payments



19




20 Prosthetic and Orthotic Payments



20




21 Part B deductibles billed to Medicare patients (exclude coinsurance)



21




22 Subtotal (sum of lines 10 thru 20 minus line 21)



22




23 Excess reasonable cost (from line 8)



23




24 Subtotal (line 22 minus line 23)



24




25 Coinsurance billed to program patients (from your records)



25




26 Net cost (line 24 minus line 25)



26




27 Reimbursable bad debts (from your records)



27




28 Reimbursable bad debts for dual eligible beneficiaries (see instructions)



28




29 Total costs - current cost reporting period (line 26 plus line 27)



29




30 Other adjustments (see instructions) (specify)



30




31 Subtotal (line 29 plus/minus line 30)



31




32 Interim payments (see instructions)



32




33 Tentative settlement (for fiscal intermediary use only)



33




34 Balance due provider/program (line 31 minus lines 32 and 33)



34




35 Protested amounts (nonallowable cost report items) in accordance with CMS



35





Pub. 15-II, section 115.2
















































































FORM CMS-2510-10 (12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4145)






















41-364




Rev. 1











































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 42: H5

2/11




FORM CMS-2540-10




4190 (Cont.)
















ANALYSIS OF PAYMENTS TO PROVIDER-




PROVIDER NO.:

PERIOD:
WORKSHEET H-5
















{APP4}IALLWAYS~/lp2~q/PCOPB1~Q/pGQ/1
BASED HHAs FOR SERVICES




______________________

FROM _____________



















RENDERED TO PROGRAM BENEFICIARIES




HHA NO.:

TO ________________

























______________________






















































Description




Part A Part B

























mm/dd/yyyy Amount mm/dd/yyyy Amount

























1 2 3 4

















1 Total interim payments paid to provider









1
















2 Interim payments payable on individual bills either submitted or to









2

















be submitted to the intermediary/contractor for services rendered




























in the cost reporting period. If none, write "NONE" or enter a zero.



























3 List separately each retroactive lump sum




.01



3.01

















adjustment amount based on subsequent revision




.02



3.02

















of the interim rate for the cost reporting period.



Program .03



3.03

















Also show date of each payment. If none, write



to .04



3.04

















"NONE" or enter a zero.(1)



Provider .05



3.05























.50



3.50






















.51



3.51






















Provider .52



3.52





















to .53



3.53






















Program .54



3.54

















Subtotal (sum of lines 3.01-3.49 minus sum




























of lines 3.50-3.98)




.99



3.99
















4 Total interim payments (sum of lines 1, 2, and 3.99)









4

















(Transfer to Wkst. H-4, Part II, column as appropriate, line 32)





























































TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR






















































5 List separately each tentative settlement payment



Program .01



5.01

















after desk review. Also show date of each



to .02



5.02

















payment. If none, write "NONE" or enter



Provider .03



5.03

















a zero. (1)



Provider .50



5.50






















to .51



5.51






















Program .52



5.52

















Subtotal (sum of lines 5.01-5.49 minus sum




























of lines 5.50-5.98)




.99



5.99
















6 Determine net settlement amount (balance due)



Program























based on the cost report (see instructions)



to .01



























Provider




6.01






















Provider




























to .02



























Program




6.02
















7 TOTAL MEDICARE PROGRAM LIABILITY









7

















(see instructions)



























8 Name of Intermediary/Contractor






Intermediary Number

8












































































9 Signature of Authorized Person






Date: (mm/dd/yyyy)

9












































































(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider




























agrees to the amount of repayment, even though total repayment is not accomplished until a later date.













































































































































































































































Rev. 1










36-365























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1


















Sheet 43: I1

2/11

FORM CMS-2540-10




4190 ( Cont.)

ANALYSIS OF SNF-BASED RURAL HEALTH PROVIDER NO:
PERIOD:





CLINIC/FEDERALLY QUALIFIED

FROM___________________
WORKSHEET I-1


HEALTH CENTER COSTS COMPONENT NO:
TO____________________





Check Applicable Box:
[ ] RHC [ ] FQHC













RECLASSIFIED
NEW EXPENSES




COMPEN- OTHER TOTAL RECLASSIFI- TRIAL ADJUSTMENTS FOR




SATION COSTS (Col. 1 + Col. 2) CATIONS BALANCE
ALLOCATION








(Col. 3 +/- Col. 4)
(Col. 5 +/- Col.6)




1 2 3 4 5 6 7


FACILITY HEALTH CARE STAFF COSTS










1 Physician






1

2 Physician Assistant






2

3 Nurse Practitioner






3

4 Visiting Nurse






4

5 Other Nurse






5

6 Clinical Psychologist






6

7 Clinical Social Worker






7

8 Laboratory Technician






8

9 Other Facility Health Care Staff Costs






9

10 Subtotal (Sum of lines 1 - 9)






10

COSTS UNDER AGREEMENT










11 Physician Services Under Agreement






11

12 Physician Supervision Under Agreement






12

13 Other Costs Under Agreement






13

14 Subtotal (Sum of lines 11 - 13)






14

OTHER HEALTH CARE COSTS










15 Medical Supplies






15

16 Transportation (Health Care Staff)






16

17 Depreciation - Medical Equipment






17

18 Professional Liability Insurance






18

19 Other Health Care Costs






19

20 Allowable GME Pass-through cost.






20

21 Subtotal (Sum of lines 15 - 19, less line 20)






21

22 Total Cost of Health Care Services






22


(Sum of lines 10, 14, and 21)









COSTS OTHER THAN RHC/FQHC SERVICES










23 Pharmacy






23

24 Dental






24

25 Optometry






25

26 All other non reimbursable costs






26

27 Nonallowable GME Pass-through cost






27

28 Total nonreimbursable costs (Sum of lines






28


23 - 27)









FACILITY OVERHEAD










29 Facility Costs






29

30 Administrative Costs






30

31 Total Facility Overhead (Sum of lines 29-30)






31

32 Total Facility Costs (Sum of lines 22, 28 and 31)






32


* 'The net expenses for cost allocation on Worksheet A for the RHC/FQHC cost center line must equal the total facility costs in column 7, line 32 of this worksheet.









FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II. SECTION 4148)










Rev. 1







41-366



























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 44: I2

4190 ( Cont. )
FORM CMS-2540-10



2/11





PROVIDER NO:
PERIOD:






ALLOCATION OF OVERHEAD


FROM___________________
WORKSHEET



TO RHC / FQHC SERVICES
COMPONENT NO:


I - 2







TO____________________






Check Applicable Box:
[ ] RHC [ ] FQHC




















PART I - VISITS AND PRODUCTIVITY











Number
Productivity Minimum Greater of






of FTE Total Standard Visits Column 2 or






Personnel Visits (1) Col. 1 X Col. 3) Column 4






1 2 3 4 5




1 Physicians




1



2 Physician Assistants




2



3 Nurse Practitioners




3



4 Subtotal (Sum of lines 1 - 3)




4



5 Visiting Nurse




5



6 Clinical Psychologist




6



7 Clinical Social Worker




7



8 Total Staff Costs (Sum of lines 4 - 7)




8



9 Physician Services Under Agreements




9
















PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES









10 Total costs of Health Care Services ( From Worksheet I - 1, column 7, line 22)




10



11 Total nonreimbursable costs (From Worksheet I - 1, column 7, line 28)




11



12 Cost of all services - excluding overhead (Sum of lines 10 and 11)




12



13 Ratio of RHC / FQHC services ( Line 10 divided by line 12)




13



14 Total facility overhead (From Worksheet I - 1, column 7, line 31)




14



15 GME Overhead (See instructions)




15



16 Net Facility Overhead




16



17 Parent provider overhead allocated to facility ( See instructions)




17



18 Total overhead (Sum of lines 16 and 17)




18



19 Overhead applicable to RHC / FQHC services (Lines 13 X line 18)




19



20 Total allowable cost of RHC / FQHC services ( Sum of lines 10 and 19)




20















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






































































FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,










SECTION 4149)






















41-367





Rev. 1

















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 45: I3

2/11

FORM CMS-2540-10


4190 (Cont.)



CALCULATION OF PROVIDER NO.:
PERIOD:






REIMBURSEMENT ______________________
FROM__________________
WORKSHEET



SETTLEMENT FOR COMPONENT NO.:


I - 3



RHC/FQHC SERVICES _______________
TO_____________________






Check one:
[ ] Title V [ ] Title XVIII [ ] Title XIX





Check Applicable Box:
[ ] RHC [ ] FQHC







PART I - DETERMINATION OF RATE FOR RHC / FQHC SERVICES










1 Total Allowable Cost of RHC/FQHC Services (From Worksheet I - 2, Part II, line 20)




1



2 Cost of vaccines and their administration (From Worksheet I-4, line 15)




2



3 Total Allowable Cost Excluding Vaccine (Line 1 minus line 2)




3



4 Total FTE's and VISITS (From Worksheet I-2, column 5, line 8)




4



5 Physicians Visits Under Agreement (From Worksheet I - 2, column 5, line 9)




5



6 Total Adjusted Visits (line 4 plus line 5)




6



7 Adjusted Cost Per Visit (line 3 divided by line 6)




7



CALCULATION OF LIMIT



Prior to On or after





Lines 8 through 14: Fiscal year providers use columns 1 and 2.


January 1 January 1





Lines 8 through 14: Calendar year providers use column 2 only.


1 2




8 Rate per visit limit (From your intermediary/contractor)




8



9 Rate for Medicare Covered Visits (See instructions)




9



PART II - CALCULATION OF SETTLEMENT










10 Medicare Covered Visits Excluding Mental Health Services




10




(From intermediary/contractor Records)









11 Medicare Cost Excluding Costs for Mental Health Services




11




(Line 9 x line 10)









12 Medicare Covered Visits for Mental Health Services




12




(From Intermediary/Contractor Records)









13 Medicare Covered Cost from Mental Health Services




13




(Line 9 x line 12)









14 Limit Adjustment for Mental Health Services




14




(See instructions)









15 Allowable GME Pass-through Cost (See instructions)




15



16 Total Medicare Cost (Sum of line 11 column 1 and 2, plus line 14 columns 1 and 2, plus line 15.




16



17 Primary payer amounts




17



18 Less: Beneficiary Deductible for RHC only. (See instructions)(From intermediary/contractor records)




18



19 Net Medicare Cost Excluding Vaccines (Line 16 minus sum of lines 17 and 18)




19



20 Reimbursable Cost of RHC/FQHC Services, Excluding Vaccine (80% of line 19)




20



21 Program cost of vaccines and their administration (From Worksheet I -4 line 16)




21



22 Total Reimbursable Program Cost (Line 20 plus 21)




22



23 Reimbursable Bad Debts




23



24 Reimbursable Bad Debts for dual eligible beneficiaries (See Instructions)




24



25 Other Adjustments




25



26 Net reimbursable amount (Line 22 plus line 23, plus or minus line 25 )




26



27 Interim payments (From Worksheet I-5, line 4)




27



28 Tentative settlement (for fiscal intermediary/contractor use only)




28



29 Balance due Component/Program (line 26 minus lines 27 and 28)




29



30 Protested amounts (nonallowable cost report items) in accordance with




30




CMS Pub. 15-II, section 115.2









FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,










SECTION 4150 )






















Rev. 1





41-368





























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 46: I4

4190 (Cont.)
FORM CMS-2540-10
2/11








PROVIDER NO.: PERIOD:







COMPUTATION OF PNEUMOCOCCAL _______________ FROM____________ WORKSHEET





AND INFLUENZA VACCINE COST COMPONENT NO.:
I - 4







_______________ TO_______________







Check one:
[ ] Title V [ ] Title XVIII [ ] Title XIX






Check Applicable Box:
[ ] RHC [ ] FQHC








CALCULATION OF COST
PNEUMOCOCCAL INFLUENZA









1 2






1 Health care staff cost (from Worksheet I -1, column 7, line 10)


1





2 Ratio of PNEUMOCOCCAL and influenza vaccine staff time to


2






total health care staff time









3 PNEUMOCOCCAL and influenza vaccine health care staff cost


3






(Line 1 x line 2)









4 Medical supplies cost - PNEUMOCOCCAL and influenza vaccine


4






(From your records)









5 Direct cost of PNEUMOCOCCAL and influenza vaccine


5






(Sum of lines 3 and 4)









6 Total direct cost of the facility (From Wkst. I -1, col. 7, line 22)


6





7 Total overhead (From Worksheet I - 2, line 18)


7





8 Ratio of PNEUMOCOCCAL and influenza vaccine direct cost to


8






Total direct cost (Line 5 divided by Line 6)









9 Overhead cost - PNEUMOCOCCAL and influenza vaccine


9






(Line 7 x Line 8)









10 Total PNEUMOCOCCAL and influenza vaccine cost and its (their)


10






administration (Sum of lines 5 and 9)









11 Total number of PNEUMOCOCCAL and influenza vaccine injections


11






(From your records)









12 Cost per PNEUMOCOCCAL and influenza vaccine injection


12






(Line 10 divided by Line 11)









13 Number of PNEUMOCOCCAL and influenza vaccine injections


13






Administered to medicare beneficiaries









14 Medicare cost of PNEUMOCOCCAL and influenza vaccine and


14






its (their) administration (Line 12 x line 13)









15 Total Cost of PNEUMOCOCCAL and influenza vaccine and its (their) administration


15






(Sum of columns 1 and 2, line 10) (Transfer this amount to Worksheet I-3, line 2)









16 Total medicare cost of PNEUMOCOCCAL and influenza vaccine and its (their) administration


16






(Sum of columns 1 and 2, line 14) (Transfer this amount to Worksheet I-3, line 21)





































































FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II,










SECTION 4151 )






















41-369



Rev. 1



























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 47: I-5


2/11
FORM CMS-2540-10


4190 ( Cont. )



ANALYSIS OF PAYMENTS TO PROVIDER NO.:
PERIOD:






SNF-BASED RURAL HEALTH ___________________
FROM ______________
WORKSHEET I - 5




CLINIC AND FEDERALLY COMPONENT NO.:








QUALIFIED HEALTH CENTERS ___________________
TO






Check Applicable Box:

[ ] R.H.C. [ ] F.Q.H.C.










mm/dd/yyyy Amount





Description


1 2




1 Total interim payments paid to provider




1



2 Interim payments payable on individual bills, either submitted or to




2




be submitted to the intermediary/contractor, for services rendered in










the cost reporting period. If none, write "none", or enter zero.









3 List separately each retroactive lump sum

.01

3.01




adjustment amount based on subsequent

.02

3.02




revision of the interim rate for the cost
Program to .03

3.03




reporting period.
Provider .04

3.04







.05

3.05




Also show date of each payment.

.50

3.50




If none, write "NONE," or enter a zero.(1)

.51

3.51






Provider to .52

3.52






Program .53

3.53







.54

3.54




SUBTOTAL (Sum of lines 3.01 - 3.05

.99

3.99




minus sum of lines 3.50 - 3.55)









4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)




4




(Transfer to Worksheet I-3: line 27)






















TO BE COMPLETED BY INTERMEDIARY / CONTRACTOR









5 List separately each tentative settlement
Program to .01

5.01




payment after desk review.
Provider .02

5.02







.03

5.03




Also show date of each payment.
Provider to .50

5.50




If none, write "NONE," or enter a zero.(1)
Program .51

5.51







.52

5.52




SUBTOTAL (Sum of lines 5.01 - 5.03

.99

5.99




minus sum of lines 5.50 - 5.52)









6 Determined net settlement
Program to .01

6.01




amount (balance due) based
Provider .02

6.02




on the cost report. (1)
Provider to .50

6.50






Program .51

6.51



7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)




7



8 Name of Intermediary/Contractor


Intermediary/Contractor Number
8



























9 Signature of Authorized Person


Date (mm/dd/yyy)
9



























(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the











provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.





















FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,











SECTION 4152)





















Rev. 1





41-373





































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 48: J-1-I

4190 ( Cont. )

FORM CMS-2540-10



2/11





PROVIDER NO.:
PERIOD:





ALLOCATION OF GENERAL SERVICE COSTS

FROM ____________
WORKSHEET J - 1



TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: _______________
TO _______________
PART I






























NET CAPITAL RELATED. COST

ADMINIS-





EXPENSES

EMPLOYEE SUBTOTAL TRATIVE



COMPONENT COST CENTER
FOR COST BUILDS. & MOVABLE BENEFITS
&



(Omit Cents)
ALLOCATION FIXTURES EQUIPMENT
(COLS. 0-3) GENERAL





0 1 2 3 3a 4


1 Administrative and General






1

2 Skilled Nursing






2

3 Physical Therapy






3

4 Occupational Therapy






4

5 Speech Pathology






5

6 Medical Social Services






6

7 Respiratory Therapy






7

8 Psychiatric/Psychological Services






8

9 Individual Therapy






9

10 Group Therapy






10

11 Individualized Activity Therapy






11

12 Family Counseling






12

13 Diagnostic Services






13

14 Appr. Patient Training & Education






14

15 Prosthetic and Orthotic Devices






15

16 Drugs and Biologicals






16

17 Medical Supplies






17

18 Medical Appliances






18

19 Durable Medical Equipment - Rented






19

20 Durable Medical Equipment - Sold






20

21 Other General Service Cost






21

22 Totals ( Sum of lines 1-21) (1)





22














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





































































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)






















41-371







Rev. 1


2/11
FORM CMS-2540-10




4190 ( Cont. )




PROVIDER NO.:
PERIOD:





ALLOCATION OF GENERAL SERVICE COSTS

FROM ____________
WORKSHEET J - 1



TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: _______________
TO _______________
PART I (CONT. )































PLANT










OPERATION LAUNDRY HOUSE -
NURSING



COMPONENT COST CENTER

MAINTENANCE & LINEN KEEPING DIETARY ADMINIS-



(Omit Cents)

& REPAIRS SERVICE

TRATION






5 6 7 8 9


1 Administrative and General






1

2 Skilled Nursing






2

3 Physical Therapy






3

4 Occupational Therapy






4

5 Speech Pathology






5

Medical Social Services






6

7 Respiratory Therapy






7

8 Psychiatric/Psychological Services






8

9 Individual Therapy






9

10 Group Therapy






10

11 Individualized Activity Therapy






11

12 Family Counseling






12

13 Diagnostic Services






13

14 Appr. Patient Training & Education






14

15 Prosthetic and Orthotic Devices






15

16 Drugs and Biologicals






16

17 Medical Supplies






17

18 Medical Appliances






18

19 Durable Medical Equipment - Rented






19

20 Durable Medical Equipment - Sold






20

21 Other General Service Cost






21

22 Totals ( Sum of lines 1-21) (1)





22














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

















































































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)










Rev. 1







41-372

4190 ( Cont. )

FORM CMS 2540-10


2/11





PROVIDER NO.:
PERIOD:





ALLOCATION OF GENERAL SERVICE COSTS

FROM ____________
WORKSHEET J - 1



TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: _______________
TO _______________
PART I (CONT. )










































CENTRAL
MEDICAL SOCIAL INTERNS OTHER



COMPONENT COST CENTER
SERVICES PHARMACY RECORDS SERVICES & GENERAL



(Omit Cents)
& SUPPLY
& LIBRARY
RESIDENTS SERVICE





10 11 12 13 14 15


1 Administrative and General






1

2 Skilled Nursing






2

3 Physical Therapy






3

4 Occupational Therapy






4

5 Speech Pathology






5

6 Medical Social Services






6

7 Respiratory Therapy






7

8 Psychiatric/Psychological Services






8

9 Individual Therapy






9

10 Group Therapy






10

11 Individualized Activity Therapy






11

12 Family Counseling






12

13 Diagnostic Services






13

14 Appr. Patient Training & Education






14

15 Prosthetic and Orthotic Devices






15

16 Drugs and Biologicals






16

17 Medical Supplies






17

18 Medical Appliances






18

19 Durable Medical Equipment - Rented






19

20 Durable Medical Equipment - Sold






20

21 Other General Service Cost






21

22 Totals ( Sum of lines 1-21) (1)





22


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

















































































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)






















41-373







Rev. 1


2/11
FORM CMS-2540-10




4190 ( Cont. )




PROVIDER NO.:
PERIOD:
WORKSHEET J-1



ALLOCATION OF GENERAL SERVICE COSTS

FROM ____________
PART I ( CONT. )



TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: ______
TO _______________














































POST
ALLOCATED TOTAL



COMPONENT COST CENTER

SUBTOTAL STEP-DOWN SUBTOTAL A & G (SUM OF COLS



(Omit Cents)


ADJUSTMENTS
(SEE PART II) 18 AND 19)






16 17 18 19 20


1 Administrative and General






1

2 Skilled Nursing






2

3 Physical Therapy






3

4 Occupational Therapy






4

5 Speech Pathology






5

6 Medical Social Services






6

7 Respiratory Therapy






7

8 Psychiatric/Psychological Services






8

9 Individual Therapy






9

10 Group Therapy






10

11 Individualized Activity Therapy






11

12 Family Counseling






12

13 Diagnostic Services






13

14 App. Patient Training & Education






14

15 Prosthetic and Orthotic Devices






15

16 Drugs and Biologicals






16

17 Medical Supplies






17

18 Medical Appliances






18

19 Durable Medical Equipment - Rented






19

20 Durable Medical Equipment - Sold






20

21 Other General Service Cost






21

22 Totals ( Sum of lines 1-21)






22

23 Unit Cost Multiplier (See Instructions)






23













FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153)










Rev. 1







41-374




































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 49: J-1-II

4190 (Cont.)
FORM CMS-2540-10



2/11





PROVIDER NO.:
PERIOD:






ALLOCATION OF GENERAL SERVICE COSTS

FROM ____________
WORKSHEET J - 1





TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: ______
TO _______________
PART II
































CAPITAL RELATED COST
ADMINIS-







COST BUILDS. COST MOVABLE EMPLOYEE TRATIVE




COMPONENT COST CENTER

& FIXTURES EQUIPMENT BENEFITS & GENERAL







(Square Feet) (Value or (Gross Salaries) (Accumulated








Square Feet
Cost)




(Omit Cents)

1 2 3 4



1 Administrative and General





1


2 Skilled Nursing





2


3 Physical Therapy





3


4 Occupational Therapy





4


5 Speech Pathology





5


6 Medical Social Services





6


7 Respiratory Therapy





7


8 Psychiatric/Psychological Services





8


9 Individual Therapy





9


10 Group Therapy





10


11 Individualized Activity Therapy





11


12 Family Counseling





12


13 Diagnostic Services





13


14 App. Patient Training & Education





14


15 Prosthetic and Orthotic Devices





15


16 Drugs and Biologicals





16


17 Medical Supplies





17


18 Medical Appliances





18


19 Durable Medical Equipment - Rented





19


20 Durable Medical Equipment - Sold





20


21 Other General Service Cost





21


22 Totals ( Sum of lines 1-21)





22


23 Total Cost to be Allocated





23


24 Unit Cost Multiplier





24


















































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )






















41-375






Rev. 1



2/11 FORM CMS-2540-10




4190 (Cont.)




PROVIDER NO.:
PERIOD:






ALLOCATION OF GENERAL SERVICE COSTS

FROM ____________
WORKSHEET J - 1





TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: ______
TO _______________
PART II (Cont.)































PLANT LAUNDRY

NURSING






OPERATION & LINEN HOUSE -
ADMINIS






MAINTENANCE SERVICE KEEPING DIETARY TRATION




COMPONENT COST CENTER
& REPAIRS (Pounds of (Hours of (Meals (Direct Nursing






(Square Feet) Laundry) Service) Served) Hours of Service)




(Omit Cents)
5 6 7 8 9



1 Administrative and General





1


2 Skilled Nursing





2


3 Physical Therapy





3


4 Occupational Therapy





4


Speech Pathology





5


6 Medical Social Services





6


7 Respiratory Therapy





7


8 Psychiatric/Psychological Services





8


9 Individual Therapy





9


10 Group Therapy





10


11 Individualized Activity Therapy





11


12 Family Counseling





12


13 Diagnostic Services





13


14 App. Patient Training & Education





14


15 Prosthetic and Orthotic Devices





15


16 Drugs and Biologicals





16


17 Medical Supplies





17


18 Medical Appliances





18


19 Durable Medical Equipment - Rented





19


20 Durable Medical Equipment - Sold





20


21 Other General Service Cost





21


22 Totals ( Sum of lines 1-21)





22


23 Total Cost to be Allocated





23


24 Unit Cost Multiplier





24






























































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )










Rev. 1






41-376


4190 (Cont.)
FORM CMS-2540-10


2/11




ALLOCATION OF GENERAL SERVICE COSTS PROVIDER NO.:
PERIOD:










FROM ______________________
WORKSHEET J - 1





TO COST CENTERS FOR C.M.H.C. COMPONENT NO.: ______
TO ____________________
PART II (Cont.)






























CENTRAL










SERVICES
MEDICAL
INTERNS & OTHER





& SUPPLY PHARMACY RECORDS & SOCIAL RESIDENTS GENERAL




COMPONENT COST CENTER (Costed (Costed LIBRARY SERVICES
SERVICE




(Omit Cents) Requisitions) Requisitions) (Time Spent) (Time Spent) (Assigned Time) ( )





10 11 12 13 14 15



1 Administrative and General





1


2 Skilled Nursing





2


3 Physical Therapy





3


4 Occupational Therapy





4


5 Speech Pathology





5


6 Medical Social Services





6


7 Respiratory Therapy





7


8 Psychiatric/Psychological Services





8


9 Individual Therapy





9


10 Group Therapy





10


11 Individualized Activity Therapy





11


12 Family Counseling





12


13 Diagnostic Services





13


14 App. Patient Training & Education





14


15 Prosthetic and Orthotic Devices





15


16 Drugs and Biologicals





16


17 Medical Supplies





17


18 Medical Appliances





18


19 Durable Medical Equipment - Rented





19


20 Durable Medical Equipment - Sold





20


21 Other General Service Cost





21


22 Totals ( Sum of lines 1-21)





22


23 Total Cost to be Allocated





23


24 Unit Cost Multiplier





24



`









FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4153 )


























































41-377






Rev. 1

































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 50: J-2


2/11


FORM CMS-2540-10




4190 (Cont.)
COMPUTATION OF C.M.H.C. PROVIDER NO.:

PERIOD:




REHABILITATION COSTS


FROM ____________

WORKSHEET J - 2




COMPONENT NO.: __________

TO _______________

PART I
PART I - APPORTIONMENT OF REHABILITATION COST CENTERS














TOTAL COSTS
RATIO OF TITLE V TITLE XVIII TITLE XIX



(FR. WKST. J-1 TOTAL COSTS TO CHARGES COSTS CHARGES COSTS CHARGES COSTS



PART I, Col. 20) CHARGES CHARGES (1)
(Col 3 X Col 4)
(Col 3 X col 6)
(Col. 3 X Col 6)



1 2 3 4 5 6 7 8 9
1 Administrative and General









1
2 Skilled Nursing Care









2
3 Physical Therapy









3
4 Occupational Therapy









4
5 Speech Pathology









5
6 Medical Social Services









6
7 Respiratory Therapy









7
8 Psychiatric/Psychological Services









8
9 Individual Therapy









9
10 Group Therapy









10
11 Individualized Activity Therapy









11
12 Family Counseling









12
13 Diagnostic Services









13
14 App. Patient Training & Education









14
15 Prosthetic and Orthotic Devices









15
16 Drugs and Biologicals









16
17 Medical Supplies









17
18 Medical Appliances









18
19 Durable Medical Equipment - Rented









19
20 Durable Medical Equipment - Sold









20
21 Other General Service Cost









21
22 Totals ( Sum of lines 2-21) (2)








22




























































































































































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4154)
























Rev. 1










41-378













4190 (Cont.)



FORM CMS-2540-10




2/11
COMPUTATION OF C.M.H.C. PROVIDER NO.:

PERIOD:




REHABILITATION COSTS


FROM ____________

WORKSHEET J - 2




COMPONENT NO.: __________

TO _______________

PART II
PART II - APPORTIONMENT OF COST OF REHAB SERVICES FURNISHED BY SHARED DEPARTTMENTS
















RATIO OF TITLE V TITLE XVIII TITLE XIX





COSTS TO CHARGES COSTS CHARGES COSTS CHARGES COSTS





CHARGES
(Col 3 X Col 4)
(Col 3 X col 6)
(Col. 3 X Col 8)





3 4 5 6 7 8 9
23 Oxygen (Inhalation) Therapy









23
24 Physical Therapy









24
25 Occupational Therapy









25
Speech Pathology









26
27 Medical Supplies Charged to Patients









27
28 Drugs Charged to Patients









28
29 Other Costs Furnished by shared Departments









29
30 Total (Sum of lines 23 through 29)









30
31 Total component cost. Add the amount from Part I, line









31

22 and the amount from line 30, columns 5, 7, and 9.











(Transfer Titles V , XVIII, and XIX amounts











to Worksheet J-3, columns 1,2 & 3 respectively.)










(1) Ratio of cost to charges: Part I - column 1 divided by column 2; Part II - From Wkst. C, col. 3, lines as applicable








i

(2) Charges for Part II, col. 2 are obtained from provider records


















































FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 4154 )





































41-379










Rev. 1


































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 51: J-3


2/11 FORM CMS-2540-10

4190 (Cont.)















CALCULATION OF PROVIDER NO.: PERIOD:

















REIMBURSEMENT SETTLEMENT

FROM ____________ WORKSHEET J - 3















OF C.M.H.C. SERVICES COMPONENT NO.: TO ______________









































Title V Title XVIII Title XIX


















PROGRAM PROGRAM PROGRAM


















COST COST COST


















1 2 3
















1 Cost of REHAB services (From Wkst. J-2,


1














2

Part II, line. 31: Title V - col. 5; Title




















XVIII 'col 7; Title XIX - column 9)



















2 Amounts paid and payable by Worker's


2














5

Compensation and other primary payers



















3 Subtotal (Line 1 minus line 2)


3














7






















4 Part B deductible billed to Program


4














9

patients (Exclude coinsurance amounts)



















5 Net Cost (Line 3 minus line 4)


5














11






















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


6














13






















7 Actual coinsurance billed to Program


7














15

patients (From provider records)



















8 Net cost less actual billed coinsurance


8
















(Line 5 minus line 7)



















9 Reimbursable bad debts (See Instructions)


9





































10 Reimbursable bad debts for dual eligible


10
















beneficiaries (see instructions)



















11 Net reimbursable amount (See Instructions)


11





































12 Amounts applicable to prior cost reporting


12
















periods resulting from disposition of




















depreciable assets



















13 Recovery of excess depreciation resulting


13
















from facility's termination or a decrease




















in Program utilization



















14 Other Adjustments


14





































15 Total cost - reimbursable to provider


15





































16 Interim payments


16





































17 Balance due Component/Program


17
















(Line 15 minus line 16)




















(Indicate overpayments in brackets)



















18 Protested amounts (Non allowable


18
















cost report items) in accordance with




















CMS Pub. 15-II, section 115.2



















FORM CMS 2540-10 ( 12/10 ) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN




















CMS PUB 15-II, SECTION 4155 )










































Rev. 1



41-380





















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1










Sheet 52: J-4

4190 (Cont.)

FORM CMS-2540-10

2/11




ANALYSIS OF PAYMENTS TO PROVIDER NO.:
PERIOD:






PROVIDER - BASED C.M.H.C. ___________________
FROM ______________
WORKSHEET J - 4




FOR SERVICES RENDERED COMPONENT NO.:








TO PROGRAM BENEFICIARIES ___________________
TO











mm/dd/yyyy Amount





Description


1 2




1 Total interim payments paid to provider




1



2 Interim payments payable on individual bills, either submitted or to




2




be submitted to the intermediary, for services rendered in the cost










reporting period. If none, write "none", or enter zero.









3 List separately each retroactive

.01

3.01




lump sum adjustment amount

.02

3.02




based on subsequent revision
Program to .03

3.03




of the interim rate for the cost
Provider .04

3.04




reporting period.

.05

3.05







.50

3.50




Also show date of each payment.

.51

3.51






Provider to .52

3.52




If none, write "NONE," or enter a zero.(1)
Program .53

3.53







.54

3.54




SUBTOTAL (Sum of lines 3.01 - 3.05

.99

3.99




minus sum of lines 3.50 - 3.55)









4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 & 3.99)




4




(Transfer to Worksheet J-3: Part I line 17)






















TO BE COMPLETED BY INTERMEDIARY/CONTRACTOR









5 List separately each tentative
Program to .01

5.01




settlement payment after desk review.
Provider .02

5.02







.03

5.03




Also show date of each payment.
Provider to .50

5.50




If none, write "NONE," or enter a zero.(1)
Program .51

5.51







.52

5.52




SUBTOTAL (Sum of lines 5.01 - 5.03

.99

5.99




minus sum of lines 5.50 - 5.52)









6 Determined net settlement
Program to .01

6.01




amount (balance due) based
Provider .02

6.02




on the cost report. (1)
Provider to .50

6.50






Program .51

6.51



7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)




7



8 Name of Intermediary/Contractor


Intermediary/Contractor Number
8



























9 Signature of Authorized Person


Date (mm/dd/yyyy)
9



























(1) On lines 3, 5, and 6, where an amount is due "Provider to Program," show the amount and date on which the











provider agrees to the amount of repayment, even though total repayment is not accomplished until a later date.





















FORM CMS 2540-10 ( 1210 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,











SECTION 4156)





















41-381





Rev. 1

















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 53: K


2/11


FORM CMS-2540-10





4190 (Cont.)







PROVIDER NO.: ___________
PERIOD:


ANALYSIS OF PROVIDER-BASED HOSPICE COSTS







FROM ____________
WORKSHEET K







HOSPICE NO.: ____________
TO _______________







CON-









EMPLOYEE
TRACTED








SALARIES BENEFITS TRANSPOR- SERVICES


SUBTOTAL
TOTAL

COST CENTER DESCRIPTIONS (from (from TATION (from
TOTAL RECLASSI- (col. 6 ADJUST- (col. 8


Wkst. K-1) Wkst. K-2) (see inst.) Wkst. K-3) OTHER (cols. 1-5) FICATION ± col. 7) MENTS ± col. 9)


1 2 3 4 5 6 7 8 9 10

GENERAL SERVICE COST CENTERS










1 Capital Related Costs-Bldg and Fixt.








1
2 Capital Related Costs-Movable Equip.








2
3 Plant Operation and Maintenance









3
4 Transportation - Staff









4
5 Volunteer Service Coordination









5
6 Administrative and General









6

INPATIENT CARE SERVICE










7 Inpatient - General Care









7
8 Inpatient - Respite Care









8

VISITING SERVICES










9 Physician Services









9
10 Nursing Care









10
11 Nursing Care-Continuous Home Care









11
12 Physical Therapy









12
13 Occupational Therapy









13
14 Speech/ Language Pathology









14
15 Medical Social Services









15
16 Spiritual Counseling





16
17 Dietary Counseling









17
18 Counseling - Other









18
19 Home Health Aide and Homemaker









19
20 HH Aide & Homemaker-Cont. Home Care









20
21 Other









21

OTHER HOSPICE SERVICE COSTS










22 Drugs, Biological and Infusion Therapy









22
23 Analgesics









23
24 Sedatives / Hypnotics









25
25 Other - Specify









25
26 Durable Medical Equipment/Oxygen









26
27 Patient Transportation









27
28 Imaging Services









28
29 Labs and Diagnostics









29
30 Medical Supplies









30
31 Outpatient Services (including E/R Dept.)









31
32 Radiation Therapy









32
33 Chemotherapy









33
34 Other









34

HOSPICE NONREIMBURSABLE SERVICE










35 Bereavement Program Costs









35
36 Volunteer Program Costs









36
37 Fundraising









37
38 Other Program Costs









38
39 Total (sum of lines 1 thru 38)









39
FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4157)











Rev. 1










41-382


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 54: K-1

4190 (Cont.)


FORM CMS-2540-10





2/11



PROVIDER NO:
HOSPICE NO:
PERIOD:



HOSPICE COMPENSATION ANALYSIS



FROM ________________
WORKSHEET K-1
SALARIES AND WAGES
_

TO _______________




COST CENTER DESCRIPTIONS ADMINIS
SOCIAL SUPER-
TOTAL




(omit cents) TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)


1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Moveable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
11 Nursing Care- Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling




16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homaker - Cont. Home Care








20
21 Other








21

OTHER HOSPICE SERVICE COSTS









22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedative/Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen







26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (incl. E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34

HOSPICE NONREIMBURSABLE SERV.









35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total








39
(1) Transfer the amount in column 9 to Wkst K, column 1










FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4158)










41-383









Rev.1


































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 55: K-2

2/11



FORM CMS-2540-10




4190 (Cont.)



PROVIDER NO:
HOSPICE NO:
PERIOD:



HOSPICE COMPENSATION ANALYSIS



FROM ____________________
WORKSHEET K-2
EMPLOYEE BENEFITS (PAYROLL RELATED)



TO _______________




COST CENTER DESCRIPTIONS ADMINIS
SOCIAL SUPER-
TOTAL




(omit cents) TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)


1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Moveable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care- Continuous Home Care








10
11 Nursing Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling




16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homaker - Cont. Home Care








20
21 Other








21

OTHER HOSPICE SERVICE COSTS









22 Drugs Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedative/Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/ Oxygen








26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (incl. E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34

HOSPICE NONREIMBURSABLE SERV.









35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total








39
(1) Transfer the amounts in column 9 to Wkst K, column 2










FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4159)










Rev. 1









41-384


































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 56: K-3

4190 (Cont.)



FORM CMS-2540-10




2/11



PROVIDER NO:
HOSPICE NO:
PERIOD:



HOSPICE COMPENSATION ANALYSIS



FROM ___________________
WORKSHEET K-3
CONTRACTED SERVICES / PURCHASED SERVICES
_

TO _______________




COST CENTER DESCRIPTIONS ADMINIS
SOCIAL SUPER-
TOTAL




(omit cents) TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)


1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Moveable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
11 Nursing Care- Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services








15
16 Spiritual Counseling




16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemaker








19
20 HH Aide & Homaker - Cont. Home Care








20
21 Other








21

OTHER HOSPICE SERVICE COSTS









22 Drugs, Biological and Infusion Therapy








22
23 Analgesics








23
24 Sedative/Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen







26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (incl. E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34

HOSPICE NONREIMBURSABLE SERV.









35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total








39
(1) Transfer the amounts in column 9 to Wkst K, column 4










FORM CMS-2540-10 ( 12/10 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4160)










41-385









Rev. 1


































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 57: K-4-1

2/11



FORM CMS-2540-10




4190 (Cont.)



PROVIDER NO:
HOSPICE NO:
PERIOD:



COST ALLOCATION - HOSPICE



FROM ____________
WORKSHEET K-4
GENERAL SERVICE COST

_
TO _______________
PART I


FR. WKST. K CAPITAL CAPITAL PLANT TRANS VOLUNTEER SUBTOTAL ADMINIS- TOTAL


COL. 10: NET RELATED RELATED OPERATION PORTATION SERV. (col. 0 - 5) TRATIVE &



EXPENSES COST BLDG COST & MAINT.
COORDI-
GENERAL


COST CENTER DESCRIPTIONS FOR COST & FIXTURES MOVABLE

NATOR





ALLOC. (1)
EQUIPMENT








0 1 2 3 4 5 5A 6 7

GENERAL SERVICE COST CENTERS







1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
11 Nursing Care- Continuous Home Care








11
12 Physical Therapy








12
13 Occupational Therapy








13
14 Speech/ Language Pathology








14
15 Medical Social Services - Direct








15
16 Spiritual Counseling






16
17 Dietary Counseling








17
18 Counseling - Other








18
19 Home Health Aide and Homemakers








19
20 HH Aide & Homaker - Cont. Home Care








20
21 Other








21

OTHER HOSPICE SERVICE COSTS









22 Drugs, Biologicals and Infusion








22
23 Analgesics








23
24 Sedative/Hypnotics








24
25 Other - Specify








25
26 Durable Medical Equipment/Oxygen








26
27 Patient Transportation








27
28 Imaging Services








28
29 Labs and Diagnostics








29
30 Medical Supplies








30
31 Outpatient Services (incl. E/R Dept.)








31
32 Radiation Therapy








32
33 Chemotherapy








33
34 Other








34

HOSPICE NONREIMBURSABLE SERV.









35 Bereavement Program Costs








35
36 Volunteer Program Costs








36
37 Fundraising








37
38 Other Program Costs








38
39 Total








39

(1) Column 0, line 29 must agree with Wkst. A, column 7, line 83.









FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4161)










Rev.1









41-386






























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 58: K-4-2

4190 (Cont.)


FORM CMS-2540-10



2/11



PROVIDER NO:
HOSPICE NO:
PERIOD:




COST ALLOCATION -



FROM ____________
WORKSHEET K-4


HOSPICE STATISTICAL BASIS

_
TO _______________
PART II




CAPITAL CAPITAL PLANT TRANS- VOLUNTEER RECONCI- ADMINIS-




RELATED RELATED OPERATION PORTATION SERV. LIATION TRATIVE &




COST BLDG COST & MAINT. MILEAGE COORDI-
GENERAL




& FIXTURES MOVABLE (SQ. FT.)
NATOR
(ACC. COST)



COST CENTER DESCRIPTIONS (SQ. FT.) EQUIPMENT

(HOURS)







$ VALUE)









1 2 3 4 5 6A 6



GENERAL SERVICE COST CENTERS







1 Capital Related Costs-Buildings and Fixtures




1

2 Capital Related Costs-Movable Equipment




2

3 Plant Operation and Maintenance






3

4 Transportation-staff






4

5 Volunteer Service Coordination






5

6 Administrative and General






6


INPATIENT CARE SERVICE









7 Inpatient - General Care






7

8 Inpatient - Respite Care






8


VISITING SERVICES









9 Physician Services






9

10 Nursing Care






10

11 Nursing Care- Continuous Home Care






11

12 Physical Therapy






12

13 Occupational Therapy






13

14 Speech/ Language Pathology






14

15 Medical Social Services - Direct






15

16 Spiritual Counseling




16

17 Dietary Counseling






17

18 Counseling - Other






18

19 Home Health Aide and Homemakers






19

20 HH Aide & Homaker - Cont. Home Care






20

21 Other






21


OTHER HOSPICE SERVICE COSTS









22 Drugs, Biologicals and Infusion






22

23 Analgesics






23

24 Sedative/Hypnotics






24

25 Other - Specify






25

26 Durable Medical Equipment/Oxygen






26

27 Patient Transportation






27

28 Imaging Services






28

29 Labs and Diagnostics






29

30 Medical Supplies






30

31 Outpatient Services (incl. E/R Dept.)






31

32 Radiation Therapy






32

33 Chemotherapy






33

34 Other






34


HOSPICE NONREIMBURSABLE SERV.









35 Bereavement Program Costs






35

36 Volunteer Program Costs






36

37 Fundraising






37

38 Other Program Costs






38

49 Cost To be Allocated (per Wkst K-4, Part I)






49

50 Unit Cost Multiplier






50

FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4161)










41-387







Rev.1



















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 59: K-5-1

2/11


FORM CMS-2540-10




4190 (Cont.) 4190 (Cont.)


FORM CMS-2540-10



2/11 2/11


FORM CMS-2540-10



4190 (Cont.)




PROVIDER NO.:
PERIOD






PROVIDER NO.:
PERIOD






PROVIDER NO.:
PERIOD



ALLOCATION OF GENERAL SERVICE

FROM:_______________
WORKSHEET K-5,
ALLOCATION OF GENERAL SERVICE


FROM:_______________
WORKSHEET K-5,
ALLOCATION OF GENERAL SERVICE


FROM:_______________
WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS HOSPICE NO.:
TO: _________________
PART I
COSTS TO HOSPICE COST CENTERS
HOSPICE NO.:
TO: _________________
Part I (Cont.)
COSTS TO HOSPICE COST CENTERS
HOSPICE NO.:
TO: _________________
Part I (Cont.)



From HOSPICE CAPITAL CAPITAL EMPLOYEE SUBTOTAL ADMINIS-


PLANT LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY


MEDICAL SOCIAL INTERNS & OTHER SUBTOTAL ALLOCATED TOTAL



Wkst. TRIAL RELATED RELATED BENEFITS (cols. 0-3) TRATIVE &


OPERATION & LINEN KEEPING
ADMINIS- SERVICES &



RECORDS & SERVICE RESIDENTS GENERAL (Sum of Columns HOSPICE HOSPICE

HOSPICE COST CENTER
K-4 BALANCE BLDGS. & MOVABLE GENERAL

HOSPICE COST CENTER MAINTENANCE SERVICE

TRATION SUPPLY


HOSPICE COST CENTER LIBRARY

SERVICE 4a through 15) A&G (see COSTS

(omit cents)
Part I, (1) FIXTURES EQUIPMENT




(omit cents) & REPAIRS







(omit cents)




Part II)




col. 6,





























line - 0 1 2 3 4A 4


5 6 7 8 9 10 11


12 13 14 15 16 17 18
6 Administrative and General
6





6 6 Administrative and General






6 6 Administrative and General






6
7 Inpatient - General Care
7





7 7 Inpatient - General Care






7 7 Inpatient - General Care






7
8 Inpatient - Respite Care
8





8 8 Inpatient - Respite Care






8 8 Inpatient - Respite Care






8
9 Physician Services
9





9 9 Physician Services






9 9 Physician Services






9
10 Nursing Care
10





10 10 Nursing Care






10 10 Nursing Care






10
11 Nursing Care- Continuous Home Care
11





11 11 Nursing Care- Continuous Home Care






11 11 Nursing Care- Continuous Home Care






11
12 Physical Therapy
12





12 12 Physical Therapy






12 12 Physical Therapy






12
13 Occupational Therapy
13





13 13 Occupational Therapy






13 13 Occupational Therapy






13
14 Speech/ Language Pathology
14





14 14 Speech/ Language Pathology






14 14 Speech/ Language Pathology






14
15 Medical Social Services - Direct
15





15 15 Medical Social Services - Direct






15 15 Medical Social Services - Direct






15
16 Spiritual Counseling
16





16 16 Spiritual Counseling






16 16 Spiritual Counseling






16
17 Dietary Counseling
17





17 17 Dietary Counseling






17 17 Dietary Counseling






17
18 Counseling - Other
18





18 18 Counseling - Other






18 18 Counseling - Other






18
19 Home Health Aide and Homemakers
19





19 19 Home Health Aide and Homemakers






19 19 Home Health Aide and Homemakers






19
20 HH Aide & Homaker - Cont. Home Care
20





20 20 HH Aide & Homaker - Cont. Home Care






20 20 HH Aide & Homaker - Cont. Home Care






20
21 Other
21





21 21 Other






21 21 Other






21
22 Drugs, Biologicals and Infusion
22





22 22 Drugs, Biologicals and Infusion






22 22 Drugs, Biologicals and Infusion






22
23 Analgesics
23





23 23 Analgesics






23 23 Analgesics






23
24 Sedative/Hypnotics
24





24 24 Sedative/Hypnotics






24 24 Sedative/Hypnotics






24
25 Other - Specify
25





25 25 Other - Specify






25 25 Other - Specify






25
26 Durable Medical Equipment/Oxygen
26





26 26 Durable Medical Equipment/Oxygen






26 26 Durable Medical Equipment/Oxygen






26
27 Patient Transportation
27





27 27 Patient Transportation






27 27 Patient Transportation






27
28 Imaging Services
28





28 28 Imaging Services






28 28 Imaging Services






28
29 Labs and Diagnostics
29





29 29 Labs and Diagnostics






29 29 Labs and Diagnostics






29
30 Medical Supplies
30





30 30 Medical Supplies






30 30 Medical Supplies






30
31 Outpatient Services (incl. E/R Dept.)
31





31 31 Outpatient Services (incl. E/R Dept.)






31 31 Outpatient Services (incl. E/R Dept.)






31
32 Radiation Therapy
32





32 32 Radiation Therapy






32 32 Radiation Therapy






32
33 Chemotherapy
33





33 33 Chemotherapy






33 33 Chemotherapy






33
34 Other
34





34 34 Other






34 34 Other






34
35 Bereavement Program Costs
35





35 35 Bereavement Program Costs






35 35 Bereavement Program Costs






35
36 Volunteer Program Costs
36





36 36 Volunteer Program Costs






36 36 Volunteer Program Costs






36
37 Fundraising
37





37 37 Fundraising






37 37 Fundraising






37
38 Other Program Costs
38





38 38 Other Program Costs






38 38 Other Program Costs






38
39 Totals (sum of lines 1-28)







39 39 Totals (sum of lines 1-28) (2)






39 39 Totals (sum of lines 1-28) (2)






39
50 Unit Cost Multiplier:







50 50 Unit Cost Multiplier:






50 50 Unit Cost Multiplier:






50

Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.









Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.








Column 16, line 1 divided by the sum of column 16, line 39, minus column 16, line 1, rounded to 6 decimal places.







(2) Columns 0 through 16 , line 29 must agree with the corresponding columns of Wkst. B, Part I, line 83.





























FORM CMS-2540-10 ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)









FORM CMS-2540-10 ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)








FORM CMS-2540-10 ( 12/10) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)







































Rev. 1








41-388 41-389







Rev. 1 Rev. 1







41-390



























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1



















Sheet 60: K-5-II

4190 (Cont.)



FORM CMS-2540-10



2/11 2/11

FORM CMS-2540-10




4190 (Cont.) 4190 (Cont.)

FORM CMS-2540-10




2/11




PROVIDER NO.:
PERIOD






PROVIDER NO.:
PERIOD






PROVIDER NO.:
PERIOD



ALLOCATION OF GENERAL SERVICE

FROM:_______________
WORKSHEET K-5,
ALLOCATION OF GENERAL SERVICE


FROM:_______________
WORKSHEET K-5,
ALLOCATION OF GENERAL SERVICE


FROM:_______________
WORKSHEET K-5,
COSTS TO HOSPICE COST CENTERS HOSPICE NO.:
TO: _________________
PART II
COSTS TO HOSPICE COST CENTERS
HOSPICE NO.:
TO: _________________
Part II (Cont.)
COSTS TO HOSPICE COST CENTERS
HOSPICE NO.:
TO: _________________
Part II (Cont.)





CAPITAL CAPITAL EMPLOYEE RECONCIL ADMINIS-


PLANT LAUNDRY HOUSE DIETARY NURSING CENTRAL PHARMACY


MEDICAL SOCIAL INTERNS & OTHER




HOSPICE COST CENTER


RELATED RELATED BENEFITS LATION TRATIVE &

HOSPICE COST CENTER OPERATION & LINEN KEEPING (Meals Served) ADMINIS- SERVICES & (Costed

HOSPICE COST CENTER RECORDS & SERVICE RESIDENTS GENERAL




(omit cents)


BLDGS. & MOVABLE (Gross Salaries)
GENERAL

(omit cents) MAINTENANCE SERVICE (Hours of
TRATION SUPPLY Requisitions)

(omit cents) LIBRARY (Time Spent) (Assigned Time) SERVICE








FIXTURES EQUIPMENT

(Accum. Cost)


& REPAIRS (Pounds of Service)
(Direct Nursing (Costed



(Time Spent)

(Specify)








(Square Feet) (Dollar Value)





(Square Feet) Laundry)

Hours) Requisitions)
















1 2 3 4a 4


5 6
8 9 10 11


12 13 14 15



6 Administrative and General







6 6 Administrative and General






6 6 Administrative and General






6
7 Inpatient - General Care







7 7 Inpatient - General Care






7 7 Inpatient - General Care






7
8 Inpatient - Respite Care







8 8 Inpatient - Respite Care






8 8 Inpatient - Respite Care






8
9 Physician Services







9 9 Physician Services






9 9 Physician Services






9
10 Nursing Care







10 10 Nursing Care






10 10 Nursing Care






10
11 Nursing Care- Continuous Home Care







11 11 Nursing Care- Continuous Home Care






11 11 Nursing Care- Continuous Home Care






11
12 Physical Therapy







12 12 Physical Therapy






12 12 Physical Therapy






12
13 Occupational Therapy







13 13 Occupational Therapy






13 13 Occupational Therapy






13
14 Speech/ Language Pathology







14 14 Speech/ Language Pathology






14 14 Speech/ Language Pathology






14
15 Medical Social Services - Direct







15 15 Medical Social Services - Direct






15 15 Medical Social Services - Direct






15
16 Spiritual Counseling







16 16 Spiritual Counseling






16 16 Spiritual Counseling






16
17 Dietary Counseling







17 17 Dietary Counseling






17 17 Dietary Counseling






17
18 Counseling - Other







18 18 Counseling - Other






18 18 Counseling - Other






18
19 Home Health Aide and Homemakers







19 19 Home Health Aide and Homemakers






19 19 Home Health Aide and Homemakers






19
20 HH Aide & Homaker - Cont. Home Care







20 20 HH Aide & Homaker - Cont. Home Care






20 20 HH Aide & Homaker - Cont. Home Care






20
21 Other







21 21 Other






21 21 Other






21
22 Drugs, Biologicals and Infusion







22 22 Drugs, Biologicals and Infusion






22 22 Drugs, Biologicals and Infusion






22
23 Analgesics







23 23 Analgesics






23 23 Analgesics






23
24 Sedative/Hypnotics







24 24 Sedative/Hypnotics






24 24 Sedative/Hypnotics






24
25 Other - Specify







25 25 Other - Specify






25 25 Other - Specify






25
26 Durable Medical Equipment/Oxygen







26 26 Durable Medical Equipment/Oxygen






26 26 Durable Medical Equipment/Oxygen






26
27 Patient Transportation







27 27 Patient Transportation






27 27 Patient Transportation






27
28 Imaging Services







28 28 Imaging Services






28 28 Imaging Services






28
29 Labs and Diagnostics







29 29 Labs and Diagnostics






29 29 Labs and Diagnostics






29
30 Medical Supplies







30 30 Medical Supplies






30 30 Medical Supplies






30
31 Outpatient Services (incl. E/R Dept.)







31 31 Outpatient Services (incl. E/R Dept.)






31 31 Outpatient Services (incl. E/R Dept.)






31
32 Radiation Therapy







32 32 Radiation Therapy






32 32 Radiation Therapy






32
33 Chemotherapy







33 33 Chemotherapy






33 33 Chemotherapy






33
34 Other







34 34 Other






34 34 Other






34
35 Bereavement Program Costs







35 35 Bereavement Program Costs






35 35 Bereavement Program Costs






35
36 Volunteer Program Costs







36 36 Volunteer Program Costs






36 36 Volunteer Program Costs






36
37 Fundraising







37 37 Fundraising






37 37 Fundraising






37
38 Other Program Costs







38 38 Other Program Costs






38 38 Other Program Costs






38
39 Totals (sum of lines 1-28)







39 39 Totals (sum of lines 1-28)






39 39 Totals (sum of lines 1-28)






39
50 Unit Cost Multiplier







50 50 Unit Cost Multiplier






50 50 Unit Cost Multiplier






50
FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)









FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)








FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)








41-391








Rev. 1 Rev. 1







41-392 41-393







Rev. 1
























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1



















Sheet 61: K-5-III


2/11

FORM CMS-2540-10




4190(Cont.)




PROVIDER NO.:
PERIOD:
WORKSHEET


APPORTIONMENT OF HOSPICE SHARED SERVICES




From:

K-5





HOSPICE NO.:
To:

Part III













PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS










Hospice shared cost computation





Total Hospice
Hospice Shared



Facility Cost Cost to Charge Ratio
Charges
Ancillary Costs



From Worksheet K-5, Part I From Worksheet C, Col. 3
(From Provider
(col. 4 x col. 5)


COST CENTER Line: Amount: Line : Ratio
Records)





1 2 3 4
5
6

ANCILLARY SERVICE COST CENTERS










1 Physical Therapy 12
44




1
2 Occupational Therapy 13
45




2
3 Speech/ Language Pathology 14
46




3
4 Drugs, Biologicals and Infusion 22
49




4
5 Labs and Diagnostics 29
41




5
6 Medical Supplies 30
48




6
7 Radiation Therapy 32
40




7
8 Other 34
52




8
9 Total (sum of lines 1-8)







9




























































































































































FORM CMS-2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4162)






















Rev. 1








41-394














































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1

Sheet 62: K6

4190 (Cont.)

FORM CMS-2540-10


2/11




CALCULATION OF PROVIDER NO.
PERIOD:







PER DIEM COST

FROM ________________
WORKSHEET K-6






_________________
TO ________________































COMPUTATION OF PER DIEM COST
TITLE XVIII TITLE XIX OTHER TOTAL







1 2 3 4




1 Total cost (Worksheet K, line 39 less line 38, col. 7)




1



2 Total Unduplicated Days (Worksheet S-8, line 5, col. 6)




2



3 Average cost per diem (line 1 divided by line 2)




3



4 Unduplicated Medicare Days (Worksheet S-8, line 5, col. 1)




4



5 Average Medicare cost (line 3 times line 4)




5



6 Unduplicated Medicaid Days (Worksheet S-8, line 5, col. 2)




6



7 Average Medicaid cost (line 3 times line 6)




7



8 Unduplicated SNF days (Worksheet S-8, line 5, col. 3)




8



9 Average SNF cost (line 3 times line 8)




9



10 Unduplicated NF days (Worksheet S-8, line 5, col. 4)




10



11 Average NF cost (line 3 times line 10)




11



12 Other Unduplicated days (Worksheet S-8, line 5, col. 5)




12



13 Average cost for other days (line 3 times line 12)




13



































































































































































FORM CMS 2540-10 ( 12/10 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4163)










41-395





Rev. 1

































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Rev. 1
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