CMS-2540-10 Skilled Nursing Facility and Skilled Nursing Facility He

---

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