Form CMS-2552-10 Hospitals and Health Care Complex Cost Report

10-12

FORM CMS-2552-10

4090 (Cont.)
FORM APPROVED
OMB NO. 0938-0050
WORKSHEET S
PARTS I, II & III

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).

HOSPITAL AND HOSPITAL HEALTH CARE
PROVIDER CCN:
PERIOD
COMPLEX COST REPORT CERTIFICATION
FROM __________
AND SETTLEMENT SUMMARY
______________
TO _____________
PART I - COST REPORT STATUS
Provider use only
1. [ ] Electronically filed cost report
Date:
Time:
2. [ ] Manually submitted cost report
3. [ ] If this is an amended report enter the number of times the provider resubmitted this cost report
4 [ ] Medicare Utilization. Enter "F" for full or "L" for low.
Contractor
5. [ ] Cost Report Status
6. Date Received:_________
10. NPR Date:__________
use only
(1) As Submitted
7. Contractor No.:________
11. Contractor's Vendor Code: ___________
12. [ ] If line 5 , column 1 is 4: Enter number of
(2) Settled without audit
8. [ ] Initial Report for this Provider CCN
(3) Settled with audit
9. [ ] Final Report for this Provider CCN
times reopened = 0-9.
(4) Reopened
(5) Amended
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,
CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN
THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above certification 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 Name(s)
and Number(s)}for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief,
this report and statement are true, correct, complete and prepared from the books and records of the provider in accordance with applicable
instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that
the services identified in this cost report were provided in compliance with such laws and regulations.
(Signed) ______________________________________________
Officer or Administrator of Provider(s)
______________________________________________
Title
______________________________________________
Date
PART III - SETTLEMENT SUMMARY
TITLE V
1

TITLE XVIII
PART A
PART B
2
3

HIT
4

TITLE XIX
5

1 HOSPITAL

1

2 SUBPROVIDER - IPF

2

3 SUBPROVIDER - IRF

3

4 SUBPROVIDER (OTHER)

4

5 SWING BED - SNF

5

6 SWING BED - NF

6

7 SKILLED NURSING FACILITY

7

8 NURSING FACILITY

8

9 HOME HEALTH AGENCY

9

10 HEALTH CLINIC - RHC

10

11 HEALTH CLINIC - FQHC
OUTPATIENT REHABILITATION
12 PROVIDER (Specify)

11

200 TOTAL
The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated.

12
200

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 0938-0050. The time required to complete this information collection is estimated 673 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-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4003.1-4003.3)

Rev. 3

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4090 (Cont.)

FORM CMS-2552-10

10-12

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA
Hospital and Hospital Health Care Complex Address:
1 Street:
2 City:
Hospital and Hospital-Based Component Identification:
Component
0
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

PROVIDER CCN: PERIOD
FROM __________
______________ TO _____________
P.O. Box:
State:

Zip Code:
Component
Name
1

WORKSHEET S-2
PART I

1
2

County:
CCN
Number
2

CBSA
Number
3

Provider
Type
4

Date
Certified
5

V
6

Payment System (P, T, O, or N)
XVIII
XIX
7
8

Hospital
Subprovider- IPF
Subprovider- IRF
Subprovider- (Other)
Swing Beds-SNF
Swing Beds-NF
Hospital-Based SNF
Hospital-Based NF
Hospital-Based OLTC
Hospital-Based HHA
Separately Certified ASC
Hospital-Based Hospice
Hospital-Based Health Clinic-RHC
Hospital-Based Health Clinic-FQHC
Hospital-Based (CMHC, CORF and OPT )
Renal Dialysis
Other

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

20 Cost Reporting Period (mm/dd/yyyy)
From:_______________
To: ______________
21 Type of control (see instructions)
Inpatient PPS Information
22 Does this facility qualify and is it currently receiving payments for disproportionate share hospital adjustment, in accordance with 42 CFR §412.106?
In column 1, enter "Y" for yes or "N" for no. Is this facility subject to 42 CFR §412.06 (c )(2) (Pickle amendment hospital)? In column 2, enter "Y" for yes or "N" for no.
23 Which method is used to determine Medicaid days on lines 24 and/or 25 below? In column 1, enter 1 if date of admission, 2 if census days, or 3 if date of discharge.
Is the method of identifying the days in this cost reporting period different from the method used in the prior cost reporting period? In column 2, enter "Y" for yes or "N" for no.
In-State
Medicaid
paid days
1

In-State
Medicaid eligible
unpaid days
2

Out-of State
Medicaid
paid days
3

20
21
1

2
22
23

Out-of State
Medicaid eligible
unpaid days
4

Medicaid
HMO
days
5

Other
Medicaid
days
6

If this provider is an IPPS hospital , enter the in-state Medicaid paid days in col. 1, in-state Medicaid
eligible unpaid days in col. 2, out-of-state Medicaid paid days in col. 3, out-of-state Medicaid eligible unpaid days
in col. 4, Medicaid HMO paid and eligible but unpaid days in col. 5, and other Medicaid days in col. 6.
25 If this provider is an IRF , enter the in-state Medicaid paid days in col. 1, in-state Medicaid eligible unpaid
days in col. 2, out-of-state Medicaid paid days in col. 3, out-of state Medicaid eligible unpaid days
in col. 4 Medicaid HMO paid and eligible but unpaid days in col. 5 and other Medicaid days in col. 6.

24

26 Enter your standard geographic classification (not wage) status at the beginning of the cost reporting period. Enter "1" for urban or "2" for rural.
27 Enter your standard geographic classification (not wage) status at the end of the cost reporting period. Enter in column 1, "1" for urban or "2" for rural.
If applicable enter the effective date of the geographic reclassification in column 2.

26
27

24

25

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

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Rev. 3

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FORM CMS-2552-10

4090 (Cont.)

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA
35
36
37
38

PROVIDER CCN: PERIOD
FROM __________
______________ TO _____________

If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the cost reporting period.
Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number of periods in excess of one and enter subsequent dates.
If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in the cost reporting period.
Enter applicable beginning and ending dates of MDH status. Subscript line 38 for number of periods in excess of one and enter subsequent dates.

WORKSHEET S-2
PART I (CONT.)

Beginning:_______________

Ending: ______________

Beginning:_______________

Ending: ______________

Prospective Payment System (PPS)-Capital
45 Does this facility qualify and receive capital payment for disproportionate share in accordance with 42 CFR §412.320? (see instructions)
46 Is this facility eligible for additional payment exception for extraordinary circumstances pursuant to 42 CFR §412.348(f) ? If yes, complete Worksheet L, Part III and L-1, Parts I through III.
47 Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes or "N" for no.
48 Is the facility electing full federal capital payment? Enter "Y" for yes or "N" for no.
Teaching Hospitals
56 Is this a hospital involved in training residents in approved GME programs? Enter "Y" for yes or "N" for no.
57 If line 56 is yes, is this the first cost reporting period during which residents in approved GME programs trained at this facility? Enter "Y" for yes or "N" for no in column 1.
If column 1 is "Y" did residents start training in the first month of this cost reporting period? Enter "Y" for yes or "N" for no in column 2. If column 2 is "Y", complete Worksheet E-4.
If column 2 is "N", complete Worksheet D, Parts III & IV and D-2, Part II, if applicable.

V
1

XVIII
2

35
36
37
38

XIX
3
45
46
47
48

1

2

3
56
57

58 If line 56 is yes, did this facility elect cost reimbursement for physicians' services as defined in CMS Pub. 15-1, section 2148?
If yes, complete Worksheet D-5.
59 Are costs claimed on line 100 of Worksheet A? If yes, complete Worksheet D-2, Part I.
60 Are you claiming nursing school and/or allied health costs for a program that meets the provider-operated criteria under §413.85? Enter "Y" for yes or "N" for no. (see instructions)

58
59
60
Y/N

IME Average

Direct
GME Average

61 Did your facility receive additional FTE slots under ACA section 5503? Enter "Y" for yes or "N" for no in column 1. If "Y", effective for portions of cost reporting periods beginning
on or after July 1, 2011 enter the average number of primary care FTE residents for IME in column 2 and direct GME in column 3, from the hospital’s three most recent
cost reports ending and submitted before March 23, 2010. (see instructions)

61

ACA Provisions Affecting the Health Resources and Services Administration (HRSA)
62 Enter the number of FTE residents that your hospital trained in this cost reporting period for which your hospital received HRSA PCRE funding (see instructions)
62 Enter the number of FTE residents that rotated from a Teaching Health Center (THC) into your hospital during in this cost reporting period of HRSA THC program. (see instructions)

62
62.01

Teaching Hospitals that Claim Residents in Non-Provider Settings
63 Has your facility trained residents in non-provider settings during this cost reporting period? Enter "Y" for yes or "N" for no. If yes, complete lines 64-67. (see instructions)

63

Section 5504 of the ACA Base Year FTE Residents in Nonprovider settings--This base year is your cost reporting period that begins on or after July 1, 2009 and before June 30, 2010.
64 Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the number of unweighted non-primary care resident FTEs attributable to rotations occurring
in all non-provider settings. Enter in column 2 the number of unweighted non-primary care resident FTEs that trained in your hospital.
Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)

Program Name
1
65 Enter in column 1, if line 63 is yes, or your facility trained residents in the base year period, the program name.
Enter in column 2 the program code, enter in column 3 the number of unweighted primary care FTE residents attributable to
rotations occurring in all non-provider settings. Enter in column 4 the number of unweighted primary care resident FTEs that
trained in your hospital. Enter in column 5 the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)

Program Code
2

Unweighted
FTEs
Nonprovider Site

Unweighted
FTEs
in Hospital

Ratio
(col. 1/
(col. 1 + col. 2))
64

Unweighted
FTEs
Nonprovider Site
3

Unweighted
FTEs
in Hospital
4

Ratio
(col. 3/
(col. 3 + col. 4))
5
65

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

Rev. 3

40-505

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

10-12
PROVIDER CCN: PERIOD
FROM __________
______________ TO _____________
Unweighted
FTEs
Nonprovider Site
1

Section 5504 of the ACA Current Year FTE Residents in Nonprovider settings--Effective for cost reporting periods beginning on or after July 1, 2010
66 Enter in column 1 the number of unweighted non-primary care resident FTEs attributable to rotations occurring in all non-provider settings. Enter in column 2 the number of
unweighted non-primary care resident FTEs that trained in your hospital. Enter in column 3 the ratio of (column 1 divided by (column 1 + column 2)). (see instructions)

Program Name
1

WORKSHEET S-2
PART I (CONT.)
Unweighted
FTEs
in Hospital
2

Ratio
(col. 1/
(col. 1 + col. 2))
3
66

Program Code
2

Unweighted
FTEs
Nonprovider Site
3

Unweighted
FTEs
in Hospital
4

Ratio
(col. 3/
(col. 3 + col. 4))
5

67 Enter in column 1 the program name. Enter in column 2 the program code. Enter in column 3 the number of
unweighted primary care FTE residents attributable to rotations occurring in all non-provider settings.
Enter in column 4 the number of unweighted primary care resident FTEs that trained in your hospital.
Enter in column 5 the ratio of (column 3 divided by (column 3 + column 4)). (see instructions)
Inpatient Psychiatric Facility PPS
70 Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider? Enter "Y" for yes or "N" for no.
71 If line 70 yes:
Column 1: Did the facility have a teaching program in the most recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no.
Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4
in column 3, or if the subsequent academic years of the new teaching program in existence, enter 5. (see instructions)

67

1

2

3
70
71

Inpatient Rehabilitation Facility PPS
75 Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF subprovider? Enter "Y" for yes or "N" for no.
76 If line 75 yes:
Column 1: Did the facility have a teaching program in the most recent cost reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for no.
Column 2: Did this facility train residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.
Column 3: If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions) If this cost reporting period covers the beginning of the fourth year, enter 4
in column 3, or if the subsequent academic years of the new teaching program in existence, enter 5. (see instructions)

75
76

Long Term Care Hospital PPS
80 Is this a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no.
TEFRA Providers
85 Is this a new hospital under 42 CFR §413.40(f)(1)(i) TEFRA? Enter "Y" for yes or "N" for no.
86 Did this facility establish a new Other subprovider (excluded unit) under 42 CFR §413.40(f)(1)(ii)? Enter "Y" for yes or "N" for no.
Title V and XIX Inpatient Services
90 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for yes or "N" for no in applicable column.
91 Is this hospital reimbursed for title V and/or XIX through the cost report either in full or in part? Enter "Y" for yes or "N" for no in the applicable column.
92 Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see instructions) Enter "Y" for yes or "N" for no in the applicable column.
93 Does this facility operate an ICF\MR facility for purposes of title V and XIX? Enter "Y" for yes or "N" for no in the applicable column.
94 Does title V or title XIX reduce capital cost? Enter "Y" for yes or "N" for no in the applicable column.
95 If line 94 is "Y", enter the reduction percentage in the applicable column.
96 Does title V or title XIX reduce operating cost? Enter "Y" for yes or "N" for no in the applicable column.
97 If line 96 is "Y", enter the reduction percentage in the applicable column.

80
85
86
V
1

XIX
2
90
91
92
93
94
95
96
97

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

40-506

Rev. 3

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FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

4090 (Cont.)
PROVIDER CCN: PERIOD
FROM __________
______________ TO _____________

WORKSHEET S-2
PART I (CONT.)

Rural Providers
105 Does this hospital qualify as a Critical Access Hospital (CAH)?
106 If this facility qualifies as a CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions)
107 Column 1: If this facility qualifies as a CAH, is it eligible for cost reimbursement for I &R training programs? Enter "Y" for yes or "N" for no in column 1. (see
instructions) If yes, the GME elimination would not be on Worksheet B, Part I, column 25 and the program would be cost reimbursed. If yes complete Worksheet D-2, Part II.
Column 2: If this facility is a CAH, do I&Rs in an approved medical education program train in the CAH's excluded IPF and/or IRF unit? Enter "Y" for
yes or "N" for no in column 2. (see instructions)
108 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR §412.113(c). Enter "Y" for yes or "N" for no.

1

2
105
106
107

108
Physical

Occupational

Speech

Respiratory

109 If this hospital qualifies as a CAH or a cost provider, are therapy services provided by outside supplier? Enter "Y" for yes or "N" for no for each therapy.
Miscellaneous Cost Reporting Information
115 Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If yes, enter the method used (A, B, or E only) in column 2.
If column 2 is "E", enter in column 3 either "93" percent for short term hospital or "98" percent for long term care (includes psychiatric, rehabilitation and long term hospitals
providers) based on the definition in CMS 15-1 §2208.1.
116 Is this facility classified as a referral center? Enter "Y" for yes or "N" for no.
117 Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for no.
118 Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy is claim- made. Enter 2 if the policy is occurrence.
118.01 List amounts of malpractice premiums and paid losses:

109

115

Premiums

118.02 Are malpractice premiums and paid losses reported in a cost center other than the Administrative and General? If yes, submit supporting schedule listing cost centers and amounts contained therein.
119 What is the liability limit for the malpractice insurance policy? Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year.
120 Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 1 "Y" for yes or "N" for no. Is this a
rural hospital with <100 beds that qualifies for the Outpatient Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions) Enter in column 2 "Y" for yes or "N" for no.
121 Did this facility incur and report costs for implantable devices charged to patients? Enter "Y" for yes or "N" for no.
Transplant Center Information
125 Does this facility operate a transplant center? Enter "Y" for yes or "N" for no. If yes, enter certification date(s) (mm/dd/yyyy) below.
126 If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
127 If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
128 If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
129 If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
130 If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
131 If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
132 If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
133 If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date, if applicable, in column 2.
134 If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date, if applicable, in column 2.

Paid losses

Self insurance

116
117
118
118.01
118.02
119
120
121
125
126
127
128
129
130
131
132
133
134

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

Rev. 3

40-507

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE
COMPLEX IDENTIFICATION DATA

10-12
PROVIDER CCN: PERIOD
FROM __________
______________ TO _____________

WORKSHEET S-2
PART I (CONT.)

All Providers
1

2

140 Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? Enter "Y" for yes or "N" for no in column 1.
If yes, and home office costs are claimed, enter in column 2 the home office chain number. (see instructions)

140

If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the home office and enter the home office contractor name and contractor number.
141 Name:
Contractor's Name: ___________________
142 Street:
P. O. Box:
143 City:
State:
Zip Code:
144 Are provider based physicians' costs included in Worksheet A?
145 If costs for renal services are claimed on Worksheet A, line 74 are they costs for inpatient services only? Enter "Y" for yes or "N" for no.
146 Has the cost allocation methodology changed from the previously filed cost report? Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, section 4020)
If yes, enter the approval date (mm/dd/yyyy) in column 2.

Contractor's Number:

__________

141
142
143
144
145
146

147 Was there a change in the statistical basis? Enter "Y" for yes or "N" for no.
148 Was there a change in the order of allocation? Enter "Y" for yes or "N" for no.
149 Was there a change to the simplified cost finding method? Enter "Y" for yes or "N" for no.
Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs or charges?
Enter "Y" for yes or "N" for no for each component for Part A and Part B. (See 42 CFR §413.13)
155
156
157
158
159
160
161

147
148
149
Title XVIII
Part A
1

Part B
2

Title V
3

Title XIX
4

Hospital
Subprovider - IPF
Subprovider - IRF
Subprovider - Other
SNF
HHA
CMHC

155
156
157
158
159
160
161

Multicampus
165 Is this hospital part of a multicampus hospital that has one or more campuses in different CBSAs? Enter "Y" for yes or "N" for no.

166 If line 165 is yes, for each campus enter the name in column 0, county in column 1, state in column 2, zip in column 3, CBSA in column 4, FTE/Campus in column 5.
Name
County
0
1

Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act
167 Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no.
168 If this provider is a CAH (line 105 is "Y") and is a meaningful user (line 167 is "Y"), enter the reasonable cost incurred for the HIT assets. (see instructions)
169 If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the transition factor. (see instructions)

165

166
State
2

Zip Code
3

CBSA
4

FTE/Campus
5

167
168
169

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4004.1)

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Rev. 3

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FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:
______________

4090 (Cont.)
PERIOD
FROM __________
TO _____________

WORKSHEET S-2
Part II

General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
Enter all dates in the mm/dd/yyyy format.
COMPLETED BY ALL HOSPITALS

Y/N
1

Provider Organization and Operation
1 Has the provider changed ownership immediately prior to the beginning of the cost reporting period?
If yes, enter the date of the change in column 2. (see instructions)

Date
2
1

Y/N
1

Date
2

V/I
3

2 Has the provider terminated participation in the Medicare Program?
If yes, 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 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)

2
3

Y/N
1

Financial Data and Reports
4 Column 1: Were the financial statements prepared by a Certified Public Accountant?
Column 2: If yes, enter "A" for Audited, "C" for Compiled, or "R" for Reviewed. Submit complete copy or enter
date available in column 3. (see instructions) If no, see instructions.
5 Are the cost report total expenses and total revenues different from those on the filed financial statements?
If yes, submit reconciliation.

Type
2

Date
3
4

5

Y/N
1

Approved Educational Activities
6 Column 1: Are costs claimed for nursing school?
Column 2: If yes, is the provider is the legal operator of the program?
7 Are costs claimed for allied health programs? If yes, see instructions.
8 Were nursing school and/or allied health programs approved and/or renewed during the cost reporting period?
If yes, see instructions.
9 Are costs claimed for Intern-Resident programs claimed on the current cost report? If yes, see instructions.
10 Was an Intern-Resident program initiated or renewed in the current cost reporting period? If yes, see instructions.
11 Are GME costs directly assigned to cost centers other than I & R in an Approved Teaching Program on Worksheet A?
If yes, see instructions.

Y/N
2
6
7
8
9
10
11

Bad Debts
12 Is the provider seeking reimbursement for bad debts? If yes, see instructions.
13 If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting period? If yes, submit copy.
14 If line 12 is yes, were patient deductibles and/or co-payments waived? If yes, see instructions.

Y/N
12
13
14

Bed Complement
15 Did total beds available change from the prior cost reporting period? If yes, see instructions.

15
Part A

PS&R Report Data
16 Was the cost report prepared using the PS&R Report only? If either column 1 or 3 is yes, enter the
paid-through date of the PS&R Report used in columns 2 and 4. (see instructions)
17 Was the cost report prepared using the PS&R Report for totals and the provider's records for allocation?

Y/N
1

Part B
Date
2

If either column 1 or 3 is yes, enter the paid-through date in columns 2 and 4. (see instructions)
18 If line 16 or 17 is yes, were adjustments made to PS&R Report data for additional claims that have been
billed but are not included on the PS&R Report used to file the cost report? If yes, see instructions.
19 If line 16 or 17 is yes, were adjustments made to PS&R Report data for corrections of other
PS&R Report information? If yes, see instructions.
20 If line 16 or 17 is yes, were adjustments made to PS&R Report data for Other?
Describe the other adjustments: _________________________________
21 Was the cost report prepared only using the provider's records? If yes, see instructions.

Y/N
3

Date
4
16
17

18
19
20
21

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4004.2)

Rev. 3

40-509

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
REIMBURSEMENT QUESTIONNAIRE

PROVIDER CCN:
______________

10-12
PERIOD
FROM __________
TO _____________

WORKSHEET S-2
Part II (CONT.)

General Instruction: Enter Y for all YES responses. Enter N for all NO responses.
Enter all dates in the mm/dd/yyyy format.
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)

Capital Related Cost
22 Have assets been relifed for Medicare purposes? If yes, see instructions.
23 Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period?
If yes, see instructions.
24 Were new leases and/or amendments to existing leases entered into during this cost reporting period? If yes, see instructions.
25 Have there been new capitalized leases entered into during the cost reporting period? If yes, see instructions.
26 Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see instructions.
27 Has the provider's capitalization policy changed during the cost reporting period? If yes, see instructions.

22
23
24
25
26
27

Interest Expense
28 Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If yes, see instructions.
29 Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation
account? If yes, see instructions.
30 Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see instructions.
31 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see instructions.

28
29
30
31

Purchased Services
32 Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services?
If yes, see instructions.
33 If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?
If no, see instructions.

32
33

Provider-Based Physicians
34 Are services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions.
35 If line 34 is yes, were there new agreements or amended existing agreements with the provider-based physicians during the cost
reporting period? If yes, see instructions.
Y/N
1

Home Office Costs
36 Are home office costs claimed on the cost report?
37 If line 36 is yes, has a home office cost statement been prepared by the home office? If yes, see instructions.
38 If line 36 is yes , was the fiscal year end of the home office different from that of the provider?
If yes, enter in column 2 the fiscal year end of the home office.
39 If line 36 is yes, did the provider render services to other chain components? If yes, see instructions.
40 If line 36 is yes, did the provider render services to the home office? If yes, see instructions.
Cost Report Preparer Contact Information
41 First name:
Last name:
42 Employer:
43 Phone number:

34
35

Date
2
36
37
38
39
40

Title:
E-mail Address:

41
42
43

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2 , SECTIONS 4004.2)

40-510

Rev. 3

10-12

FORM CMS-2552-10

4090 (Cont.)

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
STATISTICAL DATA

PROVIDER CCN:

Inpatient Days / Outpatient Visits / Trips

Component

Worksheet
A
Line
No.
1

No. of
Beds
2

Bed Days
Available
3

CAH
Hours
4

Title V
5

Title
XVIII
6

Title
XIX
7

Total
All
Patients
8

1 Hospital Adults & Peds. (columns 5,
6, 7 and 8 exclude Swing Bed,
Observation Bed and Hospice days)
2 HMO
3 HMO IPF Subprovider
4 HMO IRF Subprovider
5 Hospital Adults & Peds. Swing Bed SNF
6 Hospital Adults & Peds. Swing Bed NF
7 Total Adults and Peds. (exclude
observation beds) (see instructions)
8 Intensive Care Unit
9 Coronary Care Unit
10 Burn Intensive Care Unit
11 Surgical Intensive Care Unit
12 Other Special Care
13 Nursery
14 Total (see instructions)
15 CAH visits
16 Subprovider - IPF
17 Subprovider - IRF
18 Subprovider - Other
19 Skilled Nursing Facility
20 Nursing Facility
21 Other Long Term Care
22 Home Health Agency
23 ASC (Distinct Part)
24 Hospice (Distinct Part)
25 CMHC
26 RHC/FQHC (specify)
27 Total (sum of lines 14-26)
28 Observation Bed Days
29 Ambulance Trips
30 Employee discount days (see instructions)
31 Employee discount days -IRF
32 Labor & delivery days (see instructions)
33 LTCH non-covered days

______________
Full Time Equivalents
Total
Employees
Interns &
On
Residents
Payroll
9
10

Nonpaid
Workers
11

PERIOD
WORKSHEET S-3
FROM __________
PART I
TO _____________
Discharges

Title V
12

Title
XVIII
13

Title
XIX
14

Total
All
Patients
15
1

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.1)

Rev. 3

40-511

4090 (Cont.)

FORM CMS-2552-10
PROVIDER CCN:

HOSPITAL WAGE INDEX INFORMATION

______________

10-12
PERIOD
FROM __________
TO _____________

WORKSHEET S-3
PART II

Part II - Wage Data
Worksheet
A
Line
Number
1
1
2
3
4
4.01
5
6
7
7.01
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
22.01
23
24
25

Amount
Reported
2

Reclassification
of Salaries
(from
Worksheet A-6)
3

Adjusted
Salaries
(column 2 ±
column 3)
4

Paid Hours
Related
to Salaries
in column 4
5

SALARIES
Total salaries (see instructions)
Non-physician anesthetist Part A
Non-physician anesthetist Part B
Physician-Part A - Administrative
Physician-Part A - Teaching
Physician-Part B
Non-physician-Part B
Interns & residents (in an approved program)
Contracted interns & residents (in an approved program)
Home office personnel
SNF
Excluded area salaries (see instructions)
OTHER WAGES AND RELATED COSTS
Contract labor (see instructions)
Contract management and administrative services
Contract labor: Physician-Part A - Administrative
Home office salaries & wage-related costs
Home office: Physician Part A - Administrative
Home office & Contract Physicians Part A - Teaching
WAGE-RELATED COSTS
Wage-related costs (core) Worksheet S-3, Part IV line 24
Wage-related costs (other) Worksheet S-3, Part IV line 25
Excluded areas
Non-physician anesthetist Part A
Non-physician anesthetist Part B
Physician Part A - Administrative
Physician Part A - Teaching
Physician Part B
Wage-related costs (RHC/FQHC)
Interns & residents (in an approved program)

Average
Hourly Wage
(column 4 ÷
column 5)
6
1
2
3
4
4.01
5
6
7
7.01
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
22.01
23
24
25

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)

46-512

Rev. 3

10-12

FORM CMS-2552-10

HOSPITAL WAGE INDEX INFORMATION

PROVIDER CCN:
______________

4090 (Cont.)

PERIOD
FROM __________
TO _____________

WORKSHEET S-3
PART II & III

Part II - Wage Data
Worksheet
A
Line
Number
1
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

OVERHEAD COSTS - DIRECT SALARIES
Employee Benefits
Administrative & General
Administrative & General under contract (see instructions)
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Housekeeping under contract (see instructions)
Dietary
Dietary under contract (see instructions)
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service

Amount
Reported
2

Reclassification
of Salaries
(from
Worksheet A-6)
3

Adjusted
Salaries
(column 2 ±
column 3)
4

Paid Hours
Related
to Salaries
in column 4
5

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Part III - Hospital Wage Index Summary
1 Net salaries (see instructions)
2 Excluded area salaries (see instructions)
3 Subtotal salaries (line 1 minus line 2)
4 Subtotal other wages and related costs (see instructions)
5 Subtotal wage-related costs (see instructions)
6 Total (sum of lines 3 through 5)
7 Total overhead cost (see instructions)

Average
Hourly Wage
(column 4 ÷
column 5)
6
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

1
2
3
4
5
6
7

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.2 - 4005.3)

Rev. 3

40-513

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL WAGE RELATED COSTS

PROVIDER CCN:
______________

10-12
PERIOD
FROM __________
TO _____________

WORKSHEET S-3,
PART IV

Part IV - Wage Related Cost
Part A - Core List

Amount
Reported

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

RETIREMENT COST
401k Employer Contributions
Tax Sheltered Annuity (TSA) Employer Contribution
Nonqualified Defined Benefit Plan Cost (see instructions)
Qualified Defined Benefit Plan Cost (see instructions)
PLAN ADMINISTRATIVE COSTS (Paid to External Organization):
401k/TSA Plan Administration fees
Legal/Accounting/Management Fees-Pension Plan
Employee Managed Care Program Administration Fees
HEALTH AND INSURANCE COST
Health Insurance (Purchased or Self Funded)
Prescription Drug Plan
Dental, Hearing and Vision Plan
Life Insurance (If employee is owner or beneficiary)
Accident Insurance (If employee is owner or beneficiary)
Disability Insurance (If employee is owner or beneficiary)
Long-Term Care Insurance (If employee is owner or beneficiary)
Workers' Compensation Insurance
Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106. Non cumulative portion)
TAXES
FICA-Employers Portion Only
Medicare Taxes - Employers Portion Only
Unemployment Insurance
State or Federal Unemployment Taxes
OTHER
Executive Deferred Compensation (Other Than Retirement Cost Reported on lines 1 through 4 above)see instructions))
Day Care Cost and Allowances
Tuition Reimbursement
Total Wage Related cost (Sum of lines 1 -23)

Part B - Other than Core Related Cost
25 Other Wage Related Costs (specify)_________________________________________

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

25

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4005.4)

40-514

Rev. 3

10-12
HOSPITAL CONTRACT LABOR AND BENEFIT COST

FORM CMS-2552-10

4090 (Cont.)
PROVIDER CCN:
______________

PERIOD:
FROM __________
TO _____________

WORKSHEET S-3,
PART V

Part V - Contract Labor and Benefit Cost
Hospital and Hospital-Based Component Identification:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Component
0
Total facility contract labor and benefit cost
Hospital
Subprovider- IPF
Subprovider- IRF
Subprovider- (Other)
Swing Beds-SNF
Swing Beds-NF
Hospital-Based SNF
Hospital-Based NF
Hospital-Based OLTC
Hospital-Based HHA
Separately Certified ASC
Hospital-Based Hospice
Hospital-Based Health Clinic RHC
Hospital-Based Health Clinic FQHC
Hospital-Based-CMHC
Renal Dialysis
Other

Contract
Labor
1

Benefit
Cost
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4005.5)

Rev. 3

40-515

4090 (Cont.)
HOSPITAL-BASED HOME HEALTH AGENCY
STATISTICAL DATA

FORM CMS-2552-10

10-12

PROVIDER CCN:
______________
HHA CCN:
______________

HOME HEALTH AGENCY STATISTICAL DATA

Description
1 Home Health Aide Hours
2 Unduplicated Census Count (see instructions)

PERIOD:
FROM __________
TO _____________

WORKSHEET S-4

County: __________________
Title V
1

Title XVIII
2

Title XIX
3

Other
4

Total
5
1
2

HOME HEALTH AGENCY - NUMBER OF EMPLOYEES
Number of Employees
(Full Time Equivalent)
Staff
Contract
Total
1
2
3

Enter the number of hours in
your normal work week _______
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Administrator and Assistant Administrator(s)
Director(s) and Assistant Director(s)
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Service Supervisor
Home Health Aide
Home Health Aide Supervisor
Other (specify)

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

HOME HEALTH AGENCY CBSA CODES
19 Enter the number of CBSAs where you provided services during the cost reporting period.
20 List those CBSA code(s) serviced during this cost reporting period (line 20 contains the first code).

19
20

PPS ACTIVITY
Full Episodes
Without
With
Outliers
Outliers
1
2
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

LUPA
Episodes
3

Skilled Nursing Visits
Skilled Nursing Visit Charges
Physical Therapy Visits
Physical Therapy Visit Charges
Occupational Therapy Visits
Occupational Therapy Visit Charges
Speech Pathology Visits
Speech Pathology Visit Charges
Medical Social Service Visits
Medical Social Service Visit Charges
Home Health Aide Visits
Home Health Aide Visit Charges
Total visits (sum of lines 21, 23, 25, 27, 29, and 31)
Other Charges
Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34)
Total Number of Episodes (standard/non-outlier)
Total Number of Outlier Episodes
Total Non-Routine Medical Supply Charges

PEP only
Episodes
4

Total
(columns 1
through 4)
5
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4006)

40-516

Rev. 3

10-12

FORM CMS-2552-10

HOSPITAL RENAL DIALYSIS DEPARTMENT
STATISTICAL DATA

PROVIDER CCN:
______________

4090 (Cont.)
PERIOD:
FROM ___________
TO ______________

WORKSHEET S-5

RENAL DIALYSIS STATISTICS
Outpatient
DESCRIPTION

Regular
1

High Flux
2

Training
Hemodialysis
3

CAPD
CCPD
4

Home
Hemodialysis
5

CAPD
CCPD
6

1 Number of patients in program at
end of cost reporting period
2 Number of times per week patient
receives dialysis
3 Average patient dialysis time including setup
4 CAPD exchanges per day
5 Number of days in year dialysis furnished
6 Number of stations
7 Treatment capacity per day per station
8 Utilization (see instructions)
9 Average times dialyzers re-used
10 Percentage of patients re-using dialyzers

1

3
4
5
6
7
8
9
10

TRANSPLANT INFORMATION
11 Number of patients on transplant list
12 Number of patients transplanted during the cost reporting period

11
12

2

13
14
15
16

EPOETIN
Net costs of Epoetin furnished to all maintenance dialysis patients by the provider
Epoetin amount from Worksheet A for home dialysis program
Number of EPO units furnished relating to the renal dialysis department
Number of EPO units furnished relating to the home dialysis department

13
14
15
16

17
18
19
20

ARANESP
Net costs of ARANESP furnished to all maintenance dialysis patients by the provider
ARANESP amount from Worksheet A for home dialysis program
Number of ARANESP units furnished relating to the renal dialysis department
Number of ARANESP units furnished relating to the home dialysis department

17
18
19
20

PHYSICIAN PAYMENT METHOD (Enter "X" for applicable method(s))
21 MCP_________
INITIAL METHOD__________

21

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4007)

Rev. 3

40-517

4090 (Cont.)

FORM CMS-2552-10

HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND
OTHER OUTPATIENT REHABILITATION
PROVIDER STATISTICAL DATA

10-12
PROVIDER CCN:
_______________
COMPONENT CCN:
_______________

PERIOD:
FROM ___________
TO ______________

WORKSHEET S-6

COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)
Check
applicable
box:

[ ] CMHC
[ ] CORF
[ ] OPT

[ ] OOT
[ ] OSP

Enter the number of hours in your normal workweek ________

Staff
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Contract
2

Administrator and Assistant Administrator(s)
Director(s) and Assistant Director(s)
Other Administrative Personnel
Direct Nursing Service
Nursing Supervisor
Physical Therapy Service
Physical Therapy Supervisor
Occupational Therapy Service
Occupational Therapy Supervisor
Speech Pathology Service
Speech Pathology Supervisor
Medical Social Service
Medical Social Service Supervisor
Respiratory Therapy Service
Respiratory Therapy Supervisor
Psychiatric/Psychological Service
Psychiatric/Psychological Service Supervisor
Other (specify)

Total
(column 1 + column 2)
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4008)

40-518

Rev. 3

10-12

FORM CMS-2552-10

PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA

4090 (Cont.)

PROVIDER CCN:
________________

PERIOD:
WORKSHEET S-7
FROM ____________
TO ______________
Y/N
1

Date
2

1 If this facility contains a hospital-based SNF, were all patients under managed care or was there no Medicare
utilization? Enter "Y" for yes and do not complete the rest of this worksheet.
2 Does this hospital have an agreement under either section 1883 or section 1913 for swing beds? Enter "Y" for
yes or "N" for no in column 1. If yes, enter the agreement date (mm/dd/yyyy) in column 2.

Group
1
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54

SNF
Days
2

1
2

Swing Bed SNF
Days
3

RUX
RUL
RVX
RVL
RHX
RHL
RMX
RML
RLX
RUC
RUB
RUA
RVC
RVB
RVA
RHC
RHB
RHA
RMC
RMB
RMA
RLB
RLA
ES3
ES2
ES1
HE2
HE1
HD2
HD1
HC2
HC1
HB2
HB1
LE2
LE1
LD2
LD1
LC2
LC1
LB2
LB1
CE2
CE1
CD2
CD1
CC2
CC1
CB2
CB1
CA2
CA1

TOTAL
(sum of col. 2 + 3)
4
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)

Rev. 3

40-519

4090 (Cont.)

FORM CMS-2552-10

PROSPECTIVE PAYMENT FOR SNF
STATISTICAL DATA

10-12

PROVIDER CCN:
________________

Group
1
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
199
200

SNF
Days
2

PERIOD:
WORKSHEET S-7
FROM ____________ (CONT.)
TO ______________
Swing Bed SNF
Days
3

TOTAL
(sum of col. 2 + 3)
4

SE3
SE2
SE1
SSC
SSB
SSA
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
AAA
TOTAL

55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
199
200

SNF SERVICES
CBSA at
Beginning of
Cost Reporting
Period
1
201 Enter in column 1 the SNF CBSA code, or 5 character non-CBSA code if a rural facility, in effect at the beginning
of the cost reporting period.
Enter in column 2 the code in effect on or after October 1 of the cost reporting period (if applicable).

CBSA on/after
October 1 of the
Cost Reporting
Period (if applicable)
2
201

A notice published in the Federal Register Volume 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003. Congress expected this
increase to be used for direct patient care and related expenses. For lines 202 through 207: Enter in column 1 the amount of the expense for each category. Enter in column 2
the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I, line 7, column 3. In column 3, enter "Y" or "N" for no if the spending
reflects increases associated with direct patient care and related expenses for each category. (see instructions)
Associated with
Direct Patient Care
Expenses
Percentage
and Related Expenses?
1
2
3
202 Staffing
202
203 Recruitment
203
204 Retention of employees
204
205 Training
205
206 Other (Specify)
206
207 Total SNF revenue (Worksheet G-2, Part I, line 7, column 3)
207

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4009)

40-520

Rev. 3

10-12

FORM CMS-2552-10

HOSPITAL-BASED RURAL HEALTH CLINIC/
FEDERALLY QUALIFIED HEALTH CENTER
STATISTICAL DATA
Check
applicable box:

4090 (Cont.)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO ______________

WORKSHEET S-8

[ ] RHC
[ ] FQHC

Clinic Address and Identification:
1 Street:
2 City:
State:
Zip Code:
3 FQHCs ONLY: Designation - Enter "R" for rural or "U" for urban

1
2
3

County:

Source of Federal Funds:
Grant Award
1
4
5
6
7
8
9

Date
2

Community Health Center (Section 330(d), PHS Act)
Migrant Health Center (Section 329(d), PHS Act)
Health Services for the Homeless (Section 340(d), PHS Act)
Appalachian Regional Commission
Look-alikes
Other (specify)

4
5
6
7
8
9
1

2

10 Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes or "N" for no in column 1.
If yes, indicate the number of other operations in column 2.

10

Facility hours of operations (1)
Type Operation
0

Sunday
from
to
1
2

Monday
from
to
3
4

Tuesday
from
to
5
6

Wednesday
from
to
7
8

Thursday
from
to
9
10

Friday
from
to
11
12

Saturday
from
to
13
14

11 Clinic
(1) Enter clinic hours of operation on line 11 and other type operations on subscripts of line 11 (both type and hours of operation).
List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400.

11

1

2

12 Have you received an approval for an exception to the productivity standard?
13 Is this a consolidated cost report as defined in CMS Pub. 104-04, chapter 9, section 30.8 ? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in column 2 the number of providers included in this report. List the names of all providers and numbers below.
14 Provider name: _______________________________________________
CCN number: ________________

Y/N
1
15 Have you provided all or substantially all GME cost? Enter "Y" for yes or "N" for no in column 1.
If yes, enter in columns 2, 3 and 4 the number of program visits performed by Intern & Residents for titles V,
XVIII, and XIX, as applicable. Enter in colum 5 the number of total visits for this provider. (see instructions)

V
2

12
13
14

XVIII
3

XIX
4

Total
Visits
5
15

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4010)

Rev. 3

40-521

4090 (Cont.)

FORM CMS-2552-10

HOSPICE IDENTIFICATION DATA

PROVIDER CCN:
________________
HOSPICE NO.:
________________

10-12
PERIOD:
FROM ___________
TO ______________

WORKSHEET S-9
PARTS I & II

PART I - ENROLLMENT DAYS

Title XVIII
1
1
2
3
4
5

Title XIX
2

Unduplicated Days
Title XVIII
Title XIX
Skilled Nursing
Nursing
Facility
Facility
3
4

All
Other
5

Total
(sum of
cols. 1, 2 & 5)
6

Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Total Hospice Days

1
2
3
4
5

PART II - CENSUS DATA

Title XVIII
1

Title XIX
2

Title XVIII
Skilled Nursing
Facility
3

Title XIX
Nursing
Facility
4

6 Number of Patients Receiving Hospice Care
7 Total Number of Unduplicated Continuous
Care Hours Billable to Medicare
8 Average Length of Stay (line 5/line 6)
9 Unduplicated Census Count

All
Other
5

Total
(sum of
cols. 1, 2 & 5)
6
6
7
8
9

NOTE: Parts I & II, columns 1 and 2 also include the days reported in columns 3 and 4 .

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTIONS 4011)

40-522

Rev. 3

10-12

FORM CMS-2552-10

HOSPITAL UNCOMPENSATED AND INDIGENT
CARE DATA

4090 (Cont.)
PROVIDER CCN:
________________

PERIOD:
FROM ___________
TO ______________

WORKSHEET S-10

Uncompensated and indigent care cost computation
1 Cost to charge ratio (Worksheet C, Part I line 202 column 3 divided by line 202 column 8)

1

Medicaid (see instructions for each line)
2 Net revenue from Medicaid
3 Did you receive DSH or supplemental payments from Medicaid?
4 If line 3 is yes, does line 2 include all DSH or supplemental payments from Medicaid?
5 If line 4 is no, enter DSH or supplemental payments from Medicaid
6 Medicaid charges
7 Medicaid cost (line 1 times line 6)
8 Difference between net revenue and costs for Medicaid program (line 7 minus lines 2 and 5 ) .
If line 7 is less than the sum of lines 2 and 5, then enter zero.

2
3
4
5
6
7
8

State Children's Health Insurance Program (SCHIP) (see instructions for each line)
9 Net revenue from stand-alone SCHIP
10 Stand-alone SCHIP charges
11 Stand-alone SCHIP cost (line 1 times line 10)
12 Difference between net revenue and costs for stand-alone SCHIP (line 11 minus line 9 ).
If line 11 is less than line 9, then enter zero.

9
10
11
12

Other state or local government indigent care program (see instructions for each line)
13 Net revenue from state or local indigent care program (not included on lines 2, 5 or 9)
14 Charges for patients covered under state or local indigent care program (not included in lines 6 or 10)
15 State or local indigent care program cost (line 1 times line 14)
16 Difference between net revenue and costs for state or local indigent care program (line 15 minus line 13 )
If line 15 is less than line 13, then enter zero.

13
14
15
16

Uncompensated care (see instructions for each line)
17 Private grants, donations, or endowment income restricted to funding charity care
18 Government grants, appropriations or transfers for support of hospital operations
19 Total unreimbursed cost for Medicaid, SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16)
Uninsured
patients
1

17
18
19
Insured
patients
2

Total
(col. 1 + col. 2)
3

20 Total initial obligation of patients approved for charity care (at full charges excluding
non-reimbursable cost centers) for the entire facility
21 Cost of initial obligation of patients approved for charity care (line 1 times line 20)
22 Partial payment by patients approved for charity care
23 Cost of charity care (line 21 minus line 22)

20

24 Does the amount in line 20, column 2 include charges for patient days beyond a length of stay limit imposed on patients covered
by Medicaid or other indigent care program?
25 If line 24 is yes, enter charges for patient days beyond an indigent care program's length of stay limit (see instructions)
26 Total bad debt expense for the entire hospital complex (see instructions)
27 Medicare bad debts for the entire hospital complex (see instructions)
28 Non-Medicare and non-reimbursable bad debt expense (line 26 minus line 27)
29 Cost of non-Medicare bad debt expense (line 1 times line 28)
30 Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29)
31 Total unreimbursed and uncompensated care cost (line 19 plus line 30)

24

21
22
23

25
26
27
28
29
30
31

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4012)

Rev. 3

40-523

4090 (Cont.)

FORM CMS-2552-10

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

10-12

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

00100
00200
00300
00400
00500
00600
00700
00800
00900
01000
01100
01200
01300
01400
01500
01600
01700

30
31
32
33
34
35
40
41
42
43
44
45
46

03000
03100
03200
03300
03400

01900
02000
02100
02200
02300

04000
04100
04200
04300
04400
04500
04600

SALARIES
1

OTHER
2

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Other Capital Related Costs
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Subprovider - IPF
Subprovider - IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

PERIOD:
FROM ____________
TO _______________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
ADJUSTMENTS
5
6

WORKSHEET A

NET EXPENSES
FOR ALLOCATION
(col. 5 ± col. 6)
7

-0-

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)

40-524

Rev. 3

10-12

FORM CMS-2552-10

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

4090 (Cont.)

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS
(omit cents)

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76

05000
05100
05200
05300
05400
05500
05600
05700
05800
05900
06000
06100
06200
06300
06400
06500
06600
06700
06800
06900
07000
07100
07200
07300
07400
07500

88
89
90
91
92
93

08800
08900
09000
09100
09200

SALARIES
1

OTHER
2

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

PERIOD:
FROM ____________
TO _______________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
ADJUSTMENTS
5
6

WORKSHEET A

NET EXPENSES
FOR ALLOCATION
(col. 5 ± col. 6)
7
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)

Rev. 3

40-525

4090 (Cont.)

FORM CMS-2552-10

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

10-12

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS
(omit cents)

94
95
96
97
98
99
100
101

09400
09500
09600
09700

105
106
107
108
109
110
111
112
113
114
115
116
117
118

10500
10600
10700
10800
10900
11000
11100

190
191
192
193
194
200

19000
19100
19200
19300

10000
10100

11300
11400
11500
11600

SALARIES
1

OTHER
2

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Interest Expense
Utilization Review-SNF
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
TOTAL (sum of lines 118-199)

PERIOD:
FROM ____________
TO _______________
RECLASSIFIED
TRIAL BALANCE
(col. 3 ± col. 4)
ADJUSTMENTS
5
6

WORKSHEET A

NET EXPENSES
FOR ALLOCATION
(col. 5 ± col. 6)
7
94
95
96
97
98
99
100
101

-0-0-

-0-

105
106
107
108
109
110
111
112
113
114
115
116
117
118
190
191
192
193
194
200

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4013)

40-526

Rev. 3

10-12

FORM CMS-2552-10

4090 (Cont.)

RECLASSIFICATIONS

PROVIDER CCN:
________________
INCREASES

EXPLANATION OF RECLASSIFICATION(S)

CODE
(1)
1

COST CENTER
2

LINE #
3

SALARY
4

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
500 Total reclassifications (sum of columns 4 and 5
must equal sum of columns 8 and 9)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.

OTHER
5

COST CENTER
6

PERIOD:
FROM ____________
TO _______________
DECREASES
LINE #
7

SALARY
8

WORKSHEET A-6

OTHER
9

Wkst.
A-7
Ref.
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
500

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4014)

Rev. 3

40-527

4090 (Cont.)

FORM CMS-2552-10

RECONCILIATION OF CAPITAL COSTS CENTERS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

WORKSHEET A-7,
PARTS I, II & III

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
Acquisitions
Description

Beginning
Balances
1

Purchases
2

Donation
3

Total
4

Disposals
and
Retirements
5

Ending
Balance
6

Fully
Depreciated
Assets
7

1 Land
2 Land Improvements
3 Buildings and Fixtures
4 Building Improvements
5 Fixed Equipment
6 Movable Equipment
7 HIT-designated Assets
8 Subtotal (sum of lines 1-7)
9 Reconciling Items
10 Total (line 7 minus line 9)
PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 AND 2

1
2
3
4
5
6
7
8
9
10
SUMMARY OF CAPITAL

Description
*

Depreciation
9

Lease
10

Interest
11

Insurance
(see instructions)
12

Taxes
(see instructions)
13

Other CapitalRelated Costs
(see instructions)
14

Total (1)
(sum of
cols. 9 through 14)
15

1
2
3
(1)

Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Total (sum of lines 1-2)
The amount in columns 9 through 14 must equal the amount on Worksheet A, column 2, lines 1 and 2. Enter in each column the appropriate amounts including any directly assigned cost that may have been included in Worksheet A,
column 2, lines 1 and 2.
* All lines numbers are to be consistent with Worksheet A line numbers for capital cost centers.
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS
COMPUTATION OF RATIOS
ALLOCATION OF OTHER CAPITAL
Gross Assets
Total
Capitalized
for Ratio
Ratio
Other Capital(sum of
Description
Gross Assets
Leases
(col. 1 - col. 2)
(see instructions)
Insurance
Taxes
Related Costs
cols. 5 through 7)
*
1
2
3
4
5
6
7
8
1 Capital Related Costs-Buildings and Fixtures
2 Capital Related Costs-Movable Equipment
3 Total (sum of lines 1-2)
1.000000

1
2
3

1
2
3

SUMMARY OF CAPITAL

Description
*
1
2
3
(2)

Depreciation
9

Lease
10

Interest
11

Insurance
(see instructions)
12

Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Total (sum of lines 1-2)
The amounts on lines 1 and 2 must equal the corresponding amounts on Worksheet A, column 7, lines 1 and 2. Columns 9 through 14 should include related
Worksheet A-6 reclassifications, Worksheet A-8 adjustments, and Worksheet A-8-1 related organizations and home office costs. (See instructions.)
FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4015)

40-528

Taxes
(see instructions)
13

Other CapitalRelated Costs
(see instructions)
14

Total (2)
(sum of
cols. 9 through 14)
15
1
2
3

Rev. 3

10-12

FORM CMS-2552-10

ADJUSTMENTS TO EXPENSES

PROVIDER CCN:
________________

DESCRIPTION (1)
BASIS/CODE (2)
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
50

Investment income - buildings and fixtures (chapter 2)
Investment income - movable equipment (chapter 2)
Investment income - other (chapter 2)
Trade, quantity, and time discounts (chapter 8)
Refunds and rebates of expenses (chapter 8)
Rental of provider space by suppliers (chapter 8)
Telephone services (pay stations excluded) (chapter 21)
Television and radio service (chapter 21)
Parking lot (chapter 21)
Provider-based physician adjustment
Sale of scrap, waste, etc. (chapter 23)
Related organization transactions (chapter 10)
Laundry and linen service
Cafeteria-employees and guests
Rental of quarters to employee and others
Sale of medical and surgical
supplies to other than patients
Sale of drugs to other than patients
Sale of medical records and abstracts
Nursing school (tuition, fees, books, etc.)
Vending machines
Income from imposition of interest,
finance or penalty charges (chapter 21)
Interest expense on Medicare overpayments and
borrowings to repay Medicare overpayments
Adjustment for respiratory therapy
costs in excess of limitation (chapter 14)
Adjustment for physical therapy costs
in excess of limitation (chapter 14)
Utilization review - physicians' compensation (chapter 21)
Depreciation - buildings and fixtures
Depreciation - movable equipment
Non-physician Anesthetist
Physicians' assistant
Adjustment for occupational therapy costs
in excess of limitation (chapter 14)
Adjustment for speech pathology costs
in excess of limitation (chapter 14)
CAH HIT Adjustment for Depreciation
Other adjustments (specify) (3)
TOTAL (sum of lines 1 thru 49)
(Transfer to Worksheet A, column 6, line 200)

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________

AMOUNT
2

WORKSHEET A-8

EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
COST CENTER
LINE #
3
4
Buildings and Fixtures
1
Movable Equipment
2

Worksheet A-8-2
Worksheet A-8-1

Wkst.
A-7
Ref.
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

Worksheet A-8-3

Respiratory Therapy

65

Worksheet A-8-3

Physical Therapy
Utilization Review - SNF
Buildings and Fixtures
Movable Equipment
Nonphysician Anesthetist

66
114
1
2
19

Worksheet A-8-3

Occupational Therapy

67

Worksheet A-8-3

Speech Pathology

68

24
25
26
27
28
29
30
31
32
33
50

(1) Description - all chapter references in this column pertain to CMS Pub. 15-1
(2) Basis for adjustment (see instructions)
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - if cost cannot be determined
(3) Additional adjustments may be made on lines 33 thru 49 and subscripts thereof.
Note: See instructions for column 5 referencing to Worksheet A-7.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4016)

Rev. 3

40-529

4090 (Cont.)

FORM CMS-2552-10

STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS AND
HOME OFFICE COSTS

10-12

PROVIDER CCN:
________________

PERIOD:
WORKSHEET A-8-1
FROM ____________
TO _______________

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS
OR CLAIMED HOME OFFICE COSTS:
Amount
Net
Amount of
included in
Adjustments
Wkst.
Allowable
Wkst. A
(col. 4 minus
A-7
Line No.
Cost Center
Expense Items
Cost
column 5
col. 5) *
Ref.
1
2
3
4
5
6
7
1
2
3
4
5 TOTALS (sum of lines 1-4) Transfer column 6, line 5 to Worksheet
A-8, column 2, line 12.

1
2
3
4
5

* The amounts on lines 1 through 4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:
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 B of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/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.

Symbol
(1)
1

Name
2

Percentage
of
Ownership
3

Name
4

Related Organization(s) and/or Home Office
Percentage
of
Type of
Ownership
Business
5
6

6
7
8
9
10

6
7
8
9
10
(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related
FORM CMS-2552-10organization
(08/2012) (INSTRUCTIONS
and in provider. FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4013)
B. Corporation, partnership, or other organization has financial interest in provider.
C. Provider has financial interest in corporation, partnership, or other organization.
D. Director, officer, administrator, or key person of provider or relative of such
person has financial interest in related organization.
E. Individual is director, officer, administrator, or key person of provider and
related organization.
F. Director, officer, administrator, or key person of related organization or relative
of such person has financial interest in provider.
G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4017)

40-530

Rev. 3

10-12

FORM CMS-2552-10

PROVIDER-BASED PHYSICIANS ADJUSTMENTS

4090 (Cont.)

PROVIDER CCN:
________________

Wkst. A
Line #
1

Cost Center/
Physician
Identifier
2

Total
Remuneration
3

Professional
Component
4

Provider
Component
5

RCE
Amount
6

PERIOD:
FROM ____________
TO _______________
Physician/
Provider
Component Hours
7

WORKSHEET A-8-2

Unadjusted
RCE Limit
8

5 Percent of
Unadjusted
RCE Limit
9

1
2
3
4
5
6
7
8
9
10
11
200 TOTAL

Wkst. A
Line #
10

1
2
3
4
5
6
7
8
9
10
11
200

Cost Center/
Physician
Identifier
11

Cost of
Memberships
& Continuing
Education
12

Provider
Component
Share of
col. 12
13

Physician
Cost of
Malpractice
Insurance
14

1
2
3
4
5
6
7
8
9
10
11
200 TOTAL

Provider
Component
Share of
col. 14
15

Adjusted
RCE Limit
16

RCE
Disallowance
17

Adjustment
18
1
2
3
4
5
6
7
8
9
10
11
200

FORM CMS-2552-10 (10-2012)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4018)

Rev. 3

40-531

4090 (Cont.)

FORM CMS-2552-10

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS

10-12
PROVIDER CCN:
________________

Check applicable box:

[ ] Occupational

[ ] Physical

[ ] Respiratory

PERIOD:
WORKSHEET A-8-3,
FROM ____________ PARTS I & II
TO _______________

[ ] Speech Pathology

PART I - GENERAL INFORMATION
1 Total number of weeks worked (excluding aides) (see instructions)
2 Line 1 multiplied by 15 hours per week
3 Number of unduplicated days in which supervisor or therapist was on provider site (see instructions)
4 Number of unduplicated days in which therapy assistant was on provider site but neither supervisor nor therapist was on provider site (see instructions)
5 Number of unduplicated offsite visits - supervisors or therapists (see instructions)
6 Number of unduplicated offsite visits - therapy assistants (include only visits made by therapy assistant and on which
supervisor and/or therapist was not present during the visit(s)) (see instructions)
7 Standard travel expense rate
8 Optional travel expense rate per mile
Supervisors
Therapists
Assistants
1
2
3
9 Total hours worked
10 AHSEA (see instructions)
11 Standard travel allowance (columns 1 and 2, one-half of column 2,
line 10; column 3, one-half of column 3, line 10)
12 Number of travel hours (see instructions)
13 Number of miles driven (see instructions)
PART II - SALARY EQUIVALENCY COMPUTATION
14 Supervisors (column 1, line 9 times column 1, line 10)
15 Therapists (column 2, line 9 times column 2, line 10)
16 Assistants (column 3, line 9 times column 3, line10)
17 Subtotal allowance amount (sum of lines 14 and 15 for respiratory therapy or lines 14-16 for all others)
18 Aides (column 4, line 9 times column 4, line 10)
19 Trainees (column 5, line 9 times column 9, line 10)
20 Total allowance amount (sum of lines 17-19 for respiratory therapy or lines 17 and 18 for all others)
If the sum of columns 1 and 2 for respiratory therapy or columns 1 through 3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2,
make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21 through 23.
21 Weighted average rate excluding aides and trainees (line 17 divided by sum of columns 1 and 2, line 9 for respiratory therapy or columns 1 through 3, line 9 for all others)
22 Weighted allowance excluding aides and trainees (line 2 times line 21)
23 Total salary equivalency (see instructions)

1
2
3
4
5
6
7
8
Aides
4

Trainees
5
9
10
11
12
13

14
15
16
17
18
19
20

21
22
23

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2 , SECTIONS 4019)

40-532

Rev. 3

10-12

FORM CMS-2552-10

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS

4090 (Cont.)
PROVIDER CCN:
________________

Check applicable box:

[ ] Occupational

[ ] Physical

[ ] Respiratory

PERIOD:
WORKSHEET A-8-3,
FROM ____________ PARTS III & IV
TO _______________

[ ] Speech Pathology

PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24 Therapists (line 3 times column 2, line 11)
25 Assistants (line 4 times column 3, line 11)
26 Subtotal (line 24 for respiratory therapy or sum of lines 24 and 25 for all others)
27 Standard travel expense (line 7 times line 3 for respiratory therapy or sum of lines 3 and 4 for all others)
28 Total standard travel allowance and standard travel expense at the provider site (sum of lines 26 and 27)
Optional Travel Allowance and Optional Travel Expense
29 Therapists (column 2, line 10 times the sum of columns 1 and 2, line 12 )
30 Assistants (column 3, line 10 times column 3, line 12)
31 Subtotal (line 29 for respiratory therapy or sum of lines 29 and 30 for all others)
32 Optional travel expense (line 8 times columns 1 and 2, line 13 for respiratory therapy or sum of columns 1-3, line 13 for all others)
33 Standard travel allowance and standard travel expense (line 28)
34 Optional travel allowance and standard travel expense (sum of lines 27 and 31)
35 Optional travel allowance and optional travel expense (sum of lines 31 and 32)
PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36 Therapists (line 5 times column 2, line 11)
37 Assistants (line 6 times column 3, line 11)
38 Subtotal (sum of lines 36 and 37)
39 Standard travel expense (line 7 times the sum of lines 5 and 6)
Optional Travel Allowance and Optional Travel Expense
40 Therapists (sum of columns 1 and 2, line 9 times column 2, line 10)
41 Assistants (column 3, line 9 times column 3, line 10)
42 Subtotal (sum of lines 40 and 41)
43 Optional travel expense (line 8 times the sum of columns 1-3, line 13)
Total Travel Allowance and Travel Expense - Offsite Services: Complete one of the following
three lines 44, 45, or 46, as appropriate.
44 Standard travel allowance and standard travel expense (sum of lines 38 and 39) (see instructions)
45 Optional travel allowance and standard travel expense (sum of lines 39 and 42) (see instructions)
46 Optional travel allowance and optional travel expense (sum of lines 42 and 43) (see instructions)

24
25
26
27
28
29
30
31
32
33
34
35

36
37
38
39
40
41
42
43

44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2 , SECTIONS 4019)

Rev. 3

40-533

4090 (Cont.)

FORM CMS-2552-10

10-12

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS

PROVIDER CCN:
________________

Check applicable box:

[ ] Occupational

[ ] Physical

[ ] Respiratory

PERIOD:
WORKSHEET A-8-3,
FROM ____________ PARTS V-VI
TO _______________

[ ] Speech Pathology

PART V - OVERTIME COMPUTATION
Therapists
1

Assistants
2

47 Overtime hours worked during reporting period (if column 5,
line 47, is zero or equal to or greater than 2,080, do not complete
lines 48-55 and enter zero in each column of line 56)
48 Overtime rate (see instructions)
49 Total overtime (including base and overtime allowance) (multiply
line 47 times line 48)
CALCULATION OF LIMIT
50 Percentage of overtime hours by category (divide the hours in each
column on line 47 by the total overtime worked in column 5 , line 47)
51 Allocation of provider's standard work year for one full-time
employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52 Adjusted hourly salary equivalency amount (see instructions)
53 Overtime cost limitation (line 51 times line 52)
54 Maximum overtime cost (enter the lesser of line 49 or line 53)
55 Portion of overtime already included in hourly computation at the AHSEA (multiply
line 47 times line 52)
56 Overtime allowance (line 54 minus line 55 - if negative enter zero) ( Enter in column 5 the
sum of columns 1, 3, and 4 for respiratory therapy and columns 1 through 3 for all others.)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
57 Salary equivalency amount (from line 23)
58 Travel allowance and expense - provider site (from lines 33, 34, or 35))
59 Travel allowance and expense - Offsite services (from lines 44, 45, or 46)
60 Overtime allowance (from column 5, line 56)
61 Equipment cost (see instructions)
62 Supplies (see instructions)
63 Total allowance (sum of lines 57-62)
64 Total cost of outside supplier services (from provider records)
65 Excess over limitation (line 64 minus line 63; if negative, enter zero)

Aides
3

Trainees
4

Total
5
47

48
49

50
51

52
53
54
55
56

57
58
59
60
61
62
63
64
65

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2 , SECTIONS 4019)

40-534

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
A col. 7)
0

WORKSHEET B,
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-535

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
A col. 7)
0

WORKSHEET B,
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
4

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-536

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
A col. 7)
0

WORKSHEET B,
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
4

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118-201)

SUBTOTAL
(cols. 0-4)
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-537

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

MAINTENANCE OF
CAFETERIA PERSONNEL
11
12

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART I

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-538

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

MAINTENANCE OF
CAFETERIA PERSONNEL
11
12

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART I

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-539

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

MAINTENANCE OF
CAFETERIA PERSONNEL
11
12

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118-201)

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART I

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-540

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART I

TOTAL
26
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-541

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART I

TOTAL
26
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-542

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - GENERAL SERVICE COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY AND
FRINGES
21

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118-201)

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

SUBTOTAL
24

INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJUSTMENTS
25

WORKSHEET B,
PART I

TOTAL
26
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-543

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

DIRECTLY
ASSIGNED
NEW CAPITAL
RELATED
COSTS
0

WORKSHEET B,
PART II

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

SUBTOTAL
(sum of
(cols. 0-2)
2A

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

EMPLOYEE
BENEFITS
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

40-544

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

DIRECTLY
ASSIGNED
NEW CAPITAL
RELATED
COSTS
0

WORKSHEET B,
PART II

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

SUBTOTAL
(sum of
(cols. 0-2)
2A

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

EMPLOYEE
BENEFITS
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

Rev. 3

40-545

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

DIRECTLY
ASSIGNED
NEW CAPITAL
RELATED
COSTS
0

WORKSHEET B,
PART II

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

SUBTOTAL
(sum of
(cols. 0-2)
2A

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118-201)

EMPLOYEE
BENEFITS
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

40-546

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART II

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

Rev. 3

40-547

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART II

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

40-548

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

4090 (Cont.)

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118-201)

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

WORKSHEET B,
PART II

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

Rev. 3

40-549

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

10-12
PROVIDER CCN:

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

PERIOD:
WORKSHEET B,
FROM ____________
PART II
________________
TO _______________
INTERN &
INTERNS &
INTERNS &
RESIDENT
RESIDENTS
RESIDENTS PARAMEDICAL
COST & POST
SALARY AND
PROGRAM
EDUCATION
STEPDOWN
FRINGES
COSTS
(SPECIFY)
SUBTOTAL
ADJUSTMENTS
TOTAL
21
22
23
24
25
26

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

40-550

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

4090 (Cont.)
PROVIDER CCN:

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

PERIOD:
WORKSHEET B,
FROM ____________
PART II
________________
TO _______________
INTERN &
INTERNS &
INTERNS &
RESIDENT
RESIDENTS
RESIDENTS PARAMEDICAL
COST & POST
SALARY AND
PROGRAM
EDUCATION
STEPDOWN
FRINGES
COSTS
(SPECIFY)
SUBTOTAL
ADJUSTMENTS
TOTAL
21
22
23
24
25
26

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

Rev. 3

40-551

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF CAPITAL-RELATED COSTS

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

10-12
PROVIDER CCN:

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

PERIOD:
WORKSHEET B,
FROM ____________
PART II
________________
TO _______________
INTERN &
INTERNS &
INTERNS &
RESIDENT
RESIDENTS
RESIDENTS PARAMEDICAL
COST & POST
SALARY AND
PROGRAM
EDUCATION
STEPDOWN
FRINGES
COSTS
(SPECIFY)
SUBTOTAL
ADJUSTMENTS
TOTAL
21
22
23
24
25
26

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
TOTAL (sum lines 118-201)

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4021)

40-552

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

4090 (Cont.)

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

CAPITAL RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

EMPLOYEE
BENEFITS
(GROSS
SALARIES)
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

RECONCILIATION
5A

PERIOD:
FROM ____________
TO _______________
ADMINISMAINTRATIVE &
TENANCE &
GENERAL
REPAIRS
(ACCUM.
(SQUARE
COST)
FEET)
5
6

WORKSHEET B-1

OPERATION
OF PLANT
(SQUARE
FEET)
7
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-553

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

10-12

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

CAPITAL RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

EMPLOYEE
BENEFITS
(GROSS
SALARIES)
4

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

RECONCILIATION
5A

PERIOD:
FROM ____________
TO _______________
ADMINISMAINTRATIVE &
TENANCE &
GENERAL
REPAIRS
(ACCUM.
(SQUARE
COST)
FEET)
5
6

WORKSHEET B-1

OPERATION
OF PLANT
(SQUARE
FEET)
7
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-554

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

4090 (Cont.)

PROVIDER CCN:
________________

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205

CAPITAL RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

EMPLOYEE
BENEFITS
(GROSS
SALARIES)
4

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross foot adjustments
Negative cost centers
Cost to be allocated (per Worksheet B, Part I)
Unit cost multiplier (Worksheet B, Part I)
Cost to be allocated (per Worksheet B, Part II)
Unit cost multiplier (Worksheet B, Part II)

RECONCILIATION
5A

PERIOD:
FROM ____________
TO _______________
ADMINISMAINTRATIVE &
TENANCE &
GENERAL
REPAIRS
(ACCUM.
(SQUARE
COST)
FEET)
5
6

WORKSHEET B-1

OPERATION
OF PLANT
(SQUARE
FEET)
7
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-555

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

10-12
PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

PERIOD:
WORKSHEET B-1
FROM ____________
________________
TO _______________
MAINNURSING
CENTRAL
MEDICAL
TENANCE OF ADMINISSERVICES &
RECORDS &
SOCIAL
PERSONNEL
TRATION
SUPPLY
PHARMACY
LIBRARY
SERVICE
(NUMBER
(DIRECT
(COSTED
(COSTED
(TIME
(TIME
HOUSED)
NURS. HRS)
REQUIS.)
REQUIS.)
SPENT)
SPENT)
12
13
14
15
16
17

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-556

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

4090 (Cont.)
PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

PERIOD:
WORKSHEET B-1
FROM ____________
________________
TO _______________
MAINNURSING
CENTRAL
MEDICAL
TENANCE OF ADMINISSERVICES &
RECORDS &
SOCIAL
PERSONNEL
TRATION
SUPPLY
PHARMACY
LIBRARY
SERVICE
(NUMBER
(DIRECT
(COSTED
(COSTED
(TIME
(TIME
HOUSED)
NURS. HRS)
REQUIS.)
REQUIS.)
SPENT)
SPENT)
12
13
14
15
16
17

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-557

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205

10-12
PROVIDER CCN:

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

PERIOD:
WORKSHEET B-1
FROM ____________
________________
TO _______________
MAINNURSING
CENTRAL
MEDICAL
TENANCE OF ADMINISSERVICES &
RECORDS &
SOCIAL
PERSONNEL
TRATION
SUPPLY
PHARMACY
LIBRARY
SERVICE
(NUMBER
(DIRECT
(COSTED
(COSTED
(TIME
(TIME
HOUSED)
NURS. HRS)
REQUIS.)
REQUIS.)
SPENT)
SPENT)
12
13
14
15
16
17

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross foot adjustments
Negative cost centers
Cost to be allocated (per Worksheet B, Part I)
Unit cost multiplier (Worksheet B, Part I)
Cost to be allocated (per Worksheet B, Part II)
Unit cost multiplier (Worksheet B, Part II)

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-558

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

4090 (Cont.)
PROVIDER CCN:

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASGND TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

________________
INTERNS & RESIDENTS
PARASALARY AND
PROGRAM
MEDICAL
FRINGES
COSTS
EDUCATION
(ASSIGNED
(ASSIGNED
(ASSIGNED
TIME)
TIME)
TIME)
21
22
23

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Education Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

PERIOD:
WORKSHEET B-1
FROM ____________
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
SUBTOTAL
ADJUSTMENTS
TOTAL
24
25
26
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-559

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

10-12
PROVIDER CCN:

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASGND TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

________________
INTERNS & RESIDENTS
PARASALARY AND
PROGRAM
MEDICAL
FRINGES
COSTS
EDUCATION
(ASSIGNED
(ASSIGNED
(ASSIGNED
TIME)
TIME)
TIME)
21
22
23

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)

PERIOD:
WORKSHEET B-1
FROM ____________
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
SUBTOTAL
ADJUSTMENTS
TOTAL
24
25
26
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

40-560

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - STATISTICAL BASIS

COST CENTER DESCRIPTIONS

94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205

4090 (Cont.)
PROVIDER CCN:

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASGND TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

________________
INTERNS & RESIDENTS
PARASALARY AND
PROGRAM
MEDICAL
FRINGES
COSTS
EDUCATION
(ASSIGNED
(ASSIGNED
(ASSIGNED
TIME)
TIME)
TIME)
21
22
23

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross foot adjustments
Negative cost centers
Cost to be allocated (per Worksheet B, Part I)
Unit cost multiplier (Worksheet B, Part I)
Cost to be allocated (per Worksheet B, Part II)
Unit cost multiplier (Worksheet B, Part II)

PERIOD:
WORKSHEET B-1
FROM ____________
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
SUBTOTAL
ADJUSTMENTS
TOTAL
24
25
26
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118
190
191
192
193
194
200
201
202
203
204
205

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4020)

Rev. 3

40-561

4090 (Cont.)
POST STEPDOWN ADJUSTMENTS

FORM CMS-2552-10
PROVIDER CCN:
________________

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59

DESCRIPTION
1
Adjustment for EPO costs in Renal Dialysis cost center
Adjustment for EPO costs in Home Program Dialysis cost center
Adjustment for ARANESP costs in Renal Dialysis cost center
Adjustment for ARANESP costs in Home Program Dialysis cost center

PERIOD:
FROM ____________
TO _______________
WORKSHEET
PART
LINE NO.
2
3
1
74
1
94
1
74
1
94

10-12
WORKSHEET B-2

AMOUNT
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4022)

40-562

Rev. 3

10-12

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF RATIO OF COSTS TO CHARGES

COST CENTER DESCRIPTIONS

30
31
32
33
34
35
40
41
42
43
44
45
46
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68

PROVIDER CCN:

Total Cost
(from Wkst.
B, Part I,
col. 26)
1

Therapy
Limit
Adj.
2

Total
Costs
3

Costs
RCE
Disallowance
4

Total
Costs
5

INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Subprovider IPF
Subprovider IRF
Subprovider (Specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology

Inpatient
6

________________
Charges
Total
(column 6
Outpatient
+ column 7)
7
8

PERIOD:
FROM ____________
TO _______________

Cost or
Other Ratio
9

TEFRA
Inpatient
Ratio
10

WORKSHEET C
PART I

PPS
Inpatient
Ratio
11
30
31
32
33
34
35
40
41
42
43
44
45
46
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)

Rev. 3

40-563

4090 (Cont.)

FORM CMS-2552-10

10-12

COMPUTATION OF RATIO OF COSTS TO CHARGES

COST CENTER DESCRIPTIONS

69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

PROVIDER CCN:

Total Cost
(from Wkst.
B, Part I,
col. 26)
1

Therapy
Limit
Adj.
2

Total
Costs
3

Costs
RCE
Disallowance
4

Total
Costs
5

Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (see instructions)
Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
Subtotal (see instructions)
Less Observation Beds
Total (see instructions)

Inpatient
6

________________
Charges
Total
(column 6
Outpatient
+ column 7)
7
8

PERIOD:
FROM ____________
TO _______________

Cost or
Other Ratio
9

TEFRA
Inpatient
Ratio
10

WORKSHEET C
PART I

PPS
Inpatient
Ratio
11
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023)

40-564

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF OUTPATIENT SERVICE COST TO
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY

[ ] Title V
[ ] Title XIX

4090 (Cont.)
PROVIDER CCN:
________________

Cost Center Descriptions

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76

Total Cost
(Wkst. B,
Part I, col. 26)
1

Capital Cost
(Wkst B,
Part II,
col. 26)
2

Operating Cost
Net of
Capital Cost
(col. 1 - col. 2)
3

Capital
Reduction
4

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)

Operating Cost
Reduction
Amount
5

PERIOD:
FROM ____________
TO _______________
Cost Net of
Total
Capital and
Charges
Operating Cost
(Worksheet C,
Reduction
Part I, column 8)
6
7

WORKSHEET C,
PART II

Outpatient Cost
to Charge Ratio
(col. 6 ÷ col. 7)
8
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)

Rev. 3

40-565

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF OUTPATIENT SERVICE COST TO
CHARGE RATIOS NET OF REDUCTIONS FOR MEDICAID ONLY

[ ] Title V
[ ] Title XIX

10-12
PROVIDER CCN:
________________

Cost Center Descriptions

88
89
90
91
92
93
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

Total Cost
(Wkst. B,
Part I, col. 26)
1

Capital Cost
(Wkst B,
Part II,
col. 26)
2

Operating Cost
Net of
Capital Cost
(col. 1 - col. 2)
3

Capital
Reduction
4

OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (see instructions)
Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
Subtotal (sum of lines 50 thru 199)
Less Observation Beds
Total (line 200 minus line 201)

Operating Cost
Reduction
Amount
5

PERIOD:
FROM ____________
TO _______________
Cost Net of
Total
Capital and
Charges
Operating Cost
(Worksheet C,
Reduction
Part I, column 8)
6
7

WORKSHEET C.
PART II (CONT.)

Outpatient Cost
to Charge Ratio
(col. 6 ÷ col. 7)
8
88
89
90
91
92
93
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4023 & 4023.2)

40-566

Rev. 3

10-12

FORM CMS-2552-10

APPORTIONMENT OF INPATIENT ROUTINE
SERVICE CAPITAL COSTS

4090 (Cont.)

PROVIDER CCN:
________________

Check
applicable
boxes:

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

(A)

Cost Center Description
INPATIENT ROUTNE SERVICE COST CENTERS
Adults & Pediatrics
30 (General Routine Care)

PERIOD:
FROM ____________
TO _______________

WORKSHEET D,
PART I

[ ] PPS
[ ] TEFRA

Capital
Related Cost
(from Wkst.
B, Part II,
col. 26)
1

Swing
Bed
Adjustment
2

Reduced
Capital
Related
Cost
(col. 1 minus
col. 2)
3

Total
Patient
Days
4

Per
Diem
(col. 3 ÷
col. 4)
5

Inpatient
Program
Days
6

Inpatient
Program
Capital
Cost
(col. 5
x col. 6)
7

30

31 Intensive Care Unit

31

32 Coronary Care Unit

32

33 Burn Intensive Care Unit

33

34 Surgical Intensive Care Unit

34

35 Other Special Care Unit (specify)

35

40 Subprovider IPF

40

41 Subprovider IRF

41

42 Subprovider (Other)

42

43 Nursery

43

44 Skilled Nursing Facility

44

45 Nursing Facility

45

200 Total (lines 30-199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024 - 4024.1)

Rev. 3

40-567

4090 (Cont.)
APPORTIONMENT OF INPATIENT ANCILLARY
SERVICE CAPITAL COSTS

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200

PROVIDER CCN: ______________

COMPONENT CCN: ____________
[ ] Title V
[ ] Hospital
[ ] Title XVIII, Part A
[ ] IPF
[ ] Title XIX
[ ] IRF
Capital
Related Cost
(from Wkst.
Total Charges
B, Part II,
(from Wkst. C,
col. 26)
Part I, col. 8)
Cost Center Description
1
2
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Transfusing
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 199)

Check
applicable
boxes:

(A)

FORM CMS-2552-10

10-12
PERIOD:
FROM ____________
TO _______________
[ ] Subprovider (Other)

Ratio of Cost
to Charges
(col .1 ÷
col. 2)
3

WORKSHEET D,
PART II
[ ] PPS
[ ] TEFRA

Inpatient
Program
Charges
4

Capital
Costs
(column 3 x
column 4)
5
50
51
52
53
54
55
56
57
58
60
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.2)

40-568

Rev. 3

10-12

FORM CMS-2552-10

APPORTIONMENT OF INPATIENT ROUTINE
SERVICE OTHER PASS THROUGH COSTS

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________
Check
applicable
boxes:

(A)

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
INPATIENT ROUTINE SERVICE COST CENTERS
Adults & Pediatrics
30 (General Routine Care)

Nursing
School
1

WORKSHEET D,
PART III

[ ] PPS
[ ] TEFRA

Allied Health
Cost
2

All
Other
Medical
Education
Cost
3

Swing-Bed
Adjustment
Amount
(see
instructions)
4

Total Costs
(sum of cols.
1 through 3,
minus col. 4)
5

Total
Patient
Days
6

Per
Diem
(col. 5 ÷
col. 6)
7

Inpatient
Program
Days
8

Inpatient
Program
Pass-Through
Cost
(col. 7 x col. 8)
9

30

31 Intensive Care Unit

31

32 Coronary Care Unit

32

33 Burn Intensive Care Unit

33

34 Surgical Intensive Care Unit

34

35 Other Special Care Unit (specify)

35

40 Subprovider IPF

40

41 Subprovider IRF

41

42 Subprovider (Other)

42

43 Nursery

43

44 Skilled Nursing Facility

44

45 Nursing Facility

45

200 Total (sum of lines 30-199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.3)

Rev. 3

40-569

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY
SERVICE OTHER PASS THROUGH COSTS
Check
applicable
boxes:

(A)
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Serv.-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Transfusing
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged To Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 199)

[ ] Hospital
[ ] IPF
[ ] IRF

Non
Physician
Anesthetist
Cost
1

10-12

PROVIDER CCN: ______________
PERIOD:
FROM ____________
COMPONENT CCN: ____________
TO _______________
[ ] Subprovider (Other)
[ ] ICF/MR
[ ] PPS
[ ] SNF
[ ] TEFRA
[ ] NF

Nursing
School
2

Allied
Health
3

All
Other
Medical
Education
Cost
4

Total cost
(sum of col 1
through col. 4)
5

WORKSHEET D,
PART IV

Total
Outpatient
Cost
(sum of col. 2,
3 and 4)
6
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

40-570

Rev. 3

10-12

FORM CMS-2552-10

APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY
SERVICE OTHER PASS THROUGH COSTS

PROVIDER CCN: ______________
PERIOD:
FROM ____________
COMPONENT CCN: ____________
TO _______________
Check
[ ] Title V
[ ] Hospital
[ ] Subprovider (Other)
[ ] ICF/MR
[ ] PPS
applicable
[ ] Title XVIII, Part A
[ ] IPF
[ ] SNF
[ ] TEFRA
boxes:
[ ] Title XIX
[ ] IRF
[ ] NF
Inpatient
Outpatient
Program
Total
Ratio
Ratio
PassCharges
of Cost
of Cost
Inpatient
Through
Outpatient
(from Wkst. C,
to Charges
to Charges
Program
Costs
Program
Part I, col. 8) (col. 5 ÷ col. 7) (col. 6 ÷ col. 7)
Charges
(col. 8 x col. 10)
Charges
(A)
Cost Center Description
7
8
9
10
11
12
ANCILLARY SERVICE COST CENTERS
50 Operating Room
51 Recovery Room
52 Delivery Room and Labor Room
53 Anesthesiology
54 Radiology-Diagnostic
55 Radiology-Therapeutic
56 Radioisotope
57 Computed Tomography (CT) Scan
58 Magnetic Resonance Imaging (MRI)
59 Cardiac Catheterization
60 Laboratory
61 PBP Clinical Laboratory Serv.-Prgm. Only
62 Whole Blood & Packed Red Blood Cells
63 Blood Storing, Processing, & Transfusing
64 Intravenous Therapy
65 Respiratory Therapy
66 Physical Therapy
67 Occupational Therapy
68 Speech Pathology
69 Electrocardiology
70 Electroencephalography
71 Medical Supplies Charged To Patients
72 Implantable Devices Charged to Patients
73 Drugs Charged to Patients
74 Renal Dialysis
75 ASC (Non-Distinct Part)
76 Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
88 Rural Health Clinic (RHC)
89 Federally Qualified Health Center (FQHC)
90 Clinic
91 Emergency
92 Observation Beds
93 Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
94 Home Program Dialysis
95 Ambulance Services
96 Durable Medical Equipment-Rented
97 Durable Medical Equipment-Sold
98 Other Reimbursable (specify)
200 Total (sum of lines 50 through 199)

4090 (Cont.)
WORKSHEET D,
PART IV (Cont.)

Outpatient
Program
PassThrough
Costs
(col. 9 x col. 12)
13
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.4)

Rev. 3

40-571

4090 (Cont.)

FORM CMS-2552-10

10-12

APPORTIONMENT OF MEDICAL AND OTHER
HEALTH SERVICES COSTS

PROVIDER CCN: ______________ PERIOD:
WORKSHEET D,
FROM ____________
PART V
COMPONENT CCN: ____________TO _______________
Check
[ ] Title V - O/P
[ ] Hospital
[ ] Subprovider (Other)
[ ] Swing Bed SNF
applicable
[ ] Title XVIII, Part B
[ ] IPF
[ ] SNF
[ ] Swing Bed NF
boxes:
[ ] Title XIX - O/P
[ ] IRF
[ ] NF
[ ] ICF/MR
PART V - APPORTIONMENT OF MEDICAL AND OTHER HEALTH SERVICES COSTS
Program Charges
Program Cost
Cost
Cost
Cost
Cost
Cost
to
Reimbursed
Reimbursed
Reimbursed
Reimbursed
Charge
PPS
Services
Services Not
PPS
Services
Services Not
Ratio from
Reimbursed
Subject to
Subject to
Services
Subject to
Subject to
Worksheet C,
Services
Ded. & Coins.
Ded. & Coins.
(see
Ded. & Coins.
Ded. & Coins.
Part I, col. 9
(see inst.)
(see inst.)
(see inst.)
(see inst.)
(see inst.)
(see inst.)
(A)
Cost Center Description
1
2
3
4
5
6
7
ANCILLARY SERVICE COST CENTERS
50 Operating Room
51 Recovery Room
52 Labor & Delivery Room
53 Anesthesiology
54 Radiology-Diagnostic
55 Radiology-Therapeutic
56 Radioisotope
57 Computed Tomography (CT) Scan
58 Magnetic Resonance Imaging (MRI)
59 Cardiac Catheterization
60 Laboratory
61 PBP Clinical Laboratory Serv.-Prgm. Only
62 Whole Blood & Packed Red Blood Cells
63 Blood Storing, Processing, & Transfusing
64 Intravenous Therapy
65 Respiratory Therapy
66 Physical Therapy
67 Occupational Therapy
68 Speech Pathology
69 Electrocardiology
70 Electroencephalography
71 Medical Supplies Charged To Patients
72 Implantable Devices Charged to Patients
73 Drugs Charged to Patients
74 Renal Dialysis
75 ASC (Non-Distinct Part)
76 Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
88 Rural Health Clinic (RHC)
89 Federally Qualified Health Center (FQHC)
90 Clinic
91 Emergency
92 Observation Bed
93 Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
94 Home Program Dialysis
95 Ambulance
96 Durable Medical Equipment-Rented
97 Durable Medical Equipment-Sold
98 Other Reimbursable Cost Center
200 Subtotal (see instructions)
201 Less PBP Clinic Lab. Services-Program
Only Charges
202 Net Charges (line 200 - line 201 )

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200
201
202

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4024.5)

40-572

Rev. 3

10-12
COMPUTATION OF INPATIENT
OPERATING COST
Check
[ ] Title V - I/P
applicable
[ ] Title XVIII, Part A
boxes:
[ ] Title XIX - I/P
PART I - ALL PROVIDER COMPONENTS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

FORM CMS-2552-10
PROVIDER CCN.: ______________
COMPONENT CCN.: ____________
[ ] Hospital
[ ] Subprovider (other)
[ ] IPF
[ ] SNF
[ ] IRF

4090 (Cont.)
PERIOD:
WORKSHEET D-1,
FROM ____________ PART I
TO _______________
[ ] ICF/MR
[ ] PPS
[ ] TEFRA
[ ] Other

INPATIENT DAYS
Inpatient days (including private room days and swing-bed days, excluding newborn)
Inpatient days (including private room days, excluding swing-bed and newborn days)
Private room days (excluding swing-bed and observation bed days). If you have only private room days, do not complete this line.
Semi-private room days (excluding swing-bed and observation bed days)
Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost reporting period
Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost reporting period (if
calendar year, enter 0 on this line)
Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost reporting period
Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost reporting period (if
calendar year, enter 0 on this line)
Total inpatient days including private room days applicable to the Program (excluding swing-bed and newborn days)
Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) through December 31 of the
cost reporting period (see instructions).
Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after December 31 of the
cost reporting period (if calendar year, enter 0 on this line)
Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) through December 31 of
the cost reporting period.
Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days) after December 31 of the
cost reporting period (if calendar year, enter 0 on this line)
Medically necessary private room days applicable to the Program (excluding swing-bed days)
Total nursery days (title V or XIX only)
Nursery days (title V or XIX only)
SWING BED ADJUSTMENT
Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost reporting period
Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost reporting period
Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost reporting period
Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost reporting period
Total general inpatient routine service cost (see instructions)
Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line 5 x line 17)
Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6 x line 18)
Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line 7 x line 19)
Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8 x line 20)
Total swing-bed cost (see instructions)
General inpatient routine service cost net of swing-bed cost (line 21 minus line 26)
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
General inpatient routine service charges (excluding swing-bed and observation bed charges)
Private room charges (excluding swing-bed charges)
Semi-private room charges (excluding swing-bed charges)
General inpatient routine service cost/charge ratio (line 27 ÷ line 28)
Average private room per diem charge (line 29 ÷ line 3)
Average semi-private room per diem charge (line 30 ÷ line 4)
Average per diem private room charge differential (line 32 minus line 33) (see instructions)
Average per diem private room cost differential (line 34 x line 31)
Private room cost differential adjustment (line 3 x line 35)
General inpatient routine service cost net of swing-bed cost and private room cost differential (line 27 minus line 36)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.1)

Rev. 3

40-573

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF INPATIENT
OPERATING COST

10-12

PROVIDER CCN: ______________

PERIOD:
WORKSHEET D-1,
FROM ____________ PART II
COMPONENT CCN: ____________
TO _______________
[ ] Hospital
[ ]Subprovider (other)
[ ] PPS
[ ] IPF
[ ] TEFRA
[ ] IRF
[ ] Other

Check
[ ] Title V - I/P
applicable
[ ] Title XVIII, Part A
boxes:
[ ] Title XIX - I/P
PART II - HOSPITAL AND SUBPROVIDERS ONLY
PROGRAM INPATIENT OPERATING COST BEFORE
PASS-THROUGH COST ADJUSTMENTS
38 Adjusted general inpatient routine service cost per diem (see instructions)
39 Program general inpatient routine service cost (line 9 x line 38)
40 Medically necessary private room cost applicable to the Program (line 14 x line 35)
41 Total Program general inpatient routine service cost (line 39 + line 40)
Total
Inpatient Cost
1

Total
Inpatient Days
2

1
38
39
40
41
Average
Per Diem
(col. 1 ÷ col. 2)
3

Program
Days
4

Program Cost
(col. 3 x col. 4)
5

42 Nursery (title V & XIX only)
Intensive Care Type Inpatient
Hospital Units
43 Intensive Care Unit
44 Coronary Care Unit
45 Burn Intensive Care Unit
46 Surgical Intensive Care Unit
47 Other Special Care Unit (specify)

42

43
44
45
46
47
1

48 Program inpatient ancillary service cost (Worksheet D-3, column 3, line 200)
49 Total Program inpatient costs (sum of lines 41 through 48) (see instructions)

50
51
52
53

PASS-THROUGH COST ADJUSTMENTS
Pass through costs applicable to Program inpatient routine services (from Worksheet D, sum of Parts I and III)
Pass through costs applicable to Program inpatient ancillary services (from Worksheet D, sum of Parts II and IV)
Total Program excludable cost (sum of lines 50 and 51)
Total Program inpatient operating cost excluding capital related, nonphysician anesthetist, and medical education costs
(line 49 minus line 52)

TARGET AMOUNT AND LIMIT COMPUTATION
Program discharges
Target amount per discharge
Target amount (line 54 x line 55)
Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53)
Bonus payment (see instructions)
Lesser of line 53 ÷ line 54 or line 55 from the cost reporting period ending 1996, updated and compounded by the market basket
Lesser of line 53 ÷ line 54 or line 55 from prior year cost report, updated by the market basket
If line 53 ÷ line 54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by which operating costs
(line 53) are less than expected costs (lines 54 x 60), or 1 % of the target amount (line 56), otherwise enter zero.
(see instructions)
62 Relief payment (see instructions)
63 Allowable Inpatient cost plus incentive payment (see instructions)

54
55
56
57
58
59
60
61

PROGRAM INPATIENT ROUTINE SWING BED COST
64 Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (see instructions)
(title XVIII only)
65 Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (see instructions)
(title XVIII only)
66 Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65) (Title XVIII only. For CAH, see instructions.)
67 Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period (line 12 x line 19)
68 Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period (line 13 x line 20)
69 Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68)

48
49

50
51
52
53

54
55
56
57
58
59
60
61

62
63

64
65
66
67
68
69

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4025.2)

40-574

Rev. 3

10-12

FORM CMS-2552-10

COMPUTATION OF INPATIENT
OPERATING COST

4090 (Cont.)

PROVIDER CCN: ______________

PERIOD:
WORKSHEET D-1,
FROM ____________ PARTS III & IV
COMPONENT CCN: ____________
TO _______________
Check
[ ] Title V - I/P
[ ] Hospital
[ ] Subprovider (other)
[ [] ]ICF/MR
ICF/MR
[ ] PPS
applicable
[ ] Title XVIII, Part A
[ ] IPF
[ ] SNF
[ ] TEFRA
boxes:
[ ] Title XIX - I/P
[ ] IRF
[ ] NF
[ ] Other
PART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY. AND ICT/MR ONLY
70 Skilled nursing facility/other nursing facility/ICF/MR routine service cost (line 37)

70

71 Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2)

71

72 Program routine service cost (line 9 x line 71)

72

73 Medically necessary private room cost applicable to Program (line 14 x line 35)

73

74 Total Program general inpatient routine service costs (line 72 + line 73)

74

75 Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Parts II, column 26, line 45)

75

76 Per diem capital-related costs (line 75 ÷ line 2)

76

77 Program capital-related costs (line 9 x line 76)

77

78 Inpatient routine service cost (line 74 minus line 77)

78

79 Aggregate charges to beneficiaries for excess costs (from provider records)

79

80 Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79)

80

81 Inpatient routine service cost per diem limitation

81

82 Inpatient routine service cost limitation (line 9 x line 81)

82

83 Reasonable inpatient routine service costs (see instructions)

83

84 Program inpatient ancillary services (see instructions)

84

85 Utilization review - physician compensation (see instructions)

85

86 Total Program inpatient operating costs (sum of lines 83 through 85)

86

PART IV - COMPUTATION OF OBSERVATION BED PASS-THROUGH COST
87 Total observation bed days (see instructions)

87

88 Adjusted general inpatient routine cost per diem (line 27 ÷ line 2)

88

89 Observation bed cost (line 87 x line 88) (see instructions)

89

COMPUTATION OF OBSERVATION BED PASS THROUGH COST

Cost
1

Routine
Cost
(from line 27)
2

column 1 ÷
column 2
3

Total
Observation
Bed Cost
(from line 89)
4

Observation Bed
Pass-Through Cost
(col. 3 x col. 4)
(see instructions)
5

90 Capital-related cost

90

91 Nursing School cost

91

92 Allied Health cost

92

93 All other Medical Education

93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4025.3 - 4025.4)

Rev. 3

40-575

4090 (Cont.)
APPORTIONMENT OF COST OF
SERVICES RENDERED BY
INTERNS AND RESIDENTS
PART I - NOT IN APPROVED TEACHING PROGRAM
Cost Centers
1 Total cost of services rendered
Hospital Inpatient Routine Services:
2
Adults & pediatrics (general routine care)
3
Intensive care unit
4
Coronary care unit
5
Burn Intensive Care Unit
6
Surgical Intensive Care Unit
7
Other Special Care (specify)
8
Nursery
9 Subtotal (sum of lines 2 through 8)
10 IPF - Inpatient routine service
11 IRF - Inpatient routine service
12 Subprovider (Other) - Inpatient routine service
13 Skilled Nursing Facility
14 Nursing Facility
15 Other Long Term Care
16 Home Health Agency
17 Outpatient Rehabilitation Providers
18 Ambulatory Surgical Center
19 Hospice
20 Subtotal (sum of lines 9 through 19)

FORM CMS-2552-10

10-12

PROVIDER CCN:
________________
Percent of
Assigned Time
1
100.00

PERIOD:
WORKSHEET D-2,
FROM ____________ PARTS I-III
TO _______________
Expense
Allocation
2

Total Inpatient Days
All Patients
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total Charges
(from Worksheet C,
Part I, column 8,
lines 88 through 93)

Hospital Outpatient Services:
21
Rural Health Clinic (RHC)
22
Federally Qualified Health Center (FQHC)
23
Clinic
24
Emergency
25
Observation beds
26
Other Outpatient Service (specify)
27 Subtotal (sum of lines 21 through 26)
28 Total (sum of lines 20 and 27)
100.00
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
Expenses Allocated
to cost centers
Net Cost
on Worksheet B, Part I
Swing Bed
(column 1 plus
columns 21 and 22
Amount
column 2)
Hospital Inpatient Routine Services:
1
2
3
29
Adults & Pediatrics (general routine care)
30
Swing Bed - SNF
31
Swing Bed - NF
32
Intensive care unit
33
Coronary care unit
34
Burn Intensive Care Unit
35
Surgical Intensive Care Unit
36
Other Special Care (specify)
37 Subtotal (sum of lines 28, and 29 through 36)
38 IPF - Inpatient routine service
39 IRF - Inpatient routine service
40 Subprovider (Other)- Inpatient routine service
41 Skilled Nursing Facility
42 Total (sum of lines 37 through 41)
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)
Not In Approved Teaching Program
(from Part I)
Amount
Hospital
1
2
43 Inpatient
column 9, line 9
44 Outpatient
column 9, line 27
45 Total Hospital (sum of lines 43 and 44)
46 IPF - Inpatient routine service
column 9, line 10
47 IRF - Inpatient routine service
column 9, line 11
48 Subprovider (Other)- Inpatient routine service
column 9, line 12
49 Skilled Nursing Facility
column 9, line 13

21
22
23
24
25
26
27
28

29
30
31
32
33
34
35
36
37
38
39
40
41
42

In Appr

43
44
45
46
47
48
49

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)

40-576

Rev. 3

10-12

FORM CMS-2552-10

APPORTIONMENT OF COST OF
SERVICES RENDERED BY
INTERNS AND RESIDENTS
PART I - NOT IN APPROVED TEACHING PROGRAM
Average Cost
Health Care Program Inpatient Days
Per Day
Title V
Title XVIII, Part B
Title XIX
4
5
6
7
1

4090 (Cont.)

PROVIDER CCN:
________________
Title V
(col. 4 x col. 5)
8

PERIOD:
WORKSHEET D-2,
FROM ____________ PARTS I-III (Cont.)
TO _______________
Title XVIII
(col. 4 x col. 6)
9

Title XIX
(col. 4 x col. 7)
10
1

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Ratio of Cost
to Charges
(column 2 ÷
column 3)

Title
V

Titles V and XIX Outpatient and
Title XVIII Part B Charges
Title XVIII
Part B

Title
XIX

Title
V

Titles V and XIX Outpatient and
Title XVIII Part B Cost
Title XVIII
Part B

21
22
23
24
25
26
27
28
PART II - IN AN APPROVED TEACHING PROGRAM (TITLE XVIII, PART B INPATIENT ROUTINE COSTS ONLY)
Average Cost
Expenses
Total
Per Day
Title XVIII
Applicable
Inpatient Days (column 3 ÷
Part B
to Title XVIII
All Patients
column 4)
Inpatient Days
(col. 5 x col. 6)
4
5
6
7
29
30
31
32
33
34
35
36
37
38
39
40
41
42
PART III - SUMMARY FOR TITLE XVIII (TO BE COMPLETED ONLY IF BOTH PARTS I AND II ARE USED)
In Approved Teaching Program
Total Title XVIII Costs
(from Part II, col. 7)
Amount
(to Wkst. E, Part B)
(col. 2 + col. 4)
3
4
5
6
43
line 37
44
45
line 2
46
line 38
line 2
47
line 39
line 2
48
line 40
line 2
49
line 41
line 2

Title
XIX
21
22
23
24
25
26
27
28

29
30
31
32
33
34
35
36
37
38
39
40
41
42

43
44
45
46
47
48
49

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4026)

Rev. 3

40-577

4090 (Cont.)

FORM CMS-2552-10

INPATIENT ANCILLARY SERVICE
COST APPORTIONMENT

Check
applicable
boxes:

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

[ ] Hospital
[ ] IPF
[ ] IRF

COST CENTER DESCRIPTION
(A)
30
31
32
33
34
35
40
41
42
43
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200
201
202

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Subprovider (other)
[ ] SNF
[ ] NF
Ratio of Cost
to Charges
1

10-12
PERIOD:
FROM ____________
TO _______________
[ ] Swing-Bed SNF
[ ] Swing-Bed NF
[ ] ICF/MR
Inpatient
Program Charges
2

INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care (specify)
Subprovider IPF
Subprovider IRF
Subprovider (Specify)
Nursery
ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Laboratory Services-Prgm. Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (see instructions)
Other Outpatient Service (specify)
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50-94 and 96-98)
Less PBP Clinic Laboratory Services-Program only charges (line 61)
Net Charges (line 200 minus line 201)

WORKSHEET D-3

[ ] PPS
[ ] TEFRA
[ ] Other
Inpatient Program Costs
(col. 1 x col. 2)
3
30
31
32
33
34
35
40
41
42
43
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93
94
95
96
97
98
200
201
202

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4027)

40-578

Rev. 3

10-12

FORM CMS-2552-10

COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS

Check
applicable box:

[ ] HEART
[ ] KIDNEY

[ ] LIVER
[ ] LUNG

PROVIDER CCN:
________________
OPO CCN:
________________
[ ] PANCREAS
[ ] INTESTINE

4090 (Cont.)
PERIOD:
WORKSHEET D-4,
FROM ____________ PART I
TO _______________
[ ] ISLET
[ ] OTHER (specify)

PART I - COMPUTATION OF ORGAN ACQUISITION COSTS (INPATIENT ROUTINE AND ANCILLARY SERVICES)
Inpatient
Organ
Computation of Inpatient
Routine Organ
Per Diem Costs
Acquisition
Routine Service Costs
Charges
(from Wkst. D-1, Part II)
Days
Applicable to Organ Acquisition
1
D
2
3
1 Adults and Pediatrics
38
2 Intensive Care
43
3 Coronary Care
44
4 Burn Intensive Care Unit
45
5 Surgical Intensive Care Unit
46
6 Other Special Care (specify)
47
7 TOTAL (sum of lines 1-6)

Computation of Ancillary
Service Costs Applicable
to Organ Acquisition
8 Operating Room
9 Recovery Room
10 Labor Room & Delivery Room
11 Anesthesiology
12 Radiology-Diagnostic
13 Radiology-Therapeutic
14 Radioisotope
15 Computed Tomography (CT) Scan
16 Magnetic Resonance Imaging (MRI)
17 Cardiac Catheterization
18 Laboratory
19 PBP Clinical Laboratory Services-Program Only
20 Whole Blood & Packed Red Blood Cells
21 Blood Storage, Processing, & Transfusing
22 IV Therapy
23 Respiratory Therapy
24 Physical Therapy
25 Occupational Therapy
26 Speech Pathology
27 Electrocardiology
28 Electroencephalography
29 Medical Supplies Charged to Patients
30 Implantable Devices Charged to Patients
31 Drugs Charged to Patients
32 Renal Dialysis
33 ASC (non-distinct part)
34 Other Ancillary (specify)
35 Rural Health Clinic (RHC)
36 Federally Qualified Health Center (FQHC)
37 Clinic
38 Emergency Room
39 Observation Beds
40 Other Outpatient Service (specify)
41 TOTAL (sum of lines 8-40)
C = Worksheet C line numbers

C
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

Ratio of Cost
to Charges
(from
Wkst. C)
1

Organ
Acquisition
Ancillary
Charges
2

Cost
(col. 2 x col. 3)
4
1
2
3
4
5
6
7
Organ
Acquisition
Ancillary
Costs
3
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41

D = Worksheet D-1 line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.1)

Rev. 3

40-579

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS

Check
applicable box:

[ ] HEART
[ ] KIDNEY

PROVIDER CCN:
________________
OPO CCN:
________________
[ ] LIVER
[ ] LUNG

10-12
PERIOD:
FROM ____________
TO _______________

WORKSHEET D-4,
PART II

[ ] PANCREAS
[ ] INTESTINE

[ ] ISLET
[ ] OTHER (specify)

PART II - COMPUTATION OF ORGAN ACQUISITION COSTS (OTHER THAN INPATIENT ROUTINE AND
ANCILLARY SERVICE COSTS)
Average Cost
Computation of the Cost of Inpatient
Per Day
Services of Interns and Residents Not
(from Wkst. D-2,
Organ
In Approved Teaching Program
Part I, col. 4)
Acquisition Days
D
1
2
42 Adults & Pediatrics (General routine care)
2
43 Intensive Care Unit
3
44 Coronary Care Unit
4
45 Burn Intensive Care Unit
5
46 Surgical Intensive Care Unit
6
47 Other Special Care (specify)
7
48 TOTAL (sum of lines 42 through 47)

Computation of the Cost of Outpatient
Services of Interns and Residents Not
In Approved Teaching Program
49
50
51
52
53
54
55

Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient Service (specify)
TOTAL (sum of lines 49 through 54)

Organ
Charges
(see instructions)
1

D
21
22
23
24
25
26

Ratio of Cost
to Charges
from Wkst. D-2,
Part I, col. 4)
2

Organ
Acquisition
Costs
(col. 1 x col. 2)
3
42
43
44
45
46
47
48

Organ
Acquisition
Costs
(col. 1 x col. 2)
3
49
50
51
52
53
54
55

D = Worksheet D-2, Part I, line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.2)

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Rev. 3

10-12

FORM CMS-2552-10

COMPUTATION OF ORGAN ACQUISITION COSTS AND CHARGES
FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT CENTERS

Check
applicable box:

[ ] HEART
[ ] KIDNEY

[ ] LIVER
[ ] LUNG

4090 (Cont.)

PROVIDER CCN:
________________
OPO CCN:
________________
[ ] PANCREAS
[ ] INTESTINE

PERIOD:
WORKSHEET D-4,
FROM ____________ PARTS III & IV
TO _______________
[ ] ISLET
[ ] OTHER (specify)

PART III - SUMMARY OF COSTS AND CHARGES
Cost
Part A
1
56
57
58
59
60
61
62
63
64
65
66
67
68
69

Charges
Part B
2

Part A
3

Part B
4

Routine and Ancillary from Part I
Interns and Residents (inpatient)
Interns and Residents (outpatient)
Direct Organ Acquisition (see instructions)
Cost of Services of Teaching Physicians (Wkst. D-5, Part II)
Total (sum of lines 56 thru 60)
Total Usable Organs (see instructions)
Medicare Usable Organs (see instructions)
Ratio of Medicare Usable Organs to Total Usable
Organs (line 63 ÷ line 62)
Medicare Cost/Charges (see instructions)
Revenue for Organs Sold
Subtotal (line 65 minus line 66)
Organs Furnished Part B
Net Organ Acquisition Cost and Charges (see instructions)

56
57
58
59
60
61
62
63
64
65
66
67
68
69

PART IV - STATISTICS
Living Related
1
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84

Cadaveric
2

Organs Excised in Provider (1)
Organs Purchased from Other Transplant Hospitals (2)
Organs Purchased from Non-Transplant Hospitals
Organs Purchased from OPOs
Total (sum of lines 70 thru 73)
Organs Transplanted
Organs Sold to Other Hospitals
Organs Sold to OPOs
Organs Sold to Transplant Hospitals
Organs Sold to Military or VA Hospitals
Organs Sold Outside the U.S.
Organs Sent Outside the U.S. (no revenue received)
Organs Used for Research
Unusable/Discarded Organs
Total (sum of lines 75 through 83 should equal line 74)

Revenue
3
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84

(1) Organs procured outside your center by a procurement team from your center are not included in the count.
(2) Organs procured outside your center by a procurement team are included in the count.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4028.3)

Rev. 3

40-581

4090 (Cont.)

FORM CMS-2552-10

10-12

APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS

PROVIDER CCN:
________________

Check applicable box:

[ ] Hospital Staff

PERIOD:
WORKSHEET D-5,
FROM ____________ PART I
TO _______________

[ ] Medical Staff

PART I - REASONABLE COMPENSATION EQUIVALENT COMPUTATION
Line
No.
1
1
2
3
4
5
6
7
8
9
10
11

Line
No.
9
1
2
3
4
5
6
7
8
9
10
11

Specialty
Description/Physician Identifier
2
General Practitioner Family Practice
Internal Medicine
Surgery
Pediatrics
Obstetrics-Gynecology
Radiology
Psychiatry
Anesthesiology
Pathology
All Other
Total

Specialty
Description/Physician Identifier
10
General Practitioner Family Practice
Internal Medicine
Surgery
Pediatrics
Obstetrics-Gynecology
Radiology
Psychiatry
Anesthesiology
Pathology
All Other
Total (transfer the amount in column 16, line 11, to
Part II, line 1, column 1 or 2, as appropriate)

Total
Remuneration
3

Professional
Component
4

RCE
Amount
5

Physician/
Professional
Component Hours
6

Unadjusted
RCE Limit
7

5 Percent
of Unadjusted
RCE Limit
8
1
2
3
4
5
6
7
8
9
10
11

Cost of
Membership
& Continuing
Education
11

Professional
Component
Share of col. 11
12

Cost of
Physician
Malpractice
Insurance
13

Professional
Component
Share of col. 13
14

Adjusted
RCE Limit
15

Adjust Cost
of Physician's
Direct Medical &
Surgical Services
16
1
2
3
4
5
6
7
8
9
10
11

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.1)

40-582

Rev. 3

10-12

FORM CMS-2552-10

APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS

Check
applicable box:

[ ] Hospital
[ ] IRF

4090 (Cont.)
PROVIDER CCN:
________________
[ ] IPF
[ ] Subprovider (other)

PERIOD:
WORKSHEET D-5,
FROM ____________ PART II
TO _______________

PART II - APPORTIONMENT OF COST FOR THE SERVICES OF TEACHING PHYSICIANS

Hospital Staff
1

Medical School
Faculty
2

1 Adjusted Cost of Physician's Direct Medical and Surgical Services
2 Total Inpatient Days and Outpatient Visit Days
3 Average Per Diem (line 1 ÷ line 2)

Total
(col 1 + col 2)
3
1
2
3

HEALTH CARE PROGRAM REIMBURSABLE DAYS
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Title V - Inpatient
Title V - Outpatient
Title XVIII - Part A
Title XVIII - Part B
Title XIX - Inpatient
Title XIX - Outpatient
Inpatient and Outpatient Kidney Acquisition
Inpatient and Outpatient Liver Acquisition
Inpatient and Outpatient Heart Acquisition
Inpatient and Outpatient Lung Acquisition
Inpatient and Outpatient Pancreas Acquisition
Inpatient and Outpatient Intestine Acquisition
Inpatient and Outpatient Islet Acquisition
Other Organ Acquisition

4
5
6
7
8
9
10
11
12
13
14
15
16
17

HEALTH CARE PROGRAM REIMBURSABLE COST
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Title V - Inpatient (line 3 x line 4)
Title V - Outpatient (line 3 x line 5)
Title XVIII - Part A (line 3 x line 6)
Title XVIII - Part B (line 3 x line 7)
Title XIX - Inpatient (line 3 x line 8)
Title XIX - Outpatient (line 3 x line 9)
Inpatient and Outpatient Kidney Acquisition (line 3 x line 10)
Inpatient and Outpatient Liver Acquisition (line 3 x line 11)
Inpatient and Outpatient Heart Acquisition (line 3 x line 12)
Inpatient and Outpatient Lung Acquisition (line 3 x line 13)
Inpatient and Outpatient Pancreas Acquisition (line 3 x line 14)
Inpatient and Outpatient Intestine Acquisition (line 3 x line 15)
Inpatient and Outpatient Islet Acquisition (line 3 x line 16)
Inpatient and Outpatient Other Organ Acquisition (line 3 x line 17)

18
19
20
21
22
23
24
25
26
27
28
29
30
31

Transfer the amounts in column 3 as follows:
Add lines 18 and 19, and transfer to Worksheet E-3, Part VII
Line 20 to Worksheet E, Part A, or Worksheet E-3, Part I to IV as appropriate
Line 21 to Worksheet E, Part B
Add lines 22 and 23, and transfer to Worksheet E-3, Part VII, as appropriate
Sum of lines 24 through 31 to Worksheet D-4, Part III, line 60

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4029.2)

Rev. 3

40-583

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT

Check
applicable box:

10-12
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO ______________

WORKSHEET E,
PART A

[ ] Hospital
[ ] Subprovider (Other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS
1
2
2.01
3
4
5
6
7
7.01
8

8.01
8.02
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

DRG amounts other than outlier payments
Outlier payments for discharges (see instructions)
Outlier reconciliation amount
Managed care simulated payments
Bed days available divided by number of days in the cost reporting period (see instructions)
Indirect Medical Education Adjustment Calculation for Hospitals
FTE count for allopathic and osteopathic programs for the most recent cost reporting period ending on or
before 12/31/1996 (see instructions)
FTE count for allopathic and osteopathic programs which meet the criteria for an add-on to the cap for new programs in
in accordance with 42 CFR 413.79(e)
MMA Section 422 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(1)
ACA Section 5503 reduction amount to the IME cap as specified under 42 CFR §412.105(f)(1)(iv)(B)(2)
If the cost report straddles July 1, 2011 then see instructions.
Adjustment (increase or decrease) to the FTE count for allopathic and osteopathic programs for affiliated programs in accordance
with 42 CFR 413.75(b), 413.79(c)(2)(iv) and Vol. 64 Federal Register, May 12, 1998, page 26340 and Vol. 67 Federal Register,
page 50069, August 1, 2002.
The amount of increase if the hospital was awarded FTE cap slots under section 5503 of the ACA.
If the cost report straddles July 1, 2011, see instructions.
The amount of increase if the hospital was awarded FTE cap slots from a closed teaching hospital under
section 5506 of ACA. (see instructions)
Sum of lines 5 plus 6 minus lines (7 and 7.01) plus/minus line 8 plus lines (8.01 and 8.02) (see instructions)
FTE count for allopathic and osteopathic programs in the current year from your records
FTE count for residents in dental and podiatric programs
Current year allowable FTE (see instructions)
Total allowable FTE count for the prior year
Total allowable FTE count for the penultimate year if that year ended on or after September 30, 1997, otherwise enter zero.
Sum of lines 12 through 14 divided by 3
Adjustment for residents in initial years of the program
Adjustment for residents displaced by program or hospital closure
Adjusted rolling average FTE count
Current year resident to bed ratio (line 18 divided by line 4)
Prior year resident to bed ratio (see instructions)
Enter the lesser of lines 19 or 20 (see instructions)
IME payment adjustment (see instructions)
Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA
Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ).
IME FTE resident count over cap (see instructions)
If the amount on line 24 is greater than -0-, then enter the lower of line 23 or line 24 (see instructions)
Resident to bed ratio (divide line 25 by line 4)
IME payments adjustment (see instructions)
IME Adjustment (see instructions)
Total IME payment (sum of lines 22 and 28)
Disproportionate Share Adjustment
Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions)
Percentage of Medicaid patient days to total days reported on Worksheet S-2, Part I, line 24. (see instructions)
Sum of lines 30 and 31
Allowable disproportionate share percentage (see instructions)
Disproportionate share adjustment (see instructions)

1
2
2.01
3
4
5
6
7
7.01
8

8.01
8.02
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4030.1)

40-584

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT

Check
applicable box:

[ ] Hospital
[ ] IRF

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM ___________
TO ______________

WORKSHEET E,
PART A (Cont.)

[ ] IPF
[ ] Subprovider (other)

PART A - INPATIENT HOSPITAL SERVICES UNDER PPS
Additional payment for high percentage of ESRD beneficiary discharges
40 Total Medicare discharges on Worksheet S-3, Part I excluding discharges for MS-DRGs 652, 682, 683,
684 and 685 (see instructions)
41 Total ESRD Medicare discharges excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions)
42 Divide line 41 by line 40 (if less than 10%, you do not qualify for adjustment)
43 Total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684 an 685 (see instructions)
44 Ratio of average length of stay to one week (line 43 divided by line 41 divided by 7 days)
45 Average weekly cost for dialysis treatments (see instructions)
46 Total additional payment (line 45 times line 44 times line 41)
47 Subtotal (see instructions)
48 Hospital specific payments (to be completed by SCH and MDH, small rural hospitals only (see instructions)
49 Total payment for inpatient operating costs SCH and MDH only (see instructions)
50 Payment for inpatient program capital (from Worksheet L, Parts I, II, as applicable)
51 Exception payment for inpatient program capital (Worksheet L, Part III) (see instructions)
52 Direct graduate medical education payment (from Worksheet E-4, line 49) (see instructions).
53 Nursing and allied health managed care payment
54 Special add-on payments for new technologies
55 Net organ acquisition cost (Worksheet D-4 Part III, col. 1, line 69)
56 Cost of teaching physicians (Worksheet D-5, Part II, col. 3, line 20)
57 Routine service other pass through costs (from Wkst D, Part III, column 9, lines 30-35) .
58 Ancillary service other pass through costs Worksheet D, Part IV, col. 11 line 200)
59 Total (sum of amounts on lines 49 through 58)
60 Primary payer payments
61 Total amount payable for program beneficiaries (line 59 minus line 60)
62 Deductibles billed to program beneficiaries
63 Coinsurance billed to program beneficiaries
64 Allowable bad debts (see instructions)
65 Adjusted reimbursable bad debts (see instructions)
66 Allowable bad debts for dual eligible beneficiaries (see instructions)
67 Subtotal (line 61 plus line 65 minus lines 62 and 63)
68 Credits received from manufacturers for replaced devices applicable to MS-DRG (see instructions)
69 Outlier payments reconciliation (Sum of lines 93, 95 and 96).(For SCH see instructions)
70 Other adjustments (specify) (see instructions)
70.95 Recovery of Accelerated depreciation
70.96 Low Volume Adjustment for Federal Fiscal year 2011
70.97 Low Volume Adjustment for Federal Fiscal year 2012
71 Amount due provider (line 67 minus lines 68 plus/minus lines 69 & 70)
72 Interim payments
73 Tentative settlement (for contractor use only)
74 Balance due provider (Program) (line 71 minus the sum of lines 72 and 73)
75 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2

90
91
92
93
94
95
96

TO BE COMPLETED BY CONTRACTOR
Operating outlier amount from Worksheet E, Part A line 2 (see instructions).
Capital outlier from Worksheet L, Part I, line 2
Operating outlier reconciliation adjustment amount (see instructions)
Capital outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money (see instructions)
Time Value of Money for operating expenses (see instructions)
Time Value of Money for capital related expenses (see instructions)

40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
70.95
70.96
70.97
71
72
73
74
75

90
91
92
93
94
95
96

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4030.1)

Rev. 3

40-585

4090 (Cont.)
CALCULATION OF
REIMBURSEMENT SETTLEMENT

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Subprovider (Other)
[ ] SNF

10-12
PERIOD:
WORKSHEET E,
FROM ____________ PART B
TO _______________

Check applicable box:
[ ] Hospital
[ ] IPF
[ ] IRF
PART B - MEDICAL AND OTHER HEALTH SERVICES
1 Medical and other services (see instructions)
2 Medical and other services reimbursed under OPPS (see instructions).
3 PPS payments
4 Outlier payment (see instructions)
5 Enter the hospital specific payment to cost ratio (see instructions)
6 Line 2 times line 5
7 Sum of line 3 and line 4 divided by line 6
8 Transitional corridor payment (see instructions)
9 Ancillary service other pass through costs from Worksheet D, Part IV, column 13, line 200
10 Organ acquisition
11 Total cost (sum of lines 1 and 10) (see instructions)
COMPUTATION OF LESSER OF COST OR CHARGES
Reasonable charges
12 Ancillary service charges
13 Organ acquisition charges (from Worksheet D-4, Part III, line 69, col. 4)
14 Total reasonable charges (sum of lines 12 and 13)
Customary charges
15 Aggregate amount actually collected from patients liable for payment for services on a charge basis
16 Amounts that would have been realized from patients liable for payment for services on a charge
basis had such payment been made in accordance with 42 CFR 413.13(e)
17 Ratio of line 15 to line 16 (not to exceed 1.000000)
18 Total customary charges (see instructions)
19 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see instructions)
20 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see instructions)
21 Lesser of cost or charges (line 11 minus line 20) (for CAH, see instructions)
22 Interns and residents (see instructions)
23 Cost of teaching physicians (see instructions, 42 CFR 415.160 and CMS Pub. 15-1, §2148)
24 Total prospective payment (sum of lines 3, 4, 8 and 9)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
25 Deductibles and coinsurance (see instructions)
26 Deductibles and Coinsurance relating to amount on line 24 (see instructions)
27 Subtotal {(lines 21 and 24 - the sum of lines 25 and 26) plus the sum of lines 22 and 23} (see instructions)
28 Direct graduate medical education payments (from Worksheet E-4, line 50)
29 ESRD direct medical education costs (from Worksheet E-4, line 36)
30 Subtotal (sum of lines 27 through 29)
31 Primary payer payments
32 Subtotal (line 30 minus line 31)
ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)
33 Composite rate ESRD (from Worksheet I-5, line 11)
34 Allowable bad debts (see instructions)
35 Adjusted reimbursable bad debts (see instructions)
36 Allowable bad debts for dual eligible beneficiaries (see instructions)
37 Subtotal (sum of lines 32, 33, and 34 or 35) (line 35 hospital and subprovider only)
38 MSP-LCC reconciliation amount from PS&R
39 Other adjustments (specify) (see instructions)
40 Subtotal (line 37 plus or minus lines 39 minus 38)
41 Interim payments
42 Tentative settlement (for contractors use only)
43 Balance due provider/program (line 40 minus the sum of lines 41, and 42)
44 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2

1
2
3
4
5
6
7
8
9
10
11

12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)

40-586

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF
REIMBURSEMENT SETTLEMENT

Check applicable box
[ ] Hospital [ ] IPF
[ ] IRF
PART B - MEDICAL AND OTHER HEALTH SERVICES

90
91
92
93
94

[ ] Subprovider(Other)

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] SNF

4090 (Cont.)
PERIOD:
WORKSHEET E,
FROM ____________ PART B (Cont.)
TO _______________

TO BE COMPLETED BY CONTRACTOR
Original outlier amount (see instructions)
Outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
Total (sum of lines 91 and 93)

90
91
92
93
94

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4030.2)

Rev. 3

40-587

4090 (Cont.)
ANALYSIS OF PAYMENTS TO PROVIDERS
FOR SERVICES RENDERED

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________

Check
[ ] Hospital
[ ] Subprovider (Other)
applicable
[ ] IPF
[ ] SNF
box:
[ ] IRF
[ ] Swing-Bed SNF
Description
1 Total interim payments paid to provider
2 Interim payments payable on individual bills, either submitted or to be submitted to the intermediary
for services rendered in the cost reporting period. If none, write "NONE" or enter a zero
3 List separately each retroactive
lump sum adjustment amount based
on subsequent revision of the
Program to
interim rate for the cost reporting period.
Provider
Also show date of each payment.
If none, write "NONE" or enter a zero. (1)
Provider to
Program
Subtotal (sum of lines 3.01- 3.49 minus sum of lines 3.50-3.98)
4 Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Wkst. E or Wkst. E-3, line
and column as appropriate)
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement
payment after desk review. Also show
date of each payment.
If none, write "NONE" or enter a zero. (1)

Program to
Provider

Provider to
Program
Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50 -5.98)
6 Determined net settlement amount (balance
due) based on the cost report (1)
7 Total Medicare program liability (see instructions)
8 Name of Contractor

Program to provider
Provider to program

10-12
PERIOD:
FROM ____________
TO _______________

WORKSHEET E-1,
PART I

Inpatient
Part A
mm/dd/yyyy
1

Part B
Amount
2

mm/dd/yyyy
3

Amount
4
1
2

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

.01
.02
.03
.50
.51
.52
.99
.01
.02

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01
6.02
7
8

Contractor Number

NPR Date (Month/Day/Year)

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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2I, SECTION 4031)

40-588

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT FOR HIT

Check
Applicable box:

[ ] Hospital

PROVIDER CCN:
________________
COMPONENT CCN:
________________

4090 (Cont.)
PERIOD:
WORKSHEET E-1,
FROM ____________ PART II
TO _______________

[ ] CAH

TO BE COMPLETED BY CONTRACTOR FOR NONSTANDAD COST REPORTS
HEALTH INFORMATION TECHNOLOGY DATA COLLECTION AND CALCULATION
1 Total hospital discharges as defined in AARA §4102 from Wkst S-3, Part I, line 14, column 15
2 Medicare days from Wkst S-3, Part I, column 6 sum of lines 1, 8-12
3 Medicare HMO days from Wkst S-3, Part I, column 6. line 2
4 Total inpatient days from S-3, Part I, column 8 sum of lines 1, 8-12
5 Total hospital charges from Wkst C, Part I, column 8 line 200
6 Total hospital charity care charges from Wkst S-10, column 3 line 20
7 CAH only - The reasonable cost incurred for the purchase of certified HIT technology from Worksheet S-2, Part I line 168
8 Calculation of the HIT incentive payment (see instructions)

INPATIENT HOSPITAL SERVICES UNDER PPS & CAH
30 Initial/interim HIT payment(s).
31 Initial/interim HIT payment adjustments (see instructions)
32 Balance due provider (line 8 minus line 30 and line 31)

1
2
3
4
5
6
7
8

30
31
32

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4031.1)

Rev. 3

40-589

4090(Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT - SWING BEDS

Check
applicable
boxes:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

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

10-12
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET E-2
FROM ____________
TO _______________

[ ] Swing Bed - SNF
[ ] Swing Bed - NF

COMPUTATION OF NET COST OF COVERED SERVICES
Inpatient routine services - swing bed-SNF (see instructions)
Inpatient routine services - swing bed-NF (see instructions)
Ancillary services (from Wkst. D-3, column 3, line 200 for Part A, and sum of Wkst. D, Part V,
columns 5 and 7, line 202 for Part B) (For CAH, see instructions)
Per diem cost for interns and residents not in approved teaching program (see instructions)
Program days
Interns and residents not in approved teaching program (see instructions)
Utilization review - physician compensation - SNF optional method only
Subtotal (sum of lines 1 through 3 plus lines 6 and 7)
Primary payer payments (see instructions)
Subtotal (line 8 minus line 9)
Deductibles billed to program patients (exclude amounts applicable to physician professional
services)
Subtotal (line 10 minus line 11)
Coinsurance billed to program patients (from provider records) (exclude coinsurance for
physician professional services)
80% of Part B costs (line 12 x 80%)
Subtotal (enter the lesser of line 12 minus line 13, or line 14)
Other adjustments (specify) (see instructions)
Reimbursable bad debts (see instructions)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Total (sum of lines 15 and 17, plus/minus line 16)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 19 minus the sum of lines 20 and 21)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II,
section 115.2

PART A
1

PART B
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4032)

40-590

Rev. 3

10-12
CALCULATION OF REIMBURSEMENT SETTLEMENT

FORM CMS-2552-10

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET E-3,
FROM ____________ PART I
TO _______________

PART I - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER - TEFRA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Inpatient hospital services (see instructions)
Organ acquisition
Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 20) (see instructions)
Subtotal (sum of lines 1 thru 3)
Primary payer payments
Subtotal (line 4 less line 5).
Deductibles
Subtotal (line 6 minus line 7)
Coinsurance
Subtotal (line 8 minus line 9)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 10 and 12)
Direct graduate medical education payments (from Worksheet E-4, line 49)
Other pass through costs (see instructions). DO NOT USE THIS LINE.
Other adjustments (specify) (see instructions)
Total amount payable to the provider (see instructions)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 18 minus the sum lines 19 and 20)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.1)

Rev. 3

40-591

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

Check
applicable
box:

10-12
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM __________
TO _____________

WORKSHEET E-3,
PART II

[ ] Hospital
[ ] Subprovider IPF

PART II - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IPF PPS
1
2
3
4
4.01
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

Net Federal IPF PPS payment (excluding outlier, ECT, and medical education payments)
Net IPF PPS Outlier payment
Net IPF PPS ECT payment
Unweighted intern and resident FTE count in the most recent cost report filed on or before November 15, 2004 (see instructions)
Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital closure,
that would not be counted without a temporary cap adjustment under §412.424(d)(1)(iii)(F)(1) or (2) (see instructions)
New teaching program adjustment (see instructions)
Current year unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program" (see instructions)
Current year unweighted I&R FTE count for residents within the first 3 years of a "new teaching program" (see instructions)
Intern and resident count for IPF PPS medical education adjustment (see instructions)
Average daily census (see instructions)
Medical Education Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}.
Medical Education Adjustment (line 1 multiplied by line 10).
Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11)
Nursing and allied health managed care payment (see instruction)
Organ acquisition
Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 20) (see instructions)
Subtotal (see instructions)
Primary payer payments
Subtotal (line 16 less line 17).
Deductibles
Subtotal (line 18 minus line 19)
Coinsurance
Subtotal (line 20 minus line 21)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 22 and 24)
Direct graduate medical education payments (from Worksheet E-4, line 49) (For freestanding IPF only)
Other pass through costs (see instructions)
Outlier payments reconciliation
Other adjustments (specify) (see instructions)
Total amount payable to the provider (see instructions)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 31 minus the sum lines 32 and 33)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

50
51
52
53

TO BE COMPLETED BY CONTRACTOR
Original outlier amount from Worksheet E-3, Part II, line 2 (see instructions)
Outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money (see instructions)
Time Value of Money (see instructions)

1
2
3
4
4.01
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

50
51
52
53

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4033.2)

40-592

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

Check
applicable
box:

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
FROM _________
TO ____________

WORKSHEET E-3,
PART III

[ ] Hospital
[ ] Subprovider IRF

PART III - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER IRF PPS
1
2
3
4
5

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

Net Federal PPS payment (see instructions)
Medicare SSI ratio (IRF PPS only) (see instructions)
Inpatient Rehabilitation LIP payments (see instructions)
Outlier payments
Unweighted intern and resident FTE count in the most recent cost reporting period ending
on or prior to November 15, 2004 (see instructions)
Cap increases for the unweighted intern and resident FTE count for residents that were displaced by program or hospital closure,
that would not be counted without a temporary cap adjustment under §412.424(d)(1)(iii)(F)(1) or (2)
New teaching program adjustment (see instructions)
Current year unweighted FTE count of I&R other than FTEs in the first 3 years of a "new teaching program" (see instructions)
Current year unweighted I&R FTE count for residents within the first 3 years of a "new teaching program" (see instructions)
Intern and resident count for IRF PPS medical education adjustment (see instructions)
Average daily census (see instructions)
Medical Education Adjustment Factor {((1 + (line 9/line 10)) raised to the power of .6876 -1}.
Medical Education Adjustment (line 1 multiplied by line 11).
Total PPS Payment (sum of lines 1, 3, 4 and 12)
Nursing and Allied Health Managed Care payment (see instructions)
Organ acquisition
Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 20) (see instructions)
Subtotal (see instructions)
Primary payer payments
Subtotal (line 17 less line 18).
Deductibles
Subtotal (line 19 minus line 20)
Coinsurance
Subtotal (line 21 minus line 22)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 23 and 25)
Direct graduate medical education payments (from Worksheet E-4, line 49) (For free standing IRF only).
Other pass through costs (see instructions)
Outlier payments reconciliation
Other adjustments (specify) (see instructions)
Total amount payable to the provider (see instructions)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 32 minus the sum lines 33 and 34)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

50
51
52
53

TO BE COMPLETED BY CONTRACTOR
Original outlier amount from Worksheet E-3, Part III, line 4 (see instructions)
Outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money (see instructions)
Time Value of Money (see instructions)

5.01

1
2
3
4
5
5.01
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

50
51
52
53

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4033.3)

Rev. 3

40-593

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

Check
applicable
box:

10-12
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET E-3,
FROM ____________ PART IV
TO _______________

[ ] Hospital
[ ] Subprovider (Other)

PART IV - CALCULATION OF MEDICARE REIMBURSEMENT SETTLEMENT UNDER LTCH PPS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Net Federal PPS payment (see instructions)
Outlier payments
Total PPS payments (sum of lines 1 and 2)
Nursing and allied health managed care payments (see instructions)
Organ acquisition
Cost of teaching physicians
Subtotal (see instructions)
Primary payer payments
Subtotal (line 7 less line 8).
Deductibles
Subtotal (line 9 minus line 10)
Coinsurance
Subtotal (line 11 minus line 12)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 13 and 15)
Direct graduate medical education payments (from Worksheet E-4, line 49 (for freestanding LTCH only )
Other pass through costs (see instructions)
Outlier payments reconciliation
Other adjustments (specify) (see instructions)
Total amount payable to the provider (see instructions)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 22 minus the sum lines 23 and 24)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

50
51
52
53

TO BE COMPLETED BY CONTRACTOR
Original PPS payment and outlier amount from Worksheet E-3, Part IV, line 3 (see instructions)
Outlier reconciliation adjustment amount (see instructions)
The rate used to calculate the Time Value of Money (see instructions)
Time Value of Money (see instructions)

50
51
52
53

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.4)

40-594

Rev. 3

10-12
CALCULATION OF REIMBURSEMENT SETTLEMENT

FORM CMS-2552-10

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET E-3,
FROM ____________ PART V
TO _______________

PART V - CALCULATION OF REIMBURSEMENT SETTLEMENT FOR MEDICARE PART A SERVICES - COST REIMBURSEMENT (CAHs)
1
2
3
4
5
6

7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

Inpatient services
Nursing and allied health managed care payment (see instruction)
Organ acquisition
Subtotal (sum of lines 1 thru 3)
Primary payer payments
Total cost (line 4 less line 5 ) (For CAH, see instructions)
COMPUTATION OF LESSER OF COST OR CHARGES
Reasonable charges
Routine service charges
Ancillary service charges
Organ acquisition charges, net of revenue
Total reasonable charges
Customary charges
Aggregate amount actually collected from patients liable for payment for services on a charge basis
Amounts that would have been realized from patients liable for payment for services on
a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
Ratio of line 11 to line 12 (not to exceed 1.000000)
Total customary charges (see instructions)
Excess of customary charges over reasonable cost (complete only if line 14 exceeds line 6) (see instructions)
Excess of reasonable cost over customary charges (complete only if line 6 exceeds line 14) (see instructions)
Cost of teaching physicians (from Worksheet D-5, Part II, column 3, line 20) (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
Direct graduate medical education payments (from Worksheet E-4, line 49)
Cost of covered services (sum of lines 6 and 17 )
Deductibles (exclude professional component)
Excess reasonable cost (from line 16)
Subtotal (line 19 minus line 20 )
Coinsurance
Subtotal (line 22 minus line 23)
Allowable bad debts (exclude bad debts for professional services) (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (sum of lines 24 and 25 or 26 )
Other adjustments (specify) (see instructions)'
Subtotal (line 28, plus or minus line 29)
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 30 minus the sum of lines 31, and 32)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

1
2
3
4
5
6

7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.5)

Rev. 3

40-595

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

10-12
PROVIDER CCN:
PERIOD:
WORKSHEET E-3,
________________
FROM ____________ PART VI
COMPONENT CCN.: TO _______________
________________

PART VI - CALCULATION OF REIMBURSEMENT SETTLEMEMENT - ALL OTHER HEALTH SERVICES FOR
TITLE XVIII PART A PPS SNF SERVICES

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

PROSPECTIVE PAYMENT AMOUNT (SEE INSTRUCTIONS)
Resource Utilization Group (RUGS) payment
Routine service other pass through costs
Ancillary service other pass through costs
Subtotal (sum of lines 1 through 3)
COMPUTATION OF NET COST OF COVERED SERVICES
Medical and other services. Do not use this line (see instructions).
Deductibles
Coinsurance
Allowable bad debts (see instructions)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Allowable reimbursable bad debts (see instructions)
Utilization review
Subtotal (Sum of lines 4, 5 minus 6 & 7 plus 10 and 11) (see instructions)
Inpatient primary payer payments
Other adjustments (specify) (see instructions)
Subtotal (line 12 minus 13 ± lines 14
Interim payments
Tentative settlement (for contractor use only)
Balance due provider/program (line 15 minus the sum of lines 16 and 17)
Protested amounts (nonallowable cost report items) in accordance with CMS
Pub. 15-2, section 115.2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.6)

40-596

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT

Check
applicable
boxes:

[ ] Title V
[ ] Title XIX

[ ] Hospital
[ ] Subprovider
[ ] SNF

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] NF
[ ] ICF/MR

PERIOD:
WORKSHEET E-3,
FROM ____________ PART VII
TO _______________
[ ] PPS
[ ] TEFRA
[ ] Other

PART VII - CALCULATION OF REIMBURSEMENT - ALL OTHER HEALTH SERVICES FOR TITLES V OR XIX SERVICES

1
2
3
4
5
6
7

8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

COMPUTATION OF NET COST OF COVERED SERVICES
Inpatient hospital/SNF/NF services
Medical and other services
Organ acquisition (certified transplant centers only)
Subtotal (sum of lines 1, 2 and 3)
Inpatient primary payer payments
Outpatient primary payer payments
Subtotal (line 4 less sum of lines 5 and 6)
COMPUTATION OF LESSER OF COST OR CHARGES
Reasonable Charges
Routine service charges
Ancillary service charges
Organ acquisition charges, net of revenue
Incentive from target amount computation
Total reasonable charges (sum of lines 8 through 11)
CUSTOMARY CHARGES
Amount actually collected from patients liable for payment for services on a charge basis
Amounts that would have been realized from patients liable for payment for services
on a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
Ratio of line 13 to line 14 (not to exceed 1.000000)
Total customary charges (see instructions)
Excess of customary charges over reasonable cost (complete only if line 16
exceeds line 4 ) (see instructions)
Excess of reasonable cost over customary charges (complete only if line 4 exceeds line 16) (see instructions)
Interns and residents (see instructions)
Cost of teaching physicians (see instructions)
Cost of covered services (enter the lesser of line 4 or line 16 )
PROSPECTIVE PAYMENT AMOUNT
Other than outlier payments
Outlier payments
Program capital payments
Capital exception payments (see instructions)
Routine and ancillary service other pass through costs
Subtotal (sum of lines 22 through 26)
Customary charges (title V or XIX PPS covered services only)
Titles V or XIX (sum of lines 21 and 27)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
Excess of reasonable cost (from line 18)
Subtotal (sum of lines 19 and 20 , plus 29 minus lines 5 and 6 )
Deductibles
Coinsurance
Allowable bad debts (see instructions)
Utilization review
Subtotal (sum of lines 31, 34 and 35 minus the sum of lines 32 and 33)
Other adjustments (specify) (see instructions)
Subtotal (line 36 ± line 37)
Direct graduate medical education payments (from Worksheet E-4)
Total amount payable to the provider (sum of lines 38 and 39)
Interim payments
Balance due provider/program (line 40 minus 41)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub 15-2, section 115.2

Inpatient
Title V or
Title XIX

Outpatient
Title V or
Title XIX
1
2
3
4
5
6
7

8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4033.7)

Rev. 3

40-597

4090 (Cont.)

FORM CMS-2552-10

10-12

DIRECT GRADUATE MEDICAL EDUCATION (GME)
PROVIDER CCN:
PERIOD:
WORKSHEET E-4
& ESRD OUTPATIENT DIRECT MEDICAL
FROM ____________
EDUCATION COSTS
________________
TO _______________
Check
[ ] Title V
applicable
[ ] Title XVIII
box:
[ ] Title XIX
COMPUTATION OF TOTAL DIRECT GME AMOUNT
1 Unweighted resident FTE count for allopathic and osteopathic programs for cost reporting periods ending on or before December 31, 1996
2 Unweighted FTE resident cap add-on for new programs per 42 CFR 413.79(e)(1) (see instructions)
3 Amount of r eduction to Direct GME c ap u nder § 422 of MMA
3.01 Direct GME cap reduction amount under ACA §5503 in accordance with CFR §413.79 (m). (see instructions
for cost reporting periods straddling 7/1/2011)
4 Adjustment (plus or minus) to the FTE cap for allopathic and osteopathic programs due to a Medicare GME
4.01
4.02
5
6
7

8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

32
33
34
35
36

affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))
ACA §5503 increase to the direct GME FTE cap (see instructions for cost reporting periods straddling 7/1/2011)
ACA §5506 number of additional direct GME FTE cap slots (see instructions for cost reporting periods straddling 7/1/2011)
FTE adjusted cap (line 1 plus line 2 minus line 3 and 3.01 plus or minus line 4 plus line 4.01 plus line 4.02 plus applicable subscripts
Unweighted resident FTE count for allopathic and osteopathic programs for the current year from your records (see instructions)
Enter the lesser of line 5 or line 6
Primary Care
Other
1
2
Weighted FTE count for physicians in an allopathic and osteopathic program for
the current year
If line 6 is less than 5 enter the amount from line 8, otherwise multiply line 8 times
the result of line 5 divided by the amount on line 6
Weighted dental and podiatric resident FTE count for the current year
Total weighted FTE count
Total weighted resident FTE count for the prior cost reporting year (see instructions)
Total weighted resident FTE count for the penultimate cost reporting year (see instr.)
Rolling average FTE count (sum of lines 11 through 13 divided by 3)
Adjustment for residents in initial years of new programs
Adjustment for residents displaced by program or hospital closure
Adjusted rolling average FTE count
Per resident amount
Approved amount for resident costs
Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 Sec. 413.79(c )(4)
Direct GME FTE unweighted resident count over cap (see instructions)
Allowable additional direct GME FTE resident count (see instructions)
Enter the locality adjustment national average per resident amount (see instructions)
Multiply line 22 time line 23
Total direct GME amount (sum of lines 19 and 24)
COMPUTATION OF PROGRAM PATIENT LOAD
Inpatient Part A
Managed Care
Inpatient days
Total inpatient days (see instructions)
Ratio of inpatient days to total inpatient days
Program direct GME amount
Reduction for direct GME payments for Medicare managed care
Net Program direct GME amount
DIRECT MEDICAL EDUCATION COSTS FOR ESRD COMPOSITE RATE - TITLE XVIII ONLY (NURSING SCHOOL AND
PARAMEDICAL EDUCATION COSTS)
Renal dialysis direct medical education costs (from Worksheet B, Part I, sum of columns 20 and 23, lines 74 and 94)
Renal dialysis and home dialysis total charges (Worksheet C, Part I, column 8, sum of lines 74 and 94)
Ratio of direct medical education costs to total charges (line 32 ÷ line 33)
Medicare outpatient ESRD charges (see instructions)
Medicare outpatient ESRD direct medical education costs (line 34 x line 35)

1
2
3
3.01
4
4.01
4.02
5
6
7

Total
3
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

32
33
34
35
36

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)

40-598

Rev. 3

10-12

FORM CMS-2552-10

DIRECT GRADUATE MEDICAL EDUCATION (GME)
PROVIDER CCN:
& ESRD OUTPATIENT DIRECT MEDICAL
EDUCATION COSTS
________________
Check
[ ] Title V
applicable
[ ] Title XVIII
box:
[ ] Title XIX
APPORTIONMENT OF MEDICARE REASONABLE COST OF GME
Part A Reasonable Cost
37 Reasonable cost (see instructions)
38 Organ acquisition costs (Worksheet D-4, Part III, column 1, line 69)
39 Cost of teaching physicians (Worksheet D-5, Part II, column 3, line 20)
40 Primary payer payments (see instructions)
41 Total Part A reasonable cost (sum of lines 37 through 39 minus line 40)
Part B Reasonable Cost
42 Reasonable cost (see instructions)
43 Primary payer payments (see instructions)
44 Total Part B reasonable cost (line 42 minus line 43)
45 Total reasonable cost (sum of lines 41 and 44)
46 Ratio of Part A reasonable cost to total reasonable cost (line 41 ÷ line 45)
47 Ratio of Part B reasonable cost to total reasonable cost (line 44 ÷ line 45)
ALLOCATION OF MEDICARE DIRECT GME COSTS BETWEEN PART A AND PART B
48 Total program GME payment (line 31)
49 Part A Medicare GME payment (line 46 x 48)(Title XVIII only) (see instructions)
50 Part B Medicare GME payment (line 47 x 48) (title XVIII only) (see instructions)

4090 (Cont.)
PERIOD:
WORKSHEET E-4
FROM ____________ (Cont.)
TO _______________

37
38
39
40
41
42
43
44
45
46
47
48
49
50

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4034)

Rev. 3

40-599

4090 (Cont.)

FORM CMS-2552-10

BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the General Fund column only)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

Assets
(Omit cents)
CURRENT ASSETS
Cash on hand and in banks
Temporary investments
Notes receivable
Accounts receivable
Other receivables
Allowances for uncollectible notes and
accounts receivable
Inventory
Prepaid expenses
Other current assets
Due from other funds
Total current assets (sum of lines 1-10)
FIXED ASSETS
Land
Land improvements
Accumulated depreciation
Buildings
Accumulated depreciation
Leasehold improvements
Accumulated depreciation
Fixed equipment
Accumulated depreciation
Automobiles and trucks
Accumulated depreciation
Major movable equipment
Accumulated depreciation
Minor equipment depreciable
Accumulated depreciation
HIT designated Assets
Accumulated depreciation
Minor equipment-nondepreciable
Total fixed assets (sum of lines 12-29)
OTHER ASSETS
Investments
Deposits on leases
Due from owners/officers
Other assets
Total other assets (sum of lines 31-34)
Total assets (sum of lines 11, 30, and 35)

PROVIDER CCN:

General
Fund
1

________________
Specific
Purpose
Fund
2

10-12
PERIOD:
WORKSHEET G
FROM ____________
TO _______________
Endowment
Fund
3

Plant
Fund
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

40-600

Rev. 3

10-12

FORM CMS-2552-10

BALANCE SHEET
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the General Fund column only)

37
38
39
40
41
42
43
44
45

Liabilities and Fund
Balances
(Omit cents)
CURRENT LIABILITIES
Accounts payable
Salaries, wages, and fees payable
Payroll taxes payable
Notes and loans payable (short term)
Deferred income
Accelerated payments
Due to other funds
Other current liabilities
Total current liabilities (sum of
lines 37 thru 44)

PROVIDER CCN:

General
Fund
1

________________
Specific
Purpose
Fund
2

4090 (Cont.)
PERIOD:
WORKSHEET G
FROM ____________ (CONT.)
TO _______________
Endowment
Fund
3

LONG TERM LIABILITIES
Mortgage payable
Notes payable
Unsecured loans
Other long term liabilities
Total long term liabilities (sum of
lines 46 thru 49)
51 Total liabilities (sum of lines 45 and 50)
46
47
48
49
50

CAPITAL ACCOUNTS
52 General fund balance
53 Specific purpose fund
54 Donor created - endowment fund
balance - restricted
55 Donor created - endowment fund
balance - unrestricted
56 Governing body created - endowment
fund balance
57 Plant fund balance - invested in plant
58 Plant fund balance - reserve for plant
improvement, replacement, and expansion
59 Total fund balances (sum of lines 52 thru 58)
60 Total liabilities and fund balances (sum of
lines 51 and 59)

Plant
Fund
4
37
38
39
40
41
42
43
44
45

46
47
48
49
50
51

52
53
54
55
56
57
58
59
60

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

Rev. 3

40-601

4090 (Cont.)

FORM CMS-2552-10

STATEMENT OF CHANGES IN FUND BALANCES

PROVIDER CCN:

GENERAL FUND
1
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

________________
SPECIFIC PURPOSE FUND
3
4

Fund balances at beginning of period
Net income (loss) (from Worksheet G-3, line 29)
Total (sum of line 1 and line 2)
Additions (credit adjustments) (specify)

Total additions (sum of lines 4-9)
Subtotal (line 3 plus line 10)
Deductions (debit adjustments) (specify)

Total deductions (sum of lines 12-17)
Fund balance at end of period per balance
sheet (line 11 minus line 18)

10-12
PERIOD:
FROM ____________
TO _______________
ENDOWMENT FUND
5
6

WORKSHEET G-1

PLANT FUND
7

8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4040)

40-602

Rev. 3

10-12

FORM CMS-2552-10

STATEMENT OF PATIENT REVENUES
AND OPERATING EXPENSES

PROVIDER CCN:
________________

4090 (Cont.)
PERIOD:
WORKSHEET G-2,
FROM ____________ PARTS I & II
TO _______________

PART I - PATIENT REVENUES

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

REVENUE CENTER
GENERAL INPATIENT ROUTINE CARE SERVICES
Hospital
Subprovider IPF
Subprovider IRF
Subprovider (Other)
Swing bed - SNF
Swing bed - NF
Skilled nursing facility
Nursing facility
Other long term care
Total general inpatient care services (sum of lines 1-9)
INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES
Intensive care unit
Coronary care unit
Burn intensive care unit
Surgical intensive care unit
Other special care (specify)
Total intensive care type inpatient hospital services (sum of
of lines 11-15)
Total inpatient routine care services (sum of lines 10 and 16)
Ancillary services
Outpatient services
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Home health agency
Ambulance
Outpatient rehabilitation providers
ASC
Hospice
Other (specify)
Total patient revenues (sum of lines 17-27) (transfer column 3 to
Worksheet G-3, line 1)

INPATIENT
1

OUTPATIENT
2

TOTAL
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

PART II - OPERATING EXPENSES
1
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

Operating expenses (per Wkst. A, column 3, line 200)
Add (specify)

Total additions (sum of lines 30-35)
Deduct (specify)

Total deductions (sum of lines 37-41)
Total operating expenses (sum of lines 29 and 36 minus line 42) (transfer to Worksheet G-3, line 4)

2
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

Rev. 3

40-603

4090 (Cont.)

FORM CMS-2552-10

STATEMENT OF REVENUES
AND EXPENSES

PROVIDER CCN:
________________

1
2
3
4
5

10-12
PERIOD:
WORKSHEET G-3
FROM ____________
TO _______________

Description
Total patient revenues (from Worksheet G-2, Part I, column 3, line 28)
Less contractual allowances and discounts on patients' accounts
Net patient revenues (line 1 minus line 2)
Less total operating expenses (from Worksheet G-2, Part II, line 43)
Net income from service to patients (line 3 minus line 4)

1
2
3
4
5

OTHER INCOME
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Contributions, donations, bequests, etc
Income from investments
Revenues from telephone and other miscellaneous communication services
Revenue from television and radio service
Purchase discounts
Rebates and refunds of expenses
Parking lot receipts
Revenue from laundry and linen service
Revenue from meals sold to employees and guests
Revenue from rental of living quarters
Revenue from sale of medical and surgical supplies to other than patients
Revenue from sale of drugs to other than patients
Revenue from sale of medical records and abstracts
Tuition (fees, sale of textbooks, uniforms, etc.)
Revenue from gifts, flowers, coffee shops, and canteen
Rental of vending machines
Rental of hospital space
Governmental appropriations
Other (specify)
Total other income (sum of lines 6-24)
Total (line 5 plus line 25)
Other expenses (specify)
Total other expenses (sum of line 27 and subscripts)
Net income (or loss) for the period (line 26 minus line 28)

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4040)

40-604

Rev. 3

10-12

FORM CMS-2552-10

ANALYSIS OF PROVIDER-BASED
HOME HEALTH AGENCY COSTS

SALARIES

EMPLOYEE
BENEFITS

1

2

COST CENTER DESCRIPTIONS
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

TRANSPORTATION
(see
instructions)
3

4090 (Cont.)

PROVIDER CCN: ______________
PERIOD:
WORKSHEET H
FROM ____________
HHA CCN: ____________
TO _______________
CONTRACTED/
RECLASSIFIED
NET
PURCHASED
TOTAL
TRIAL
EXPENSES FOR
SERVICES
(sum of cols.
RECLASSBALANCE
ALLOCATION
OTHER COSTS
1 thru 5)
IFICATIONS (col. 6 + col. 7) ADJUSTMENTS (col. 8 + col. 9)
4
5
6
7
8
9
10

GENERAL SERVICE COST CENTERS
Capital Related-Bldgs. and Fixtures
Capital Related-Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Administrative and General
HHA REIMBURSABLE SERVICES
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies (see instructions)
Drugs
DME
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Total (sum of lines 1-23)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

Column, 6 line 24 should agree with the Worksheet A, column 3, line 101, or subscript as applicable.

FORM CMS 2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-2, SECTION 4041)

Rev. 3

40-605

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - HHA GENERAL SERVICE COST

10-12

PROVIDER CCN: ______________
HHA CCN: ____________
NET EXPENSES
FOR COST
ALLOCATION
(from Wkst.
H, col. 10)
0

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

PERIOD:
FROM ____________
TO _______________

WORKSHEET H-1
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

PLANT
OPERATION &
MAINTENANCE
3

GENERAL SERVICE COST CENTERS
Capital Related-Bldgs. and Fixtures
Capital Related-Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Administrative and General
HHA REIMBURSABLE SERVICES
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies (see instructions)
Drugs
DME
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-23)

TRANSPORTATION
4

SUBTOTAL
(cols. 0-4)
4a

ADMINISTRATIVE
& GENERAL
5

TOTAL
(cols. 4a + 5)
6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)

40-606

Rev. 3

10-12
COST ALLOCATION - HHA STATISTICAL BASIS

FORM CMS-2552-10
PROVIDER CCN: ______________
HHA CCN: ____________
CAPITAL
RELATED COSTS
PLANT
BLDGS. &
MOVABLE
OPERATION &
FIXTURES
EQUIPMENT
MAINTENANCE
(SQUARE
(DOLLAR
(SQUARE
FEET)
VALUE)
FEET)
1
2
3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

GENERAL SERVICE COST CENTERS
Capital Related-Bldgs. and Fixtures
Capital Related-Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Administrative and General
HHA REIMBURSABLE SERVICES
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies (see instructions)
Drugs
DME
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Total (sum of lines 1-23)
Cost To Be Allocated (per Worksheet H-1, Part I)
Unit Cost Multiplier

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________

TRANSPORTATION
(MILEAGE)
4

WORKSHEET H-1,
PART II

RECONCILIATION
5a

ADMINISTRATIVE
& GENERAL
(ACCUM.
COST)
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4042)

Rev. 3

40-607

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

HHA COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

10-12

PROVIDER CCN: ______________

From
Wkst. H-1
Part I,
col. 6,
line
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

HHA
TRIAL
BALANCE
(1)
0

HHA CCN: ____________
CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

EMPLOYEE
BENEFITS
4

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-19) (2)
Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20
minus column 26, line 1, rounded to 6 decimal places.

SUBTOTAL
(cols. 0-4)
4A

PERIOD:
FROM ____________
TO _______________

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

WORKSHEET H-2,
PART I

OPERATION
OF PLANT
7

LAUNDRY
& LINEN
SERVICE
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

(1) Column 0, line 20 must agree with Wkst. A, column 7, line 101.
(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)

40-608

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

4090 (Cont.)

PROVIDER CCN: ______________
HHA CCN: ____________

HHA COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

HOUSE
KEEPING
9

DIETARY
10

MAINTENANCE OF
CAFETERIA PERSONNEL
11
12

NURSING
ADMINISTRATION
13

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-19) (2)
Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20
minus column 26, line 1, rounded to 6 decimal places.

PERIOD:
FROM ____________
TO _______________

CENTRAL
MEDICAL
SERVICES &
RECORDS &
SUPPLY
PHARMACY
LIBRARY
14
15
16

SOCIAL
SERVICE
17

WORKSHEET H-2,
PART I (CONT.)

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)

Rev. 3

40-609

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS

10-12

PROVIDER CCN: ______________
HHA CCN: ____________

HHA COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

NURSING
SCHOOL
20

INTERNS & RESIDENTS
SALARY AND
PROGRAM
FRINGES
COSTS
21
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-19) (2)
Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20
minus column 26, line 1, rounded to 6 decimal places.

SUBTOTAL
(sum of cols.
4a-23)
24

PERIOD:
FROM ____________
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
SUBTOTAL
ADJUSTMENTS
(cols. 23 ± 24)
25
26

WORKSHEET H-2,
PART I (CONT.)

ALLOCATED
HHA
A&G (see
Part II)
27

TOTAL
HHA COSTS
28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4043.1)

40-610

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS

HHA COST CENTER

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

4090 (Cont.)

PROVIDER CCN: ______________
HHA CCN: ____________
CAPITAL
RELATED COST
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2

EMPLOYEE
BENEFITS
(GROSS
SALARIES)
4

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-19)
Total cost to be allocated
Unit Cost Multiplier

RECONCILIATION
4A

PERIOD:
FROM ____________
TO _______________
ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

WORKSHEET H-2,
PART II

MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

OPERATION
OF PLANT
(SQUARE
FEET)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4043.2)

Rev. 3

40-611

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS

HHA COST CENTER

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

10-12
PROVIDER CCN: ______________ PERIOD:
FROM ____________
HHA CCN: ____________
TO _______________

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-19)
Total cost to be allocated
Unit Cost Multiplier

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PHARMACY
(COSTED
REQUIS.)
15

WORKSHEET H-2,
PART II (CONT.)

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4043.2)

40-612

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HHA COST CENTERS
STATISTICAL BASIS

HHA COST CENTER

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

PROVIDER CCN: ______________

SOCIAL
SERVICE
(TIME
SPENT)
17

OTHER
GENERAL
SERVICE
(SPECIFY)
18

HHA CCN: ____________
NONPHYSICIAN
ANESNURSING
THETISTS
SCHOOL
(ASSIGNED
(ASSIGNED
TIME)
TIME)
19
20

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Supplies
Drugs
DME
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Service
All Others
Totals (sum of lines 1-19)
Total cost to be allocated
Unit Cost Multiplier

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________
INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

WORKSHEET H-2,
PART II (CONT.)
PARAMEDICAL
EDUCATION
(SPECIFY)
(ASSIGNED
TIME)
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTION 4043.2)

Rev. 3

40-613

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF PATIENT SERVICE COSTS

10-12

PROVIDER CCN: ______________
HHA CCN: ____________

Check applicable box:

[ ] Title V

[ ] Title XVIII

PERIOD:
FROM ____________
TO _______________

WORKSHEET H-3,
Parts I & II

[ ] Title XIX

PART I - COMPUTATION OF THE AGGREGATE PROGRAM COST

Cost Per Visit Computation

1
2
3
4
5
6
7

From, Facility
Shared
Wkst.
Costs
Ancillary
Total
H-2,
(from
Costs
HHA
Patient Services
Part I, Wkst. H-2, (from
Costs
Total
col. 28, Part I)
Part II) (cols. 1 + 2) Visits
line
1
2
3
4
Skilled Nursing Care
2
Physical Therapy
3
Occupational Therapy
4
Speech Pathology
5
Medical Social Services 6
Home Health Aide
7
Total (sum of lines 1-6)

Program Visits
Average
Part B
Cost
Not
Per Visit
Subject to
Subject to
(col. 3
Deductibles
Deductibles
÷ col. 4) Part A & Coinsurance & Coinsurance
5
6
7
8

Part A
9

Cost of Services
Part B
Not
Total
Subject to
Subject to
Program Cost
Deductibles
Deductibles
(sum of
& Coinsurance & Coinsurance cols. 9-10)
10
11
12
1
2
3
4
5
6
7

Limitation Cost Computation

Patient Services

8
9
10
11
12
13
14

CBSA
No. (1)
1

Part A
2

Program Visits
Part B
Not Subject to
Subject to
Deductibles
Deductibles
& Coinsurance & Coinsurance
3
4

Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Home Health Aide
Total (sum of lines 8-13)

Supplies and Drugs Cost
Computations

Other Patient Services

15 Cost of Medical Supplies
16 Cost of Drugs

8
9
10
11
12
13
14

Facility
Shared
From
Costs
Ancillary Total
Total
Wkst. H-2 (from
Costs
HHA Charges Ratio
Part I, Wkst. H-2, (from
Costs (from HHA (col. 3
col. 28,
Part I)
Part II) (cols. 1 + 2)Record) ÷ col. 4)
line
1
2
3
4
5
8
9

Program Covered Charges
Part B
Not
Subject to
Subject to
Deductibles
Deductibles
Part A
& Coinsurance & Coinsurance
6
7
8

Part A
9

Cost of Services
Part B
Not
Subject to
Subject to
Deductibles
Deductibles
& Coinsurance & Coinsurance
10
11
15
16

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

1
2
3
4
5

Physical Therapy
Occupational Therapy
Speech Pathology
Cost of Medical Supplies
Cost of Drugs

From Wkst. C,
Part I, col. 9,
line
66
67
68
71
73

Cost
to Charge
Ratio
1

Total
HHA Charges HHA Shared
Transfer to
(from provider Ancillary Costs
Part I
records)
(col. 1 x col. 2) as Indicated
2
3
4
col. 2, line 2
col. 2, line 3
col. 2, line 4
col. 2, line 15
col. 2, line 16

1
2
3
4
5

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4044)

40-614

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF HHA REIMBURSEMENT
SETTLEMENT

Check applicable box:

[ ] Title V

4090 (Cont.)

PROVIDER CCN:
________________
HHA CCN:
________________
[ ] Title XVIII

PERIOD:
WORKSHEET H-4,
FROM ____________ Parts I & II
TO _______________
[ ] Title XIX

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

1
2
3
4

5
6
7
8
9

Description
Reasonable Cost of Part A & Part B Services
Reasonable cost of services (see instructions)
Total charges
Customary Charges
Amount actually collected from patients liable for payment
for services on a charge basis (from your records)
Amount that would have been realized from patients liable
for payment for services on a charge basis had such
payment been made in accordance with 42 CFR 413.13(b)
Ratio of line 3 to line 4 (not to exceed 1.000000)
Total customary charges (see instructions)
Excess of total customary charges over total reasonable
cost (complete only if line 6 exceeds line 1)
Excess of reasonable cost over customary charges
(complete only if line 1 exceeds line 6)
Primary payer amounts

Part A
1

Not Subject to
Deductibles
& Coinsurance
2

Subject to
Deductibles
& Coinsurance
3
1
2
3
4

5
6
7
8
9

PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

Description
Total reasonable cost (see instructions)
Total PPS Reimbursement - Full Episodes without Outliers
Total PPS Reimbursement - Full Episodes with Outliers
Total PPS Reimbursement - LUPA Episodes
Total PPS Reimbursement - PEP Episodes
Total PPS Outlier Reimbursement - Full Episodes with Outliers
Total PPS Outlier Reimbursement - PEP Episodes
Total Other Payments
DME Payments
Oxygen Payments
Prosthetic and Orthotic Payments
Part B deductibles billed to Medicare patients (exclude coinsurance)
Subtotal (sum of lines 10 thru 20 minus line 21)
Excess reasonable cost (from line 8)
Subtotal (line 22 minus line 23)
Coinsurance billed to program patients (from your records)
Net cost (line 24 minus line 25)
Reimbursable bad debts (from your records)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Total costs - current cost reporting period (line 26 plus line 27)
Other adjustments (see instructions) (specify)
Subtotal (line 29 plus/minus line 30)
Interim payments (see instructions)
Tentative settlement (for contractor use only)
Balance due provider/program (line 31 minus lines 32 and 33)
Protested amounts (nonallowable cost report items) in accordance with CMS
Pub. 15-II, section 115.2

Part A Services
1

Part B Services
2
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

FORM CMS-2552-12 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4045.1 - 4045.2)

Rev. 3

40-615

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO PROVIDERBASED HHAs FOR SERVICES
RENDERED TO PROGRAM BENEFICIARIES

10-12

PROVIDER CCN:
________________
HHA CCN:
________________

Description

PERIOD:
WORKSHEET H-5
FROM ____________
TO _______________

Part A
mm/dd/yyyy
1

Part B
Amount
2

mm/dd/yyyy
3

1 Total interim payments paid to provider
2 Interim payments payable on individual bills either submitted or
to be submitted to the intermediary for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
3 List separately each retroactive lump sum
.01
adjustment amount based on subsequent revision
.02
of the interim rate for the cost reporting period. Program .03
Also show date of each payment. If none, write
to
.04
"NONE" or enter a zero.(1)
Provider .05
.50
.51
Provider .52
to
.53
Program .54
Subtotal (sum of lines 3.01-3.49 minus sum
of lines 3.50-3.98)
.99
4 Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Wkst. H-4, Part II, column as appropriate, line 32)

Amount
4
1
2

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

TO BE COMPLETED BY INTERMEDIARY

8

5 List separately each tentative settlement payment Program .01
after desk review. Also show date of each
to
.02
payment. If none, write "NONE" or enter
Provider .03
a zero. (1)
Provider .50
to
.51
Program .52
Subtotal (sum of lines 5.01-5.49 minus sum
of lines 5.50-5.98)
.99
6 Determine net settlement amount (balance due) Program
based on the cost report (see instructions)
to
.01
Provider
Provider
to
.02
Program
7 TOTAL MEDICARE PROGRAM LIABILITY
(see instructions)
Name of Contractor
Contractor Number

5.01
5.02
5.03
5.50
5.51
5.52
5.99

6.01

6.02
7
NPR Date: Month, Day, Year

8

(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-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4046)

40-616

Rev. 3

10-12

FORM CMS-2552-10

ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS

Check applicable box:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

[ ] Renal Dialysis Department

Registered Nurses
Licensed Practical Nurses
Nurses Aides
Technicians
Social Workers
Dieticians
Physicians
Non-patient Care Salary
Subtotal (sum of lines 1-8)
Employee Benefits
Capital Related Costs-Bldgs. & Fixtures
Capital Related Costs-Mov. Equip.
Machine Costs & Repairs
Supplies
Drugs
Other
Subtotal (sum of lines 9-16)*
Capital Related Costs-Bldgs. & Fixtures
Capital Related Costs-Mov. Equip.
Employee Benefits
Administrative and General
Maint./Repairs-Operation-Housekeeping
Medical Education Program Costs
Central Services & Supplies
Pharmacy
Other Allocated Costs
Subtotal (sum of lines 17-26)*
Laboratory (see instructions)
Respiratory Therapy (see instructions)
Other (see instructions)
Total costs (sum of lines 27-30)

PROVIDER CCN:
________________
[ ] Home Program Dialysis
TOTAL
COSTS
BASIS
1
2
Hours of Service
Hours of Service
Hours of Service
Hours of Service
Hours of Service
Hours of Service
Accumulated Cost
Accumulated Cost

4090 (Cont.)
PERIOD:
WORKSHEET I-1
FROM ____________
TO _______________

STATISTICS
3

Salary
Square Feet
Percentage of Time
Percentage of Time
Requisitions
Requisitions
Accumulated Cost
Square Feet
Percentage of Time
Salary
Accumulated Cost
Square Feet
Requisitions
Requisitions
Accumulated Cost
Charges
Charges
Charges

FTEs per
2080 Hours
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

* Line 17, column 1 should agree with Worksheet A, column 7 for line 74 or line 94 as appropriate,
and line 27, column 1 should agree with Worksheet B, Part I, column 26 for line 74 or line 94 as appropriate.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4048)

Rev. 3

40-617

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF RENAL DEPARTMENT COSTS TO TREATMENT MODALITIES

10-12
PROVIDER CCN:
________________

Check applicable box:
OUTPATIENT SERVICES
COMPOSITE PAYMENT RATE

[ ] Renal Dialysis Department

[ ] Home Program Dialysis

CAPITAL AND
RELATED COSTS
BUILDING EQUIPMENT
1
2

DIRECT PATIENT
CARE SALARY
RNs
OTHER
3
4

EMPLOYEE
BENEFITS
5

1 Total Renal Department Costs
MAINTENANCE
2 Hemodialysis
3 Intermittent Peritoneal
TRAINING
4 Hemodialysis
5 Intermittent Peritoneal
6 CAPD
7 CCDP
HOME
8 Hemodialysis
9 Intermittent Peritoneal
10 CAPD
11 CCDP
OTHER BILLABLE SERVICES
12 Inpatient Dialysis
13 Method II Home Patient
14 EPO (included in Renal Department)
15 ARENESP (included in Renal Department)
16 Other
17 Total (sum of lines 2-16)
18 Medical Educational Program Costs
19 Total Renal Costs (line 17 + line 18)

DRUGS
6

MEDICAL
SUPPLIES
7

PERIOD:
FROM ____________
TO _______________

ROUTINE
ANCILLARY
SERVICES
8

SUBTOTAL
(sum of
cols. 1-8)
9

WORKSHEET I-2

OVERHEAD
10

TOTAL
(col. 9 +
col. 10)
11
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4049)

40-618

Rev. 3

10-12

FORM CMS-2552-10

DIRECT AND INDIRECT RENAL DIALYSIS COST ALLOCATION STATISTICAL BASIS

4090 (Cont.)
PROVIDER CCN:
________________

Check applicable box:

COMPOSITE PAYMENT SERVICES

[ ] Renal Dialysis Department
[ ] Home Program Dialysis
CAPITAL AND
RELATED COSTS
DIRECT PATIENT
BUILDING EQUIPMENT
CARE SALARY
(SQUARE
(% OF
RNs
OTHERS
FEET)
TIME)
(HOURS)
(HOURS)
1
2
3
4

1 Total Renal Department Costs
MAINTENANCE
2 Hemodialysis
3 Intermittent Peritoneal
TRAINING
4 Hemodialysis
5 Intermittent Peritoneal
6 CAPD
7 CCDP
HOME
8 Hemodialysis
9 Intermittent Peritoneal
10 CAPD
11 CCDP
OTHER BILLABLE SERVICES
12 Inpatient Dialysis Treatments __________
13 Method II Home Patient
14 EPO
15 ARENESP
16 Other
17 Total Statistical Basis
18 Unit Cost Multiplier (line 1 ÷ line 17)

EMPLOYEE
BENEFITS
(SALARY)
5

DRUGS
(REQUIST.)
6

PERIOD:
FROM ____________
TO _______________

MEDICAL
SUPPLIES
(REQUIST.)
7

ROUTINE
ANCILLARY
SERVICES
(CHARGES)
8

WORKSHEET I-3

SUBTOTAL
9

OVERHEAD
(ACCUM.
COST)
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4050)

Rev. 3

40-619

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF AVERAGE COST PER TREATMENT
FOR OUTPATIENT RENAL DIALYSIS

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________
Check applicable box:

[ ] Renal Dialysis Department

[ ] Home Program Dialysis

Number
of Total
Treatments
1
1
2
3
4
5
6
7
8

WORKSHEET I-4

Total Cost
(from Wkst.
I-2, col. 11)
2

Average Cost
of Program
Treatments
(col. 2 ÷ col. 1)
3

Number
of Program
Treatments
4

Maintenance - Hemodialysis
Maintenance - Peritoneal Dialysis
Training - Hemodialysis
Training - Peritoneal Dialysis
Training - Continuous Ambulatory Peritoneal Dialysis
Training - Continuous Cycling Peritoneal Dialysis
Home Program - Hemodialysis
Home Program - Peritoneal Dialysis

Total
Program
Expenses
(col. 4 x col. 3)
5

Total
Program
Payment
6

Average
Payment Rate
(col. 6 ÷ col. 4)
7
1
2
3
4
5
6
7
8

Patient Weeks
9 Home Program - Continuous Ambulatory Peritoneal Dialysis
10 Home Program - Continuous Cycling Peritoneal Dialysis
11 Totals (sum of lines 1-8, columns 1 and 4)
(sum of lines 1-10, columns 2, 5, and 7)

Patient Weeks
9
10
11

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4051)

40-620

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF REIMBURSABLE
BAD DEBTS - TITLE XVIII - PART B

PROVIDER CCN:
________________

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________

WORKSHEET I-5

Description
1
2
3
4
5
6
7
8
9
10

Total expenses related to care of program beneficiaries (see instructions)
Total payment (from Worksheet I-4, column 6, line 11)
Deductibles billed to Medicare (Part B) patients
Coinsurance billed to Medicare (Part B) patients
Bad debts for deductibles and coinsurance, net of bad debt recoveries

Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Net deductibles and coinsurance billed to Medicare (Part B) patients (sum of lines 3 and 4 less line 5)
Program payment (line 2 less line 3, times 80 percent)
Unrecovered from Medicare (Part B) patients (line 1 minus the sum of lines 8 and 9 )
(if negative, enter zero and do not complete line 11)
11 Reimbursable bad debts (lesser of line 10 or line 5) (transfer to Worksheet E, Part B, line 33)

1
2
3
4
5
6
7
8
9
10
11

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4052)

Rev. 3

40-621

4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

FORM CMS-2552-10
PROVIDER CCN: ______________

10-12
PERIOD:
FROM ____________
TO _______________

WORKSHEET J-1,
PART I

COMPONENT CCN: ____________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS
NET
EXPENSES
CAPITAL
COMPONENT COST CENTER
FOR COST
RELATED COSTS
ADMINISMAIN(omit cents)
ALLOCATION
BLDGS. &
MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE OPERATION
(see instru.)
FIXTURES EQUIPMENT BENEFITS
(cols. 0-4)
GENERAL & REPAIRS OF PLANT
0
1
2
4
4A
5
6
7
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychiatric/Psychological Services
9 Individual Therapy
10 Group Therapy
11 Individualized Activity Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved Patient Training & Education
15 Prosthetic and Orthotic Devices
16 Drugs and Biologicals
17 Medical Supplies
18 Medical Appliances
19 Durable Medical Equipment-Rented
20 Durable Medical Equipment-Sold
21 All Others
22 Totals (sum of lines 1-21)(1)
23 Unit Cost Multiplier (see instructions)

LAUNDRY
& LINEN
SERVICE
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

40-622

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

4090 (Cont.)

PROVIDER CCN: ______________

COMPONENT CCN: ____________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS

COMPONENT COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

HOUSEKEEPING
9

DIETARY
10

MAINTENANCE
OF
CAFETERIA PERSONNEL
11
12

NURSING
ADMINISTRATION
13

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Approved Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
All Others
Totals (sum of lines 1-21)(1)
Unit Cost Multiplier (see instructions)

CENTRAL
SERVICES
&
SUPPLY
14

PHARMACY
15

PERIOD:
FROM ____________
TO _______________

MEDICAL
RECORDS
&
LIBRARY
16

SOCIAL
SERVICE
17

WORKSHEET J-1,
PART I (CONT.)

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

Rev. 3

40-623

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

10-12

PROVIDER CCN: ______________

COMPONENT CCN: ____________
PART I - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS

COMPONENT COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

NURSING
SCHOOL
20

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
21
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Approved Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
All Others
Totals (sum of lines 1-21)(1)
Unit Cost Multiplier (see instructions)

SUBTOTAL
(sum of
cols. 4A-23)
24

PERIOD:
FROM ____________
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
ADJ.
25

SUBTOTAL
(sum of cols.
24 ± 25)
26

WORKSHEET J-1,
PART I (CONT.)

ALLOCATED
COMPONENT
A&G (see
Part II) (2)
27

TOTAL
(sum of cols.
26 ± 27)
28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

(1) Columns 0 through 26, line 22 must agree with the corresponding columns of Wkst. B, Part I, lines as appropriate. See instructions.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

40-624

Rev. 3

10-12
ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

FORM CMS-2552-10
PROVIDER CCN: ______________

COMPONENT CCN: ____________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
CAPITAL
RELATED COST
BLDGS &
MOVABLE EMPLOYEE
CMHC COST CENTER
FIXTURES EQUIPMENT BENEFITS
(omit cents)
(SQUARE
(SQUARE
(GROSS
RECONCILFEET)
FEET)
SALARIES)
IATION
0
1
2
4
4A
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychiatric/Psychological Services
9 Individual Therapy
10 Group Therapy
11 Individualized Activity Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved Patient Training & Education
15 Prosthetic and Orthotic Devices
16 Drugs and Biologicals
17 Medical Supplies
18 Medical Appliances
19 Durable Medical Equipment-Rented
20 Durable Medical Equipment-Sold
21 All Others
22 Totals (sum of lines 1-21)
23 Total Cost to be Allocated
24 Unit Cost Multiplier (see instructions)

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________

ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

WORKSHEET J-1,
PART II

MAINLAUNDRY
TENANCE & OPERATION
& LINEN
REPAIRS
OF PLANT
SERVICE
(SQUARE
(SQUARE (POUNDS OF
FEET)
FEET)
LAUNDRY)
6
7
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)

Rev. 3

40-625

4090 (Cont.)
ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

FORM CMS-2552-10
PROVIDER CCN: ______________

10-12
PERIOD:
FROM ____________
TO _______________

COMPONENT CCN: ____________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
MAINTENANCE
NURSING
CENTRAL
MEDICAL
HOUSEOF
ADMINIS- SERVICES &
RECORDS &
CORF COST CENTER
KEEPING
DIETARY
CAFETERIA PERSONNEL TRATION
SUPPLY
PHARMACY
LIBRARY
(omit cents)
(HOURS OF
(MEALS
(MEALS
(NUMBER
(DIRECT
(COSTED
(COSTED
(TIME
SERVICE)
SERVED)
SERVED)
HOUSED) NURS. HRS)* REQUIS.)
REQUIS.)
SPENT)
9
10
11
12
13
14
15
16
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychiatric/Psychological Services
9 Individual Therapy
10 Group Therapy
11 Individualized Activity Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved Patient Training & Education
15 Prosthetic and Orthotic Devices
16 Drugs and Biologicals
17 Medical Supplies
18 Medical Appliances
19 Durable Medical Equipment-Rented
20 Durable Medical Equipment-Sold
21 All Others
22 Totals (sum of lines 1-21)
23 Total Cost to be Allocated
24 Unit Cost Multiplier (see instructions)

SOCIAL
SERVICE
(TIME
SPENT)
17

WORKSHEET J-1,
PART II (CONT.)

OTHER
GENERAL
SERVICE
(SPECIFY)
18

NONPHYSICIAN
ANESTHETISTS
(ASSIGNED
TIME)
19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)

40-626

Rev. 2

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS

PROVIDER CCN: ______________

PERIOD:
FROM ____________
COMPONENT CCN: ____________
TO _______________
PART II - ALLOCATION OF GENERAL SERVICE COSTS TO COMMUNITY MENTAL HEALTH CENTER COST CENTERS - STATISTICAL BASIS
PARAINTERNS & RESIDENTS
MEDICAL
NURSING
SALARY &
PROGRAM
EDUCATION
CORF COST CENTER
SCHOOL
FRINGES
COSTS
(SPECIFY)
(omit cents)
(ASSIGNED
(ASSIGNED
(ASSIGNED
(ASSIGNED
TIME)
TIME)
TIME)
TIME)
20
21
22
23
24
25
1 Administrative and General
2 Skilled Nursing Care
3 Physical Therapy
4 Occupational Therapy
5 Speech Pathology
6 Medical Social Services
7 Respiratory Therapy
8 Psychiatric/Psychological Services
9 Individual Therapy
10 Group Therapy
11 Individualized Activity Therapies
12 Family Counseling
13 Diagnostic Services
14 Approved Patient Training & Education
15 Prosthetic and Orthotic Devices
16 Drugs and Biologicals
17 Medical Supplies
18 Medical Appliances
19 Durable Medical Equipment-Rented
20 Durable Medical Equipment-Sold
21 All Others
22 Totals (sum of lines 1-21)
23 Total Cost to be Allocated
24 Unit Cost Multiplier (see instructions)

4090 (Cont.)
WORKSHEET J-1,
PART II (CONT.)

26

27

28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.2)

Rev. 2

40-627

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

10-12

PROVIDER CCN: ______________

PERIOD:
FROM ____________
TO _______________

COMPONENT CCN: ____________

WORKSHEET J-2,
PART I

PART I - APPORTIONMENT OF CMHC COST CENTERS
(From
Wkst. J-1,
Part I,
col. 28)
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
(1)

Total
Component
Charges
2

Ratio of
Costs to
Charges
(col. 1 ÷ col. 2)
3

Title V
Component
Charges
4

Administrative and General
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Pathology
Medical Social Services
Respiratory Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapy
Family Counseling
Diagnostic Services
Approved Patient Training & Education
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
Medical Appliances
All Others (1)
Totals (sum of lines 1-19)

Title V
Component
Costs (col. 3
x col. 4)
5

Title XVIII
Component
Charges
6

Title XVIII
Component
Costs (col. 3
x col. 6)
7

Title XIX
Component
Charges
8

Title XIX
Component
Costs (col. 3
x col. 8)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Enter amount in column 1 from Worksheet J-1, Part I, column 28, line 21.

FORM CMS-2552-10(10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.1)

40-628

Rev. 3

10-12
COMPUTATION OF COMMUNITY MENTAL HEALTH CENTER PROVIDER COSTS

FORM CMS-2552-10

4090 (Cont.)

PROVIDER CCN: ______________
COMPONENT CCN: ____________

PART II - APPORTIONMENT OF COST OF CMHC PROVIDER SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS
(From
Wkst. J-1,
Total
Ratio of
Title V
Part I,
Component
Costs to
Component
col. 29)
Charges
Charges (1)
Charges (2)
1
2
3
4
21 Respiratory Therapy
22 Physical Therapy
23 Occupational Therapy
24 Speech Pathology
25 Medical Supplies Charged to Patients
26 Implantable Devices Charged to Patients
27 Drugs Charged to Patients
28 Total (sum of lines 21-28)
29 Total component costs. Add the amount from Part I, line 20
and the amounts from line 28, columns 5, 7, and 9. (3)

Title V
Component
costs (col. 3
x col. 4)
5

Title XVIII
Component
Charges (2)
6

PERIOD:
FROM ____________
TO _______________

Title XVIII
Component
costs (col. 3
x col. 6)
7

Title XIX
Component
Charges (2)
8

WORKSHEET J-2,
PART II

Title XIX
Component
costs (col. 3
x col. 8)
9
21
22
23
24
25
26
27
28
29

(1) From Worksheet C, Part I, column 9, lines as appropriate
(2) Charges for columns 4 and 8 are obtained from your records.
(3) Transfer the amounts on line 28, columns 5, 7, and 9, as appropriate, to Worksheet J-3, line 1.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4054.2)

Rev. 3

40-629

4090 (Cont.)

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT SETTLEMENT COMMUNITY
MENTAL HEALTH CENTER PROVIDER SERVICES

Check
applicable
boxes:

[ ] Title V

[ ] Title XVIII

PROVIDER CCN:
________________
COMPONENT CCN:
________________

10-12
PERIOD:
WORKSHEET J-3
FROM ____________
TO _______________

[ ] Title XIX
PROGRAM
COST

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Cost of component services (from Worksheet J-2, Part II, line 29)
PPS payments received excluding outliers
Outlier payments
Primary payer payments
Total reasonable cost (see instructions)
Total charges for program services
CUSTOMARY CHARGES
Aggregate amount actually collected from patients liable for services on a charge basis
Amount that would have been realized from patients liable for payment for services on a charge
basis had such payment been made in accordance with 42 CFR 413.13(e)
Ratio of line 7 to line 8 (not to exceed 1.000000) (see instructions)
Total customary charges (see instructions)
Excess of customary charges over reasonable cost (see instructions)
Excess of reasonable cost over customary charges (see instructions)
COMPUTATION OF REIMBURSEMENT SETTLEMENT
Total reasonable cost (from line 5)
Part B deductible billed to program patients
Net cost (line 13 minus line 14)
Excess of reasonable cost over customary charges (from line 12)
Subtotal (line 15 minus line 16)
80 percent of costs (80% of line 17) (see instructions)
Actual coinsurance billed to program patients (from provider records)
Net cost less actual billed coinsurance (line 17 minus line 19)
Reimbursable bad debts (from provider records) (see instructions)
Reimbursable bad debts for dual eligible beneficiaries (see instructions)
Net reimbursable amount (see instructions)
Other adjustments (see instructions) (specify)
Total cost (line 24 plus or minus line 25)
Interim payments (see instructions)
Tentative settlement (for contractor use only)
Balance due component/program (line 26 minus lines 27 and 28)
Protested amounts (nonallowable cost report items in accordance with CMS Pub. 15-II, section 115.2)

1
2
3
4
5
6
7
8
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4055)

40-630

Rev. 3

10-12

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO HOSPITAL-BASED COMMUNITY MENTAL HEALTH
CENTER FOR SERVICES RENDERED TO PROGRAM BENEFICIARIES

Check
applicable
boxes:

4090 (Cont.)

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET J-4
FROM ____________
TO _______________

[ ] Title XVIII
Part B
DESCRIPTION

1
2

3

4

Total interim payments paid to providers
Interim payments payable on individual bills, either
submitted or to be submitted to the intermediary, for
services rendered in the cost reporting periods. If
none, write "NONE", or enter zero.
List separately each retroactive
lump sum adjustment amount
based on subsequent revision of
the interim rate for the
cost reporting period. Also show
date of each payment.
If none, write "NONE",
or enter zero (1).

7
8

Subtotal (sum of lines 5.01-5.49 minus
sum of lines 5.50-5.98)
Determine net settlement amount
(balance due) based on the cost
report (see instructions). (1)

Total Medicare liability (see instructions)
Name of Contractor
Contractor Number

2
Amount
1
2

Program
to
Provider

Provider
to
Program

Subtotal (sum of lines 3.01-3.49
minus sum of lines 3.50-3.98)
Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Worksheet J-3, line 27)

TO BE COMPLETED BY INTERMEDIARY
5
List separately each tentative
settlement payment after desk review.
Also show date of each payment.
If none, write "NONE,"
or enter zero (1).

6

1
mm/dd/yyyy

Program
to
Provider
Provider
to
Program

Program
to
Provider
to
Program

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

.01
.02
.03
.50
.51
.52

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02

NPR Date (Month, Day, Year)

7
8

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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4053.1)

Rev. 3

40-631

4090 (Cont.)

FORM CMS-2552-10

ANALYSIS OF PROVIDER-BASED
HOSPICE COSTS

10-12

PROVIDER CCN: ______________

PERIOD:
FROM ____________
TO _______________

HOSPICE CCN: ________________

COST CENTER DESCRIPTIONS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

SALARIES
(from
Wkst. K-1)
1

EMPLOYEE
BENEFITS
(from
Wkst. K-2)
2

TRANSPORTATION
(see inst.)
3

CONTRACTED
SERVICES
(from
Wkst. K-3)
4

OTHER
5

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERVICE
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Total (sum of lines 1 thru 38)

TOTAL
(cols. 1-5)
6

RECLASSIFICATION
7

SUBTOTAL
(col. 6
± col. 7)
8

ADJUSTMENTS
9

WORKSHEET K

TOTAL
(col. 8
± col. 9)
10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4057)

40-632

Rev. 3

10-12

FORM CMS-2552-10

HOSICE COMPENSATION ANALYSIS
SALARIES AND WAGES

4090 (Cont.)

PROVIDER CCN: ______________

PERIOD:
FROM ____________
TO _______________

HOSPICE CCN: ________________
COST CENTER DESCRIPTIONS
(omit cents)

ADMINISTRATOR
1

DIRECTOR
2

MEDICAL
SOCIAL
WORKERS
3

SUPERVISORS
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker - Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 thru 38)
(1) Transfer the amount in column 9 to Wkst. K, column 1
1
2
3
4
5
6

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

WORKSHEET K-1

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4058)

Rev. 3

40-633

4090 (Cont.)

FORM CMS-2552-10

HOSPICE COMPENSATION ANALYSIS EMPLOYEE
BENEFITS (PAYROLL RELATED)

10-12

PROVIDER CCN: ______________

PERIOD:
FROM ____________
TO _______________

HOSPICE CCN: ________________
COST CENTER DESCRIPTIONS
(omit cents)

ADMINISTRATOR
1

DIRECTOR
2

MEDICAL
SOCIAL
WORKERS
3

SUPERVISORS
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker - Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 thru 38)
(1) Transfer the amount in column 9 to Wkst. K, column 2
1
2
3
4
5
6

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

WORKSHEET K-2

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4059)

40-634

Rev. 3

10-12

FORM CMS-2552-10

HOSPICE COMPENSATION ANALYSIS
CONTRACTED SERVICES/PURCHASED SERVICES

4090 (Cont.)

PROVIDER CCN: ______________

PERIOD:
FROM ____________
TO _______________

HOSPICE CCN: ________________
COST CENTER DESCRIPTIONS
(omit cents)

ADMINISTRATOR
1

DIRECTOR
2

MEDICAL
SOCIAL
WORKERS
3

SUPERVISORS
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
7 Inpatient - General Care
8 Inpatient - Respite Care
VISITING SERVICES
9 Physician Services
10 Nursing Care
11 Nursing Care-Continuous Home Care
12 Physical Therapy
13 Occupational Therapy
14 Speech/ Language Pathology
15 Medical Social Services
16 Spiritual Counseling
17 Dietary Counseling
18 Counseling - Other
19 Home Health Aide and Homemaker
20 HH Aide & Homemaker - Cont. Home Care
21 Other
OTHER HOSPICE SERVICE COSTS
22 Drugs, Biological and Infusion Therapy
23 Analgesics
24 Sedatives / Hypnotics
25 Other - Specify
26 Durable Medical Equipment/Oxygen
27 Patient Transportation
28 Imaging Services
29 Labs and Diagnostics
30 Medical Supplies
31 Outpatient Services (including E/R Dept.)
32 Radiation Therapy
33 Chemotherapy
34 Other
HOSPICE NONREIMBURSABLE SERVICE
35 Bereavement Program Costs
36 Volunteer Program Costs
37 Fundraising
38 Other Program Costs
39 Total (sum of lines 1 thru 38)
(1) Transfer the amount in column 9 to Wkst. K, column 4
1
2
3
4
5
6

NURSES
5

TOTAL
THERAPISTS
6

AIDES
7

ALL OTHER
8

WORKSHEET K-3

TOTAL (1)
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4060)

Rev. 3

40-635

4090 (Cont.)

FORM CMS-2552-10

COST ALLOCATION - HOSPICE GENERAL SERVICE COST

10-12

PROVIDER CCN: ______________

PERIOD:
FROM ____________
TO _______________

HOSPICE CCN: ________________

COST CENTER DESCRIPTIONS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

NET
EXPENSES
FOR COST
ALLOCATION
0

CAPITAL RELATED COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
1
2

PLANT
OPERATION
& MAINT.
3

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERVICE
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Total (sum of lines 1 thru 38)

TRANSPORTATION
4

VOLUNTEER
SERVICES
COORDINATOR
5

SUBTOTAL
(cols. 0 - 5)
5A

ADMINISTRATIVE &
GENERAL
6

WORKSHEET K-4,
PART I

TOTAL
(col. 5
± col. 6)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)

40-636

Rev. 3

10-12

FORM CMS-2552-10

COST ALLOCATION - HOSPICE STATISTICAL BASIS

COST CENTER DESCRIPTIONS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

PROVIDER CCN: ______________

CAPITAL RELATED COST
BUILDINGS
MOVABLE
& FIXTURES
EQUIPMENT
(SQ. FT.)
($ VALUE)
1
2

HOSPICE CCN: ________________
PLANT
OPERATION
TRANS& MAINT.
PORTATION
(SQ. FT.)
(MILEAGE)
3
4

GENERAL SERVICE COST CENTERS
Capital Related Costs-Bldg and Fixt.
Capital Related Costs-Movable Equip.
Plant Operation and Maintenance
Transportation - Staff
Volunteer Service Coordination
Administrative and General
INPATIENT CARE SERVICE
Inpatient - General Care
Inpatient - Respite Care
VISITING SERVICES
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
OTHER HOSPICE SERVICE COSTS
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
HOSPICE NONREIMBURSABLE SERVICE
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Cost To be Allocated (per Wkst. K-4, Part I)
Unit Cost Multiplier

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________
VOLUNTEER
SERVICES
COORDINATOR
RECONCIL(HOURS)
IATION
5
6A

WORKSHEET K-4,
PART II
ADMINISTRATIVE &
GENERAL
(ACC. COST)
6
1
2
3
5
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4061)

Rev. 3

40-637

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

10-12

PROVIDER CCN: ______________
HOSPICE CCN: ________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART I

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

HOSPICE COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Unit Cost Multiplier (see instructions)

From
Wkst. K-4
Part I,
col. 7,
line
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38

HOSPICE
TRIAL
BALANCE
(1)
0

CAPITAL
RELATED COSTS
BLDGS. &
MOVABLE
FIXTURES
EQUIPMENT
1
2

EMPLOYEE
BENEFITS
4

SUBTOTAL
(cols. 0-4 )
4A

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)

40-638

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

4090 (Cont.)

PROVIDER CCN: ______________
HOSPICE CCN: ________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART I (Cont.)

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

HOSPICE COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Unit Cost Multiplier (see instructions)

NURSING
ADMINISTRATION
13

CENTRAL
SERVICES &
SUPPLY
14

PHARMACY
15

MEDICAL
RECORDS &
LIBRARY
16

SOCIAL
SERVICE
17
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)

Rev. 3

40-639

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE
COSTS TO HOSPICE COST CENTERS

PROVIDER CCN: ______________
HOSPICE CCN: ________________

10-12
PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART I (Cont.)

PART I - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

HOSPICE COST CENTER
(omit cents)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

OTHER
GENERAL
SERVICE
`8

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
21
22

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Unit Cost Multiplier (see instructions)

INTERN &
PARARESIDENT
ALLOCATED
TOTAL
MEDICAL
COST & POST
HOSPICE
HOSPICE
EDUCATION SUBTOTAL STEPDOWN SUBTOTAL
A&G (see
COSTS
(cols. 4a-23 )
(cols. 24 ± 25 )
(cols. 26 ± 27 )
(SPECIFY)
ADJUST.
Part II)
23
24
25
26
27
28
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

(1) Column 0, line 34 must agree with Wkst. A, column 7, line 116.
(2) Columns 0 through 25, line 34 must agree with the corresponding columns of Wkst. B, Part I, line 116.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.1)

40-640

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS STATISTICAL BASIS

4090 (Cont.)

PROVIDER CCN: ______________
HOSPICE CCN: ________________

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS
CAPITAL
RELATED COST
BLDGS. &
MOVABLE
HOSPICE COST CENTER
FIXTURES
EQUIPMENT
(SQUARE
(DOLLAR
FEET)
VALUE)
1
2
1 Administrative and General
2 Inpatient - General Care
3 Inpatient - Respite Care
4 Physician Services
5 Nursing Care
6 Nursing Care-Continuous Home Care
7 Physical Therapy
8 Occupational Therapy
9 Speech/ Language Pathology
10 Medical Social Services
11 Spiritual Counseling
12 Dietary Counseling
13 Counseling - Other
14 Home Health Aide and Homemaker
15 HH Aide & Homemaker - Cont. Home Care
16 Other
17 Drugs, Biological and Infusion Therapy
18 Analgesics
19 Sedatives / Hypnotics
20 Other - Specify
21 Durable Medical Equipment/Oxygen
22 Patient Transportation
23 Imaging Services
24 Labs and Diagnostics
25 Medical Supplies
26 Outpatient Services (including E/R Dept.)
27 Radiation Therapy
28 Chemotherapy
29 Other
30 Bereavement Program Costs
31 Volunteer Program Costs
32 Fundraising
33 Other Program Costs
34 Totals (sum of lines 1-33) (2)
35 Total cost to be allocated
36 Unit Cost Multiplier (see instructions)

EMPLOYEE
BENEFITS
(GROSS
SALARIES)
4

RECONCILIATION
5A

PERIOD:
FROM ____________
TO _______________

ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
5

MAINTENANCE &
REPAIRS
(SQUARE
FEET)
6

WORKSHEET K-5,
PART II

OPERATION
OF PLANT
(SQUARE
FEET)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)

Rev. 3

40-641

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS STATISTICAL BASIS

10-12

PROVIDER CCN: ______________
HOSPICE CCN: ________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART II (Cont.)

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS

HOSPICE COST CENTER

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

LAUNDRY
& LINEN
SERVICE
(POUNDS OF
LAUNDRY)
8

HOUSEKEEPING
(HOURS OF
SERVICE)
9

DIETARY
(MEALS
SERVED)
10

CAFETERIA
(MEALS
SERVED)
11

MAINTENANCE OF
PERSONNEL
(NUMBER
HOUSED)
12

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Total cost to be allocated
Unit Cost Multiplier (see instructions)

NURSING
ADMINISTRATION
(DIRECT
NURS. HRS)
13

CENTRAL
SERVICES &
SUPPLY
(COSTED
REQUIS.)
14

PHARMACY
(COSTED
REQUIS.)
15

MEDICAL
RECORDS &
LIBRARY
(TIME
SPENT)
16
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)

40-642

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS STATISTICAL BASIS

4090 (Cont.)
PROVIDER CCN: ______________
HOSPICE CCN: ________________

PERIOD:
FROM ____________
TO _______________

WORKSHEET K-5,
PART II (Cont.)

PART II - ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS - STATISTICAL BASIS

HOSPICE COST CENTER

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

SOCIAL
SERVICE
(TIME
SPENT)
17

OTHER
GENERAL
SERVICE
(SPECIFY)
18

Administrative and General
Inpatient - General Care
Inpatient - Respite Care
Physician Services
Nursing Care
Nursing Care-Continuous Home Care
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Medical Social Services
Spiritual Counseling
Dietary Counseling
Counseling - Other
Home Health Aide and Homemaker
HH Aide & Homemaker - Cont. Home Care
Other
Drugs, Biological and Infusion Therapy
Analgesics
Sedatives / Hypnotics
Other - Specify
Durable Medical Equipment/Oxygen
Patient Transportation
Imaging Services
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Chemotherapy
Other
Bereavement Program Costs
Volunteer Program Costs
Fundraising
Other Program Costs
Totals (sum of lines 1-33) (2)
Total cost to be allocated
Unit Cost Multiplier (see instructions)

NONPHYSICIAN
ANESTHETISTS
(ASSIGNED
TIME)
19

NURSING
SCHOOL
(ASSIGNED
TIME)
20

INTERNS & RESIDENTS
SALARY &
PROGRAM
FRINGES
COSTS
(ASSIGNED
(ASSIGNED
TIME)
TIME)
21
22

PARAMEDICAL
EDUCATION
(SPECIFY)
(ASSIGNED
TIME)
23
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4062.2)

Rev. 3

40-643

4090 (Cont.)

FORM CMS-2552-10

APPORTIONMENT OF HOSPICE SHARED SERVICES

PROVIDER CCN: ______________

HOSPICE CCN: ________________
PART III - COMPUTATION OF TOTAL HOSPICE SHARED COSTS

COST CENTER

1
2
3
4
5
6
7
8
9
10
11

ANCILLARY SERVICE COST CENTERS
Physical Therapy
Occupational Therapy
Speech/ Language Pathology
Drugs, Biological and Infusion Therapy
Durable Medical Equipment/Oxygen
Labs and Diagnostics
Medical Supplies
Outpatient Services (including E/R Dept.)
Radiation Therapy
Other
Totals (sum of lines 1-10)

Wkst. C,
Part I,
col. 9,
line
0

10-12
PERIOD:
FROM ____________
TO _______________

Cost to
Charge
Ratio
1

WORKSHEET K-5,
PART III

Total
Hospice
Charges
(Provider
Records)
2

66
67
68
73
96
60
71
93
55
76

Hospice
Shared
Ancillary
Costs
(cols. 1 x 2)
3
1
2
3
4
5
6
7
8
9
10
11

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4062.3)

40-644

Rev. 3

10-12
CALCULATION OF HOSPICE PER DIEM COST

FORM CMS-2552-10
PROVIDER CCN: ______________
HOSPICE CCN: ________________

COMPUTATION OF PER DIEM COST
1
2
3
4
5
6
7
8
9
10
11
12
13

TITLE XVIII
1

4090 (Cont.)
PERIOD:
FROM ____________
TO _______________

TITLE XIX
2

WORKSHEET K-6

OTHER
3

Total cost (see instructions)
Total unduplicated days (Worksheet S-9, column 6, line 5)
Average cost per diem (line 1 divided by line 2)
Unduplicated Medicare days (Worksheet S-9, column 1, line 5)
Aggregate Medicare cost (line 3 times line 4)
Unduplicated Medicaid days (Worksheet S-9, column 2, line 5)
Aggregate Medicaid cost (line 3 times line 6)
Unduplicated SNF days (Worksheet S-9, column 3, line 5)
Aggregate SNF cost (line 3 times line 8)
Unduplicated NF days (Worksheet S-9, column 4, line 5)
Aggregate NF cost (line 3 times line 10)
Other Unduplicated days (Worksheet S-9, column 5, line 5)
Aggregate cost for other days (line 3 times line 12)

TOTAL
4
1
2
3
4
5
6
7
8
9
10
11
12
13

Note: The data for the SNF and NF on lines 8 through 11 are included in the Medicare and Medicaid lines 4 through 7.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4063)

Rev. 3

40-645

4090 (Cont.)
CALCULATION OF CAPITAL PAYMENT

FORM CMS-2552-10
PROVIDER CCN:
________________
COMPONENT CCN:
________________

10-12
PERIOD:
FROM ____________
TO _______________

WORKSHEET L

[ ] Title V
[ ] Hospital
[ ] PPS
[ ] Title XVIII, Part A
[ ] Subprovider (other)
[ ] Cost Method
boxes:
[ ] Title XIX
PART I - FULLY PROSPECTIVE METHOD
CAPITAL FEDERAL AMOUNT
1 Capital DRG other than outlier
2 Capital DRG outlier payments
3 Total inpatient days divided by number of days in the cost reporting period (see instructions)
4 Number of interns & residents (see instructions)
5 Indirect medical education percentage (see instructions)
6 Indirect medical education adjustment (line 1 times line 5)
7 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, Part A line 30) (see instructions)
8 Percentage of Medicaid patient days to total days (see instructions)
9 Sum of lines 7 and 8
10 Allowable disproportionate share percentage (see instructions)
11 Disproportionate share adjustment (line 10 times lines 1 )
12 Total prospective capital payments (sum of lines 1-2, 6 and 11)
PART II - PAYMENT UNDER REASONABLE COST
1 Program inpatient routine capital cost (see instructions)
2 Program inpatient ancillary capital cost (see instructions)
3 Total inpatient program capital cost (line 1 plus line 2)
4 Capital cost payment factor (see instructions)
5 Total inpatient program capital cost (line 3 x line 4)
PART III - COMPUTATION OF EXCEPTION PAYMENTS
1 Program inpatient capital costs (see instructions)
2 Program inpatient capital costs for extraordinary circumstances (see instructions)
3 Net program inpatient capital costs (line 1 minus line 2)
4 Applicable exception percentage (see instructions)
5 Capital cost for comparison to payments (line 3 x line 4)
6 Percentage adjustment for extraordinary circumstances (see instructions)
7 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6)
8 Capital minimum payment level (line 5 plus line 7)
9 Current year capital payments (from Part I, line 12 as applicable)
10 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9)
11 Carryover of accumulated capital minimum payment level over capital payment
(from prior year Worksheet L, Part III, line 14)
12 Net comparison of capital minimum payment level to capital payments (line 10 plus line 11)
13 Current year exception payment (if line 12 is positive, enter the amount on this line)
14 Carryover of accumulated capital minimum payment level over capital payment
for the following period (if line 12 is negative, enter the amount on this line)
15 Current year allowable operating and capital payment (see instructions)
16 Current year operating and capital costs (see instructions)
17 Current year exception offset amount (see instructions)
Check

applicable

1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4064.1 - 4064.3)

40-646

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

Cost Center Descriptions

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

EXTRAORDINARY
CAPITAL
RELATED
COSTS
0

WORKSHEET L-1,
PART I

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

SUBTOTAL
(sum of
cols. 0-2)
2A

EMPLOYEE
BENEFITS
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
0
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 3

40-647

4690 (Cont.)

FORM CMS-2552-10

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

10-12
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

Cost Center Descriptions

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

EXTRAORDINARY
CAPITAL
RELATED
COSTS
0

WORKSHEET L-1,
PART I (Cont.)

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)

SUBTOTAL
(sum of
cols. 0-2)
2A

EMPLOYEE
BENEFITS
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
0
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-650

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

4090 (Cont.)
PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________

Cost Center Descriptions

EXTRAORDINARY
CAPITAL
RELATED
COSTS
0

WORKSHEET L-1,
PART I (Cont.)

CAPITAL
RELATED COSTS
BLDGS. &
FIXTURES
1

MOVABLE
EQUIPMENT
2

SUBTOTAL
(sum of
cols. 0-4)
2A

EMPLOYEE
BENEFITS
4

ADMINISTRATIVE &
GENERAL
5

MAINTENANCE &
REPAIRS
6

OPERATION
OF PLANT
7

105
106
107
108
109
110
111
112
115
116
117
118

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)

94
95
96
97
98
99
100
101
0
105
106
107
108
109
110
111
112
115
116
117
118

190
191
192
193
194
200
201
202
203
204

NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
Total (sum of line 118 and lines190-201)
Total Statistical Basis
Unit Cost Multiplier

0
190
191
192
193
194
200
201
202
203
204

94
95
96
97
98
99
100
101

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 3

40-653

4090 (Cont.)

FORM CMS-2552-10

10-12

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
0
30
31
32
33
34
35
40
41
42
43
44
45
46

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

NURSING
ADMINISTRATION
13

PERIOD:
FROM ____________
TO _______________

CENTRAL
MEDICAL
SERVICES &
RECORDS &
SUPPLY
PHARMACY
LIBRARY
14
15
16

WORKSHEET L-1,
PART I (Cont.)

SOCIAL
SERVICE
17
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-648

Rev. 3

10-12

FORM CMS-2552-10

4090 (Cont.)

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
0
88
89
90
91
92
93

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)

NURSING
ADMINISTRATION
13

PERIOD:
FROM ____________
TO _______________

CENTRAL
MEDICAL
SERVICES &
RECORDS &
SUPPLY
PHARMACY
LIBRARY
14
15
16

WORKSHEET L-1,
PART I (Cont.)

SOCIAL
SERVICE
17
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 3

40-651

4090 (Cont.)

FORM CMS-2552-10

10-12

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

PROVIDER CCN:
________________

Cost Center Descriptions

94
95
96
97
98
99
100
101
0
105
106
107
108
109
110
111
112
115
116
117
118

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)

0
190
191
192
193
194
200
201
202
203
204

NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
Total (sum of line 118 and lines190-201)
Total Statistical Basis
Unit Cost Multiplier

LAUNDRY
& LINEN
SERVICE
8

HOUSEKEEPING
9

DIETARY
10

CAFETERIA
11

MAINTENANCE OF
PERSONNEL
12

NURSING
ADMINISTRATION
13

PERIOD:
FROM ____________
TO _______________

CENTRAL
MEDICAL
SERVICES &
RECORDS &
SUPPLY
PHARMACY
LIBRARY
14
15
16

WORKSHEET L-1,
PART I (Cont.)

SOCIAL
SERVICE
17
94
95
96
97
98
99
100
101
105
106
107
108
109
110
111
112
115
116
117
118

190
191
192
193
194
200
201
202
203
204

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-654

Rev. 3

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

10-12
PROVIDER CCN:
________________

Cost Center Descriptions

1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
30
31
32
33
34
35
40
41
42
43
44
45
46

OTHER
GENERAL
SERVICE
18

NONPHYSICIAN
ANESTHETISTS
19

NURSING
SCHOOL
20

INTERNS &
RESIDENTS
SALARY &
FRINGES
21

GENERAL SERVICE COST CENTERS
Capital Related Costs-Buildings and Fixtures
Capital Related Costs-Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records & Medical Records Library
Social Service
Other General Service (specify)
Nonphysician Anesthetists
Nursing School
Intern & Res. Service-Salary & Fringes (Approved)
Intern & Res. Other Program Costs (Approved)
Paramedical Ed. Program (specify)
INPATIENT ROUTINE SERVICE COST CENTERS
Adults and Pediatrics (General Routine Care)
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Other Special Care Unit (specify)
Subprovider IPF
Subprovider IRF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care

INTERNS &
RESIDENTS
PROGRAM
COSTS
22

PARAMEDICAL
EDUCATION
(SPECIFY)
23

PERIOD:
WORKSHEET L-1,
FROM ____________
PART I (Cont.)
TO _______________
INTERN &
RESIDENT
COST & POST
STEPDOWN
SUBTOTAL
ADJUSTMENTS
TOTAL
24
25
26
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
0
30
31
32
33
34
35
40
41
42
43
44
45
46

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 3

40-649

4690 (Cont.)

FORM CMS-2552-10

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

Cost Center Descriptions

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
88
89
90
91
92
93

10-12
PROVIDER CCN:

OTHER
GENERAL NONPHYSICIAN
SERVICE ANESTHETISTS
18
19

NURSING
SCHOOL
20

PERIOD:
WORKSHEET L-1,
FROM ____________
PART I (Cont.)
________________
TO _______________
INTERN &
INTERNS &
INTERNS &
RESIDENT
RESIDENTS
RESIDENTS PARAMEDICAL
COST & POST
SALARY AND
PROGRAM
EDUCATION
STEPDOWN
FRINGES
COSTS
(SPECIFY)
SUBTOTAL
ADJUSTMENTS
TOTAL
21
22
23
24
25
26

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)
OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)

50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
0
88
89
90
91
92
93

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

40-652

Rev. 3

10-12

FORM CMS-2552-10

ALLOCATION OF ALLOWABLE COSTS FOR
EXTRAORDINARY CIRCUMSTANCES

Cost Center Descriptions

4090 (Cont.)
PROVIDER CCN:

OTHER
GENERAL NONPHYSICIAN
SERVICE ANESTHETISTS
18
19

NURSING
SCHOOL
20

PERIOD:
WORKSHEET L-1,
FROM ____________
PART I (Cont.)
________________
TO _______________
INTERN &
INTERNS &
INTERNS &
RESIDENT
RESIDENTS
RESIDENTS PARAMEDICAL
COST & POST
SALARY AND
PROGRAM
EDUCATION
STEPDOWN
FRINGES
COSTS
(SPECIFY)
SUBTOTAL
ADJUSTMENTS
TOTAL
21
22
23
24
25
26

105
106
107
108
109
110
111
112
115
116
117
118

OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Outpatient Rehabilitation Provider (specify)
Intern-Resident Service (not appvd. tchng. prgm.)
Home Health Agency
SPECIAL PURPOSE COST CENTERS
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Other Organ Acquisition (specify)
Ambulatory Surgical Center (Distinct Part)
Hospice
Other Special Purpose (specify)
SUBTOTALS (sum of lines 1-117)

94
95
96
97
98
99
100
101
0
105
106
107
108
109
110
111
112
115
116
117
118

190
191
192
193
194
200
201
202
203
204

NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Other Nonreimbursable (specify)
Cross Foot Adjustments
Negative Cost Centers
Total (sum of line 118 and lines190-201)
Total Statistical Basis
Unit Cost Multiplier

0
190
191
192
193
194
200
201
202
203
204

94
95
96
97
98
99
100
101

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.1)

Rev. 3

40-655

4090 (Cont.)

FORM CMS-2552-10

COMPUTATION OF PROGRAM INPATIENT ROUTINE SERVICE
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

10-12

PROVIDER CCN:

PERIOD:
FROM ____________
TO _______________

________________
Check
applicable
box:

WORKSHEET L-1,
PART II

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX

Cost Center Description
(A)

Capital Cost
for Extraordinary
Circumstances
(from Wkst. L-1,
Part I, col. 26)
1

Swing Bed
Adjustment
2

Reduced
Capital Cost
for Extraordinary
Circumstances
(col. 1 - col. 2)
3

Total
Patient Days
4

Per Diem
(col. 3 ÷ col. 4)
5

Inpatient
Program Days
6

Inpatient Program
Capital Cost
(col. 5 x col. 6)
7

INPATIENT ROUTINE SERVICE
COST CENTERS
30 Adults & Pediatrics (General Routine Care)

30

31 Intensive Care Unit

31

32 Coronary Care Unit

32

33 Burn Intensive Care Unit

33

34 Surgical Intensive Care Unit

34

35 Other Special Care Unit (specify)

35

40 Subprovider IPF

40

41 Subprovider IRF

41

42 Subprovider (Other)

42

43 Nursery

43

200 Total (sum of lines 30-199)

200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4065.2)

40-656

Rev. 3

10-12

FORM CMS-2552-10

4090 (Cont.)

COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

Check
applicable

[ ] Hospital
[ ] Subprovider

boxes:

Cost Center Description
(A)
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET L-1,
FROM ____________ PART III
TO _______________

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX
Capital Cost for
Extraordinary
Circumstances
(from Wkst. L-1,
Part I, col. 26)
1

ANCILLARY SERVICE COST CENTERS
Operating Room
Recovery Room
Labor Room and Delivery Room
Anesthesiology
Radiology-Diagnostic
Radiology-Therapeutic
Radioisotope
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catherization
Laboratory
PBP Clinical Laboratory Service-Program Only
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Implantable Devices Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
Other Ancillary (specify)

Total Charges
(from Wkst. C,
Part I, col. 6)
2

Ratio of Cost
to Charges
(col. 1 ÷ col. 2)
3

Inpatient
Program Charges
4

Program
Extraordinary
Capital Cost
(col. 3 x col. 4)
5
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)

Rev. 3

40-657

4090 (Cont.)

FORM CMS-2552-10

10-12

COMPUTATION OF PROGRAM INPATIENT ANCILLARY SERVICE
CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES

Check
applicable

[ ] Hospital
[ ] Subprovider

boxes:

Cost Center Description
(A)
88
89
90
91
92
93
94
95
96
97
98
200

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET L-1,
FROM ____________ PART III (CONT.)
TO _______________

[ ] Title V
[ ] Title XVIII, Part A
[ ] Title XIX
Capital Cost for
Extraordinary
Circumstances
(from Wkst. L-1,
Part I, col. 26)
1

OUTPATIENT SERVICE COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds
Other Outpatient (specify)
OTHER REIMBURSABLE COST CENTERS
Home Program Dialysis
Ambulance Services
Durable Medical Equipment-Rented
Durable Medical Equipment-Sold
Other Reimbursable (specify)
Total (sum of lines 50 through 199)

Total Charges
(from Wkst. C,
Part I, col. 6)
2

Ratio of Cost
to Charges
(col. 1 ÷ col. 2)
3

Inpatient
Program Charges
4

Program
Extraordinary
Capital Cost
(col. 3 x col. 4)
5
88
89
90
91
92
93
94
95
96
97
98
200

(A) Worksheet A line numbers

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4065.3)

40-658

Rev. 3

10-12

FORM CMS-2552-10

4090 (Cont.)

ANALYSIS OF PROVIDER-BASED RURAL HEALTH CLINIC/
FEDERALLY QUALIFIED HEALTH CENTER COSTS

Check applicable box:

[ ] RHC

PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET M-1
FROM ____________
TO _______________

[ ] FQHC

COMPENSATION
1

OTHER COSTS
2

TOTAL
(col. 1 + col. 2)
3

RECLASSIFICATIONS
4

FACILITY HEALTH CARE STAFF COSTS
Physician
Physician Assistant
Nurse Practitioner
Visiting Nurse
Other Nurse
Clinical Psychologist
Clinical Social Worker
Laboratory Technician
Other Facility Health Care Staff Costs
Subtotal (sum of lines 1-9)
COSTS UNDER AGREEMENT
11 Physician Services Under Agreement
12 Physician Supervision Under Agreement
13 Other Costs Under Agreement
14 Subtotal (sum of lines 11-13)
OTHER HEALTH CARE COSTS
15 Medical Supplies
16 Transportation (Health Care Staff)
17 Depreciation-Medical Equipment
18 Professional Liability Insurance
19 Other Health Care Costs
20 Allowable GME Costs
21 Subtotal (sum of lines 15-20)
22 Total Cost of Health Care Services
(sum of lines 10, 14, and 21)
COSTS OTHER THAN RHC/FQHC SERVICES
23 Pharmacy
24 Dental
25 Optometry
26 All other nonreimbursable costs
27 Nonallowable GME costs
28 Total Nonreimbursable Costs (sum of lines 23-27)
FACILITY OVERHEAD
29 Facility Costs
30 Administrative Costs
31 Total Facility Overhead (sum of lines 29 and 30)
32 Total facility costs (sum of lines 22, 28 and 31)
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.
1
2
3
4
5
6
7
8
9
10

RECLASSIFIED
TRIAL
BALANCE
(col. 3 + col. 4)
5

ADJUSTMENTS
6

NET EXPENSES
FOR
ALLOCATION
(col. 5 + col. 6)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

23
24
25
26
27
28
29
30
31
32

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4066)

Rev. 3

40-659

4090 (Cont.)

FORM CMS-2552-10

ALLOCATION OF OVERHEAD
TO RHC/FQHC SERVICES

Check applicable box:
VISITS AND PRODUCTIVITY

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] RHC
Number
of FTE
Personnel
1

[ ] FQHC

Total
Visits
2

Positions
1 Physicians
2 Physician Assistants
3 Nurse Practitioners
4 Subtotal (sum of lines 1-3)
5 Visiting Nurse
6 Clinical Psychologist
7 Clinical Social Worker
7.01 Medical Nutrition Therapist (FQHC only)
7.02 Diabetes Self Management Training (FQHC only)
8 Total FTEs and Visits (sum of lines 4-7)
9 Physician Services Under Agreements
DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES
10 Total costs of health care services (from Worksheet M-1, column 7, line 22)
11 Total nonreimbursable costs (from Worksheet M-1, column 7, line 28)
12 Cost of all services (excluding overhead) (sum of lines 10 and 11)
13 Ratio of RHC/FQHC services (line 10 divided by line 12)
14 Total facility overhead (from Worksheet M-1, column 7, line 31)
15 Parent provider overhead allocated to facility (see instructions)
16 Total overhead (sum of lines 14 and 15)
17 Allowable Direct GME overhead (see instructions)
18 Subtract line 17 from line 16
19 Overhead applicable to RHC/FQHC services (line 13 x line 18)
20 Total allowable cost of RHC/FQHC services (sum of lines 10 and 19)
(1)

10-12
PERIOD:
WORKSHEET M-2
FROM ____________
TO _______________

Productivity
Standard (1)
3

Minimum
Visits (col. 1
x col. 3)
4

Greater of
col. 2 or
col. 4
5
1
2
3
4
5
6
7
7.01
7.02
8
9
10
11
12
13
14
15
16
17
18
19
20

The productivity standard for physicians is 4,200 and 2,100 for physician assistants and nurse practitioners. If an exception
to the standard has been granted (Worksheet S-8, line 12 equals "Y"), column 3, lines 1thru 3 of this worksheet should contain,
at a minimum, one element that is different than the standard.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4067)

40-660

Rev. 3

10-12

FORM CMS-2552-10

CALCULATION OF REIMBURSEMENT
SETTLEMENT FOR RHC/FQHC SERVICES

Check
[ ] RHC
[ ] Title V
applicable boxes:
[ ] FQHC
[ ] Title XVIII
DETERMINATION OF RATE FOR RHC/FQHC SERVICES
1 Total allowable cost of RHC/FQHC services (from Worksheet M-2, line 20)
2 Cost of vaccines and their administration (from Worksheet M-4, line 15)
3 Total allowable cost excluding vaccine (line 1 minus line 2)
4 Total visits (from Worksheet M-2, column 5, line 8)
5 Physicians visits under agreement (from Worksheet M-2, column 5, line 9)
6 Total adjusted visits (line 4 plus line 5)
7 Adjusted cost per visit (line 3 divided by line 6)

4090(Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Title XIX

PERIOD:
WORKSHEET M-3
FROM ____________
TO _______________

1
2
3
4
5
6
7
Calculation of Limit (1)
Prior to
On or after
January 1
January 1
1
2

8 Per visit payment limit (from CMS Pub. 27, Sec. 505 or your contractor)
9 Rate for Program covered visits (see instructions)
CALCULATION OF SETTLEMENT
10 Program covered visits excluding mental health services (from contractor records)
11 Program cost excluding costs for mental health services (line 9 x line 10)
12 Program covered visits for mental health services (from contractor records)
13 Program covered cost from mental health services (line 9 x line 12)
14 Limit adjustment for mental health services (see instructions)
15 Graduate Medical Education pass-through cost (see instructions)
16 Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3)
16.01 Total program charges (see instructions)(from contractor's records)
16.02 Total program preventive charges (see instructions)(from provider's records)
16.03 Total program preventive costs (see instructions)
16.04 Total program non-preventive costs (see instructions)
16.05 Total program cost (see instructions)
17 Primary payer amounts
18 Less: Beneficiary deductible for RHC only (see instructions) (from contractor records)
19 Less: Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor records)
20 Net Medicare cost excluding vaccines (see instructions)
21 Program cost of vaccines and their administration (from Worksheet M-4, line 16)
22 Total reimbursable Program cost (line 20 plus line 21)
23 Reimbursable bad debts (see instructions)
24 Reimbursable bad debts for dual eligible beneficiaries (see instructions)
25 Other adjustments (specify) (see instructions)
26 Net reimbursable amount (lines 22 plus 23 plus or minus line 25)
27 Interim payments
28 Tentative settlement (for contractor use only)
29 Balance due component/program (line 26 minus lines 27 and 28)
30 Protested amounts (nonallowable cost report items) in accordance with CMS
Pub. 15-2 , chapter 1 , section 115.2

8
9
10
11
12
13
14
15
16
16.01
16.02
16.03
16.04
16.05
17
18
19
20
21
22
23
24
25
26
27
28
29
30

(1) Lines 8 through 14: Fiscal year providers use columns 1 & 2, calendar year providers use column 2 only.

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2 , SECTIONS 4068)

Rev. 3

40-661

4090(Cont.)

FORM CMS-2552-10

COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA
VACCINE COST

Check
applicable boxes:

[ ] RHC
[ ] FQHC

[ ] Title V
[ ] Title XVIII

PROVIDER CCN:
________________
COMPONENT CCN:
________________
[ ] Title XIX

10-12
PERIOD:
WORKSHEET M-4
FROM ____________
TO _______________

PNEUMOCOCCAL
1
1 Health care staff cost (from Worksheet M-1, column 7, line 10)
2 Ratio of pneumococcal and influenza vaccine staff time to total
health care staff time
3 Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2)
4 Medical supplies cost - pneumococcal and influenza vaccine
(from your records)
5 Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4)
6 Total direct cost of the facility (from Worksheet M-1, column 7, line 22)
7 Total overhead (from Worksheet M-2, line 16)
8 Ratio of pneumococcal and influenza vaccine direct cost to total direct
cost (line 5 divided by line 6)
9 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8)
10 Total pneumococcal and influenza vaccine costs and their
administration costs (sum of lines 5 and 9)
11 Total number of pneumococcal and influenza vaccine injections
(from your records)
12 Cost per pneumococcal and influenza vaccine injection (line 10/line 11)
13 Number of pneumococcal and influenza vaccine injections administered
to Program beneficiaries
14 Program cost of pneumococcal and influenza vaccines and their
administration costs (line 12 x line 13)
15 Total cost of pneumococcal and influenza vaccines and their administration costs (sum of columns
1 and 2, line 10) (transfer this amount to Worksheet M-3, line 2)
16 Total Program cost of pneumococcal and influenza vaccines and their administration costs (sum
of columns 1 and 2, line 14) (transfer this amount to Worksheet M-3, line 21)

INFLUENZA
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

FORM CMS 2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4069)

40-662

Rev. 3

10-12

FORM CMS-2552-10

ANALYSIS OF PAYMENTS TO HOSPITAL-BASED
RHC/FQHC PROVIDER FOR SERVICES RENDERED
TO PROGRAM BENEFICIARIES
Check applicable box:

[ ] RHC

4090 (Cont.)
PROVIDER CCN:
________________
COMPONENT CCN:
________________

PERIOD:
WORKSHEET M-5
FROM ____________
TO _______________

[ ] FQHC
Part B

DESCRIPTION
1 Total interim payments paid to providers
2 Interim payments payable on individual bills, either
submitted or to be submitted to the intermediary, for
services rendered in the cost reporting periods. If
none, write "NONE", or enter zero.
3 List separately each retroactive
lump sum adjustment amount
based on subsequent revision of
the interim rate for the
cost reporting period. Also show
date of each payment.
If none, write "NONE",
or enter zero (1).

1
mm/dd/yyyy

1
2

Program
to
Provider

Provider
to
Program

Subtotal (sum of lines 3.01-3.49 minus sum of lines 3.50-3.98)
4 Total interim payments (sum of lines 1, 2, and 3.99)
(transfer to Worksheet M-3, line 27)
TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative
settlement payment after desk review.
Also show date of each payment.
If none, write "NONE,"
or enter zero (1).
Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50-5.98)
6 Determine net settlement amount
(balance due) based on the cost
report (see instructions). (1)

7 Total Medicare liability (see instructions)
8 Name of Contractor

2
Amount

Program
to
Provider
Provider
to
Program
Program
to
Provider
Provider
to
Program

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

.01
.02
.03
.50
.51
.52
.99

5.01
5.02
5.03
5.50
5.51
5.52
5.99

.01

6.01

.02

6.02
7
Date (Month/Day/Year)
8

Contractor Number

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

FORM CMS-2552-10 (10-2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4070)

Rev. 3

40-663