Download:
pdf |
pdfCHAPTER 40
HOSPITAL AND HOSPITAL
HEALTH CARE COMPLEX COST REPORT
FORM CMS-2552-10
Section
General ............................................................................................................................... 4000
Rounding Standards for Fractional Computations.................................................... 4000.1
Acronyms and Abbreviations ................................................................................... 4000.2
Recommended Sequence for Completing Form CMS-2552-10 ........................................ 4001
Sequence of Assembly ....................................................................................................... 4002
Sequence of Assembly for Non-Proprietary Hospital Participating in Medicare
and Subject to Prospective Payment System ......................................................... 4002.1
Sequence of Assembly for Proprietary Health Care Complex Participating
in Titles V, XVIII, and XIX .................................................................................... 4002.2
Worksheet S - Hospital and Hospital Health Care Complex Cost Report Certification
and Settlement Summary ................................................................................................ 4003
Part I - Cost Report Status ........................................................................................ 4003.1
Part II - Certification by Officer or Administrator of Provider(s) ............................ 4003.2
Part III - Settlement Summary .................................................................................. 4003.3
Worksheet S-2.................................................................................................................... 4004
Part I - Hospital and Hospital Health Care Complex Identification Data................. 4004.1
Part II - Hospital and Hospital Heath Care Complex Reimbursement
Questionnaire ......................................................................................................... 4004.2
Worksheet S-3 - Hospital and Hospital Health Care Complex Statistical Data and
Hospital Wage Index Information .................................................................................. 4005
Part I - Hospital and Hospital Health Care Complex Statistical Data ...................... 4005.1
Part II - Hospital Wage Index Information ............................................................... 4005.2
Part III - Hospital Wage Index Summary......................................... ........................ 4005.3
Part IV - Hospital Wage Related Cost ...................................................................... 4005.4
Part V - Hospital and Health Care Complex Contract Labor and Benefit Cost ....... 4005.5
Worksheet S-4 - Hospital-Based Home Health Agency Statistical Data .......................... 4006
Worksheet S-5 - Hospital Renal Dialysis Department Statistical Data ............................. 4007
Worksheet S-6 - Hospital-Based Outpatient Rehabilitation Provider Data......... .............. 4008
Worksheet S-7 - Statistical Data and Prospective Payment for Skilled Nursing
Facilities .................................................... ................................................................... 4009
Worksheet S-8 - Provider-Based Rural Health Clinic/Federally Qualified
Health Center Provider Statistical Data ...................................................................... 4010
Worksheet S-9 - Hospice Identification Data .................................................................... 4011
Part I - Enrollment Days Based on Level of Care .................................................... 4011.1
Part II - Census Data ................................................................................................. 4011.2
Worksheet S-10 - Hospital Uncompensated Care Data ..................................................... 4012
Rev. 3
40-1
CHAPTER 40
Section
Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses.................4013
Worksheet A-6 - Reclassifications......................................................................................4014
Worksheet A-7 - Analysis of Capital Assets...................................................................... 4015
Part I - Analysis of Changes in Capital Asset Balances............................................ 4015.1
Part II - Reconciliation of Capital Cost Centers........................................................ 4015.2
Part III - Reconciliation of Amounts from Worksheet A, Column 2,
Lines 1 thru 2.......................................................................................................... 4015.3
Worksheet A-8 - Adjustments to Expenses........................................................................ 4016
Worksheet A-8-1 - Statement of Costs of Services from Related Organizations and
Home Office Costs.......................................................................................................... 4017
Worksheet A-8-2 - Provider-Based Physician Adjustments.............................................. 4018
Worksheet A-8-3 - Reasonable Cost Determination for Therapy Services
Furnished by Outside Suppliers for Cost Based Providers.............................................. 4019
Part I - General Information.......................................................................................4019.1
Part II - Salary Equivalency Computation................................................................. 4019.2
Part III - Standard Travel Allowance and Standard Travel Expense Computation
Provider Site.......................................................................................................... 4019.3
Part IV - Standard Travel Allowance and Standard Travel Expense Off Site Services..................................................................................................... 4019.4
Part V - Overtime Computation................................................................................. 4019.5
Part VI - Computation of Therapy Limitation and Excess Cost Adjustment............ 4019.6
Worksheet B, Part I - Cost Allocation - General Service Cost and
Worksheet B-1 - Cost Allocation - Statistical Basis........................................................... 4020
Worksheet B, Part II - Allocation of Capital-Related Costs and Worksheet B.................. 4021
Worksheet B-2 - Post Stepdown Adjustments................................................................... 4022
Worksheet C - Computation of Ratio of Cost to Charges and Outpatient
Capital Reduction............................................................................................................ 4023
Part I - Computation of Ratio of Costs to Charges................................................... 4023.1
Part II - Computation of Ratio of Outpatient Service
Cost to Charge Ratios Net of reductions................................................................ 4023.2
Worksheet D - Cost Apportionment…............................................................................... 4024
Part I - Apportionment of Inpatient Routine Service Capital Costs........................... 4024.1
Part II - Apportionment of Inpatient Ancillary Service Capital Costs....................... 4024.2
Part III - Apportionment of Inpatient Routine Service Other Pass
Through Costs.......................................................................................................... 4024.3
Part IV - Apportionment of Inpatient Ancillary Service Other Pass Through
Costs..........................................................................................................................4024.4
Part V - Apportionment of Medical and Other Health Services Costs……………....4024.5
40-2
Rev. 3
CHAPTER 40
Section
Worksheet D-1 - Computation of Inpatient Operating Cost…….……………….………. 4025
Part I - All Provider Components……………………………………………………. 4025.1
Part II - Hospital and Subproviders Only……………………………………………. 4025.2
Part III - Skilled Nursing Facility and Other Nursing Facility Only………………… 4025.3
Part IV - Computation of Observation Bed Cost…………………………………….. 4025.4
Worksheet D-2 - Apportionment of Cost of Services Rendered by
Interns and Residents…….……………….……………………………………………. 4026
Part I - Not in Approved Teaching Program…….……………….…………………... 4026.1
Part II - In Approved Teaching Program (Title XVIII, Part B Inpatient Routine
Costs Only) …….……………….…………………………………………………. 4026.2
Part III - Summary for Title XVIII…….……………….……………………………. 4026.3
Worksheet D-3 - Inpatient Ancillary Service Cost Apportionment…….………………...4027
Worksheet D-4 - Computation of Organ Acquisition Costs and Charges for Hospitals
Which Are Certified Transplant Centers…….……………….……………………….. 4028
Part I - Computation of Organ Acquisition Costs (Inpatient Routine and
Ancillary Services) …….……………….…………………………………………..4028.1
Part II - Computation of Organ Acquisition Costs (Other Than Inpatients Routine
and Ancillary Service Costs) …….……………….……………………………….. 4028.2
Part III - Summary of Costs and Charges…….……………….…………………….. 4028.3
Part IV - Statistics…….……………….…………………………………………….. 4028.4
Worksheet D-5 - Apportionment of Cost for Services of Teaching Physicians…………. 4029
Part I - Reasonable Compensation Equivalent Computation…….……………….…. 4029.1
Part II - Apportionment of Cost for Services of Teaching Physicians…….………… 4029.2
Worksheet E - Calculation of Reimbursement Settlement…….……………….……….. 4030
Part A - Inpatient Hospital Services Under PPS…….……………….………………. 4030.1
Part B - Medical and Other Health Services…….……………….………………….. 4030.2
Worksheet E-1 - Analysis of Payments to Providers for Services Rendered…….……… 4031
Part I - Analysis of Payments to Providers for Services Rendered…….……………. 4031.1
Part II - Calculation of reimbursement Settlement for Health
Information Technology…….……………….…………………………………….. 4031.2
Worksheet E-2 - Calculation of Reimbursement Settlement - Swing Beds…….……….. 4032
Worksheet E-3 - Calculation of Reimbursement Settlement…….……………….……… 4033
Part I - Calculation of Medicare Reimbursement Settlement Under TEFRA…….…. 4033.1
Part II - Calculation of Reimbursement Settlement for Medicare Part A Services
- IPF PPS…….……………….……………………………………………………. 4033.2
Part III - Calculation of Reimbursement Settlement All Other Health Services
- IRF PPS…….……………….……………………………………………………. 4033.3
Part IV - Calculation of Reimbursement Settlement All Other Health Services
- LTCH PPS…….……………….…………………………………………………. 4033.4
Part V - Calculation of Reimbursement Settlement for Cost Providers…….……….. 4033.5
Part VI - Calculation of Reimbursement Settlement for SNF PPS…….……………..4033.6
Part VII - Calculation of Reimbursement Settlement for Title V & XIX…….……… 4033.7
Worksheet E-4 - Direct Graduate Medical Education and ESRD
Outpatient Direct Medical Education Costs…….……………….…………….... 4034
Rev. 2
40-3
CHAPTER 40
Section
Financial Statements Worksheets…….……………….…………………………………. 4040
Worksheet G…….……………….…………………………………………………... 4040.1
Worksheet G-1…….……………….………………………………………………… 4040.2
Worksheet G-2…….……………….………………………………………………… 4040.3
Worksheet G-3…….……………….………………………………………………… 4040.4
Worksheet H - Analysis of Provider-Based Home Health Agency Costs…….…………. 4041
Worksheet H-1 - Cost Allocation HHA Statistical Basis…….……………….…………. 4042
Worksheet H-2 - Allocation of General Service Costs to HHA Cost Centers…….…….. 4043
Part I - Allocation of General Service Costs to HHA Cost Centers…….…………… 4043.1
Part II - Allocation of General Service Cost to HHA Cost Centers – Statistical
Basis…….……………….…………………………………………………………… 4043.2
Worksheet H-3 - Apportionment of Patient Service Costs…….……………….………... 4044
Part I - Computation of Lesser of Aggregate Medicare Cost Aggregate Medicare
Limitation Cost, or Per Beneficiary Cost Limitation…….……………….……….. 4044.1
Part II - Apportionment of Cost of HHA Services Furnished by Shared Hospital
Departments…….……………….…………………………………………………. 4044.2
Worksheet H-4 - Calculation of HHA Reimbursement Settlement…….……………….. 4045
Part I - Computation of Lesser of Reasonable Cost or Customary Charges…….…… 4045.1
Part II - Computation of HHA Reimbursement Settlement…….……………….…… 4045.2
Worksheet H-5 - Analysis of Payments to Provider-Based HHAs
for Services Rendered to Program Beneficiaries…….……………….………………... 4046
Worksheet I - Analysis of Renal Dialysis Department Costs…….……………….……... 4047
Worksheet I-1 - Analysis of Renal Cost…….……………….…………………………... 4048
Worksheet I-2 - Allocation of Renal Department Costs to Treatment Modalities…….… 4049
Worksheet I-3 - Direct and Indirect Renal Dialysis Cost Allocation - Statistical Basis… 4050
Worksheet I-4 - Computation of Average Cost Per Treatment for Outpatient
Renal Dialysis…….……………….…………………………………………………… 4051
Worksheet I-5 - Calculation of Reimbursable Bad Debts - Title XVIII, Part B…….…... 4052
40-4
Rev. 2
CHAPTER 40
Section
Worksheet J-1 - Allocation of General Service Costs to CMHC Cost Centers…….…… 4053
Part I - Allocation of General Service Costs to CMHC Cost Centers…….…………. 4053.1
Part II - Allocation of General Service Costs to CMHC
Cost Centers -Statistical Basis…….……………….…………………………….. 4053.2
Worksheet J-2 - Computation of CMHC Provider Costs…….……………….…………. 4054
Part I - Apportionment of CMHC Cost Centers…….……………….…………….. 4054.1
Part II - Apportionment of Cost of CMHC Provider Services Furnished
by Shared Hospital Departments…….……………….………………………… 4054.2
Worksheet J-3 - Calculation of Reimbursement Settlement CMHC Provider Services…….……………….……………………………….. 4055
Worksheet J-4 - Analysis of Payments to Hospital-Based CMHC
for Services Rendered to Program Beneficiaries…….……………….……….. 4056
Worksheet K - Analysis of Provider-Based Hospice Costs…….……………….………. 4057
Worksheet K-1 - Compensation Analysis - Salaries and Wage…….……………….….. 4058
Worksheet K-2 - Compensation Analysis - Employee Benefits (Payroll Related) …….. 4059
Worksheet K-3 - Compensation Analysis - Contracted Services/Purchased Services….. 4060
Worksheet K-4 - Part I - Cost Allocation - General Service Costs and
Part II - Cost Allocation - Statistical Basis…….……………….………………. 4061
Worksheet K-5 - Allocation of General Service Costs to Hospice Cost Centers…….….. 4062
Part I - Allocation of General Service Costs to Hospice Cost Centers…….………. 4062.1
Part II - Allocation of General Service Costs to Hospice
Cost Centers - Statistical Basis…….……………….…………………………... 4062.2
Part III - Computation of the Total Hospice Shared Costs…….……………….….. 4062.3
Worksheet K-6 - Calculation of Per Diem Cost…….……………….………………….. .4063
Rev. 2
40-5
CHAPTER 40
Section
Worksheet L - Calculation of Capital Payment.................................................................. 4064
Part I - Fully Prospective Method............................................................................... 4064.1
Part II – Payment Under Reasonable Cost
4064.2
Part III - Computation of Exception Payments........................................................... 4064.3
Worksheet L-1.................................................................................................................... 4065
Part I - Allocation of Allowable Capital Costs for Extraordinary Circumstances…. 4065.1
Part II - Computation of Program Inpatient Ancillary Service Capital Costs for
Extraordinary Circumstances…….……………….……………………………….. 4065.2
Part II - Computation of Program Inpatient Routine Service Capital Costs for
Extraordinary Circumstances…….……………….………………………………. 4065.3
Worksheet M-1 - Analysis of Provider Based Rural Health Clinic Federally
Qualified Health Center Costs…….……………….…………………………………... 4066
Worksheet M-2 - Allocation of Overhead to RHC/FQHC Services…….………………. 4067
Worksheet M-3 - Calculation of Reimbursement Settlement for RHC/FQHC Services…4068
Worksheet M-4 - Computation of Pneumococcal and Influenza Vaccine Cost…….…… 4069
Worksheet M-5 - Analysis of Payments to Hospital-Based RHC/FQHC
Services Rendered to Program Beneficiaries…….……………….……………….. 4070
Exhibit 1 - Form CMS-2552-10 Worksheets…….……………….……………………… 4090
Exhibit 2 - Electronic Reporting Specifications for Form CMS-2552-10…….………… 4095
40-6
Rev. 2
12-10
4000.
FORM CMS-2552-10
4000
GENERAL
The Paperwork Reduction Act of 1995 requires that you be informed why information is
collected and what the information is used for by the government. Section 1886(f)(1) of the
Social Security Act (the Act) requires the Secretary to maintain a system of cost reporting for
Prospective Payment System (PPS) hospitals, which includes a standardized electronic format.
In accordance with §§1815(a), 1833(e), and 1861(v)(1)(A) of the Act, providers of service
participating in the Medicare program are required to submit annual information to achieve
settlement of costs for health care services rendered to Medicare beneficiaries. Also, 42 CFR
413.20(b) requires cost reports on an annual basis. In accordance with these provisions, all
hospital and health care complexes to determine program payment must complete Form-CMS2552-10 with a valid Office of Management and Budget (OMB) control number. In addition to
determining program payment, the data submitted on the cost report support management of the
Federal programs, e.g., data extraction in developing cost limits, data extraction in developing
and updating various prospective payment systems. The information reported on Form CMS2552-10 must conform to the requirements and principles set forth in 42 CFR, Part 412, 42 CFR,
Part 413, and in the Provider Reimbursement Manual, Part I. The filing of the cost report is
mandatory, and failure to do so results in all payments to be deemed overpayment and a withhold
up to 100 percent until the cost report is received. (See Pub. 15-2, §100.) Except for the
compensation information, the cost report information is considered public record under the
freedom of information act 45 CFR Part 5. The instructions contained in this chapter are
effective for hospitals and hospital health care complexes with cost reporting periods beginning
on or after May 1, 2010.
NOTE: This form is not used by freestanding skilled nursing facilities.
Worksheets are provided on an as needed basis dependent on the needs of the hospital. Not all
worksheets are needed by all hospitals. The following are a few examples of conditions for
which worksheets are needed:
•
Reimbursement is claimed for hospital swing beds;
•
Reimbursement is claimed for a hospital-based inpatient rehabilitation facility (IRF) or
inpatient psychiatric facility (IPF);
•
Reimbursement is claimed for a hospital-based community mental health center
(CMHC);
•
The hospital has physical therapy services furnished by outside suppliers (applicable for
cost reimbursement and Tax Equity and Fiscal responsibility Act of 1982 (PL97248)
(TEFRA providers, not PPS); or
•
The hospital is a certified transplant center (CTC).
NOTE: Public reporting burden for this collection of information is estimated to average 108
hours per response, and record keeping burden is estimated to average 565 hours per
response. This includes time for reviewing instructions, searching existing data
sources, gathering and maintaining data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing the burden,
to:
Rev. 1
o
Center for Medicare and Medicaid Services
7500 Security Boulevard
Mail Stop C5-03-03
Baltimore, MD 21244-1855
o
The Office of Information and Regulatory Affairs
Office of Management and Budget
Washington, DC 20503
40-7
4000 (Cont.)
FORM CMS-2552-10
12-10
Section 4007(b) of the omnibus reconciliation Act (OBRA 1987) states that effective with cost
reporting periods beginning on or after October 1, 1989, you are required to submit your cost
report electronically unless you receive an exemption from CMS. The legislation allows CMS to
delay or waiver implementation if the electronic submission results in financial hardship (in
particular for providers with only a small percentage of Medicare volume). Exemptions are
granted on a case-by-case basis. (See Pub. 15-2, §130.3 for electronically prepared cost reports
and requirements.)
In addition to Medicare reimbursement, these forms also provide for the computation of
reimbursement applicable to titles V and XIX to the extent required by individual State
programs. Generally, the worksheets and portions of worksheets applicable to titles V and XIX
are completed only to the extent these forms are required by the State program. However,
Worksheets S-3 and D-1 must always be completed with title XIX data.
Each electronic system provides for the step down method of cost finding. This method provides
for allocating the cost of services rendered by each general service cost center to other cost
centers, which utilize the services. Once the costs of a general service cost center have been
allocated, that cost center is considered closed. Once closed, it does not receive any of the costs
subsequently allocated from the remaining general service cost centers. After all costs of the
general service cost centers have been allocated to the remaining cost centers, the total costs of
these remaining cost centers are further distributed to the departmental classification to which
they pertain, e.g., hospital general inpatient routine, subprovider.
The cost report is designed to accommodate a health care complex with multiple entities. If a
health care complex has more than one entity reporting (except skilled nursing facilities and
nursing facilities which cannot exceed more than one hospital-based facility), add additional
lines for each entity by subscripting the line designation. For example, subprovider, line 4,
Worksheet S, Part III is subscripted 4.00 for subprovider I and 4.01 for subprovider II.
NOTE: Follow this sequence of numbering for subscripting lines throughout the cost report.
Similarly, add lines 42.00 and 42.01 to Worksheets A; B, Parts I and II; B-1; C; D, Parts I and
III; and Worksheet L-1, Parts I and II. For multiple use worksheets such as Worksheet D-1, add
subprovider II to the existing designations in the headings and the corresponding component
number.
In completing the worksheets, show reductions in expenses in parentheses ( ) unless otherwise
indicated.
4000.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost
report, required computations result in fractions. The following rounding standards must be
employed for such computations. When performing multiple calculations, round after each
calculation. However,
40-8
1.
Round to 2 decimal places:
a. Percentages
b. Averages, standard work week, payment rates, and cost limits
c. Full time equivalent employees
d. Per diems, hourly rates
2.
Round to 3 decimal places:
a. Payment to cost ratio
Rev. 1
10-12
FORM CMS-2552-10
3.
Round to 4 decimal places:
a. Wage adjustment factor
b. Medicare SSI ratio
4.
Round to 5 decimal places:
a. Payment reduction (e.g., capital reduction, outpatient cost reduction)
5.
Round to 6 decimal places:
a. Ratios (e.g., unit cost multipliers, cost/charge ratios, days to days)
4000.2
Where a difference exists within a column as a result of computing costs using a fraction or
decimal, and therefore the sum of the parts do not equal the whole, the highest amount in that
column must either be increased or decreased by the difference. If it happens that there are two
high numbers equaling the same amount, adjust the first high number from the top of the
worksheet for which it applies.
4000.2 Acronyms and Abbreviations.--Throughout the Medicare cost report and instructions, a
number of acronyms and abbreviations are used. For your convenience, commonly used
acronyms and abbreviations are summarized below.
ACA
A&G
AHSEA
ARRA
ASC
BBA
BBRA
BIPA
CAH
CAPD
CAP-REL
CBSA
CCN
CCPD
CCU
CFR
CMHC
CMS
COL
CORF
CRNA
CT
CTC
DEFRA
DPP
DRA
DRG
DSH
EACH
ECR
EHR
ESRD
FQHC
FR
FTE
GME
Rev. 3
-
Affordable Care Act
Administrative and General
Adjusted Hourly Salary Equivalency Amount
American Recovery and Reinvestment Act of 2009
Ambulatory Surgical Center
Balanced Budget Act
Balanced Budget Reform Act
Benefits Improvement and Protection Act
Critical Access Hospitals
Continuous Ambulatory Peritoneal Dialysis
Capital-Related
Core Based Statistical Areas
CMS Certification Number
Continuous Cycling Peritoneal Dialysis
Coronary Care Unit
Code of Federal Regulations
Community Mental Health Center
Centers for Medicare & Medicaid Services
Column
Comprehensive Outpatient Rehabilitation Facility
Certified Registered Nurse Anesthetist
Computer Tomography
Certified Transplant Center
Deficit Reduction Act of 1984
Disproportionate Patient Percentage
Deficit Reduction Act of 2005
Diagnostic Related Group
Disproportionate Share
Essential Access Community Hospital
Electronic Cost Report
Electronic Health Records
End Stage Renal Disease
Federally Qualified Health Center
Federal Register
Full Time Equivalent
Graduate Medical Education
40-9
4000.2 (Cont.)
FORM CMS-2552-10
HCERA
HCPCS
HCRIS
HFS
HRSA
HHA
HIT
HMO
HSR
I & Rs
ICF/MR
ICU
IME
INPT
IOM
IPF
IPPS
IRF
KPMG
LDP
LIP
LOS
LCC
LTCH
MA
M+C
-
MCP
MDH
MED-ED
MIPPA
MMA
MMEA
MRI
MS-DRG
MSP
NF
NPI
NPR
OBRA
OLTC
OOT
OPD
OPO
OPPS
OPT
OSP
ORF
PCR
PCRE
PBP
PPS
PRM
PRA
PS&R
PT
-
40-10
-
10-12
Health Care and Education Reconciliation Act of 2010
Healthcare Common Procedure Coding System
Healthcare Cost Report Information System
Health Financial Systems
Health Resources and Services Administration
Home Health Agency
Health Information Technology
Health Maintenance Organization
Hospital Specific Rate
Interns and Residents
Intermediate Care Facility Mentally Retarded
Intensive Care Unit
Indirect Medical Education
Inpatient
Internet Only Manual
Inpatient Psychiatric Facility
Inpatient Prospective Payment System
Inpatient Rehabilitation Facility
Klynveld, Peat, Marwick, & Goerdeler
Labor, Delivery and Postpartum
Low Income Patient
Length of Stay
Lesser of Reasonable Cost or Customary Charges
Long Term Care Hospital
Medicare Advantage (previously known as M+C)
Medicare + Choice (also known as Medicare Part C, Medicare Advantage
and Medicare HMO)
Monthly Capitation Payment
Medicare Dependent Hospital
Medical Education
Medicare Improvements for Patients and Providers Act of 2008
Medicare Prescription Drug Improvement and Modernization Act of 2003
Medicare and Medicaid Extenders Act of 2010
Magnetic Resonance Imaging
Medicare Severity Diagnosis-Related Group
Medicare Secondary Payer
Nursing Facility
National Provider Identifier
Notice of Program Reimbursement
Omnibus Budget Reconciliation Act
Other Long Term Care
Outpatient Occupational Therapy
Outpatient Department
Organ Procurement Organization
Outpatient Prospective Payment System
Outpatient Physical Therapy
Outpatient Speech Pathology
Outpatient Rehabilitation Facility
Payment to Cost Ratio
Primary Care Residency Expansion Program
Provider-Based Physician
Prospective Payment System
Provider Reimbursement Manual
Per Resident Amount
Provider Statistical and Reimbursement Report (or System)
Physical Therapy
Rev. 3
08-11
PTO
RCE
RHC
RPCH
RT
RUG
SCH
SCHIP
SNF
SSI
TEFRA
THC
TOPPS
UPIN
WKST
FORM CMS-2552-10
4000.3
-
Paid Time Off
Reasonable Compensation Equivalent
Rural Health Clinic
Rural Primary Care Hospitals
Respiratory Therapy
Resource Utilization Group
Sole Community Hospitals
State Children’s Health Insurance Program
Skilled Nursing Facility
Supplemental Security Income
Tax Equity and Fiscal Responsibility Act of 1982
Teaching Health Center
Transitional Corridor Payment for Outpatient Prospective Payment System
Unique Physician Identification Number
Worksheet
NOTE: In this chapter, TEFRA refers to §1886(b) of the Act and not to the entire Tax Equity
and Fiscal Responsibility Act.
4000.3 Instructional, Regulatory and Statutory Effective Dates.--Throughout the Medicare
cost report instructions, various effective dates implementing instructions, regulations and/or
statutes are utilized.
Where applicable, at the end of select paragraphs and/or sentences the effective date (s) is
indicated in parentheses ( ) for cost reporting periods ending on or after that date, i.e.,
(12/31/2010). Dates followed by a “b” are effective for cost reporting periods beginning on or
after the specified date, i.e., (9/30/2010b). Dates followed by an “s” are effective for services
rendered on or after the specified date, i.e., (4/1/2010s). Instructions not followed by an effective
date are effective retroactive back to cost reporting periods beginning on or after 5/1/2010
(transmittal 1).
Rev. 2
40-11
4001
FORM CMS-2552-10
08-11
4001.
RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-2552-10
Part I - Statistics, Departmental Cost Adjustments and Cost Allocations
Step
Worksheet
Instructions
1
S-2, Parts I & II
Read §4004.1 - 4004.2. Complete entire
worksheet.
2
S-3, Parts I - V
Read §4005 - 4005.5. Complete entire
worksheets.
S-4
Read §4006. Complete entire worksheet,
applicable.
S-5
Read §4007. Complete entire worksheet,
applicable.
S-6
Read §4008. Complete entire worksheet,
applicable.
S-7
Read §4009. Complete entire worksheet,
applicable.
S-8
Read §4010. Complete entire worksheet,
applicable.
S-9, Parts I & II
Read §4011. Complete entire worksheet,
applicable.
9
A
Read §4013.
lines 1-200.
10
A-6
Read §4014. Complete, if applicable.
11
A
Read §4013. Complete columns 4 and 5,
lines 1-200.
12
A-7, Parts I - III
Read §4015. Complete entire worksheet.
13
A-8-1
Read §4017. Complete Parts A and B.
14
A-8-2
Read §4018. Complete, if applicable.
15
A-8-3, Parts I - VI
Read §§4019 - 4019.6. Complete, if
applicable.
3
if
4
if
5
if
6
if
7
if
8
if
40-12
Complete columns 1-3,
Rev. 2
08-11
FORM CMS-2552-10
4001 (Cont.)
Step
Worksheet
Instructions
16
A-8
Read §4016. Complete entire worksheet.
17
A
Read §4013. Complete columns 6 and 7,
lines 1-200.
18
B, Part I & B-1
Read §4020.
Complete all columns
through
column 26.
19
B, Part II
Read §4021. Complete entire worksheet.
20
B-2
Read §4022. Complete, if applicable.
21
L-1, Part I
Read §§4065 and 4065.1. Complete, if
applicable.
Rev. 2
40-13
4001 (Cont.)
FORM CMS-2552-10
08-11
Part II - Departmental Cost Distribution and Cost Apportionment
Step
Worksheet
Instructions
1
C
Read §4023 - 4023.1. Complete entire
worksheet, except for line 92.
2
D, Part I
Read §§4024 and 4024.1.
entire worksheet.
3
D, Part III
Read §§4024 and 4024.3. Complete entire
worksheet.
4
L-1, Part II
Read §4065.2. Complete, if applicable.
5
D-1, Parts I & IV
Read §§4025, 4025.1 and 4025.4.
Complete both parts.
6
C
Read §4023.1. Complete line 92.
7
D, Part II
Read §§4024 and 4024.2. Complete
entire worksheet. A separate worksheet
must be completed for each applicable
healthcare program for each hospital and
subprovider subject to PPS or TEFRA
provisions.
8
D, Part IV
Read §§4024 and 4024.4. Complete
entire worksheet. A separate worksheet
must be completed for each applicable
health care program for each hospital and
subprovider subject to PPS or TEFRA
provisions.
9
L-1, Part III
Read §4065.3. Complete, if applicable.
10
D, Part V
Read §§4024 and 4024.5.
entire worksheet. A separate
must be completed for each
health care program for each
provider component.
11
D-3
Read §4027. Complete entire worksheet.
A separate copy of this worksheet must
be completed for each applicable health
care program for each applicable provider
component.
12
D-1, Parts I & II
Read §§4025, 4025.1 and 4025.2. All
providers must complete Part I. The
hospital
and
subprovider(s) must
complete Part II, lines 38-49 and lines 6469.
40-14
Complete
Complete
worksheet
applicable
applicable
Rev. 2
12-10
FORM CMS-2552-10
4001 (Cont.)
Step
Worksheet
Instructions
12
D-1, Parts III & IV
Read §§4025, 4025.3 and 4025.4. Only
the hospital-based SNF and hospitalbased NF must complete Part III, lines
70-86. All providers must complete Part
IV.
13
D-2, Parts I - III
Read §§4026 - 4026.3. Complete only
those parts that are applicable. Do not
complete Part III unless both Parts I and
II are completed.
14
L, Parts I - III
Read §4064. Complete applicable parts.
15
D-5, Parts I & II
Read §§4029 - 4029.2. Complete entire
worksheet, if applicable.
16
D-4, Parts I - IV
Read §§4028 - 4028.4. Complete only if
hospital is a certified transplant center.
17
E-4
Read §§4034.
Complete
worksheet, if applicable.
Rev. 1
entire
40-15
4001 (Cont.)
FORM CMS-2552-10
12-10
Part III - Calculation and Apportionment of Hospital-Based Facilities
A.
Title XVIII - For SNF Only Reimbursed Under PPS.--
Step
Worksheet
Instructions
1
E-3, Part VI
Read §4033.6. If applicable, complete
lines 1-15 for title XVIII SNF PPS
services.
2
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part VI.
3
E-3, Part VI
Complete the remainder
worksheet, lines 16-19.
B.
of
this
Titles V and XIX - For Hospital, Subprovider(s), NF and ICF/MRs.--
Step
Worksheet
Instructions
4
E-3, Part VII
Read §4033.7. If applicable, complete
entire worksheet for titles V and XIX
services. Use a separate worksheet for
each title.
C.
Title XVIII - For Swing Bed-SNF and Titles V and XIX - For Swing Bed-NF.--
Step
Worksheet
Instructions
5
E-2
Read §4032. Complete a separate copy of
this worksheet (lines 1-19) for each
applicable health care program for each
applicable provider component. Only
entries applicable to title XVIII are made
in column 2. Complete lines 9, 13, and 17
of column 1 for titles V and XIX and
columns 1 and 2 for title XVIII.
6
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-2 title XVIII swing bedSNF only.
7
E-2
Complete the remainder
worksheet, lines 20-23.
40-16
of
this
Rev. 1
12-10
D.
FORM CMS-2552-10
4001 (Cont.)
Title XVIII Only - For Home Health Agency.--
Step
Worksheet
Instructions
8
H
Read §4041. Complete entire worksheet,
if applicable.
9
H-1, Parts I and II
Read §4042. Complete entire worksheet,
if applicable.
10
H-2, Parts I and II
Read §§4043 - 4043.2. Complete entire
worksheet, if applicable.
11
H-3, Parts I and II
Read §§4044 - 4044.2. Complete entire
worksheet, if applicable.
12
H-4, Parts I and II
Read §§4045 - 4045.2. Complete entire
worksheet, if applicable.
13
H-5
Read §4046. Complete entire worksheet,
if applicable.
E.
Title XVIII- For ESRD.--
14
I-1
Read §§4047 - 4048. Complete a separate
worksheet
for
renal
dialysis
department(s) and a separate worksheet
for home program dialysis department(s),
if applicable.
15
I-2
Read §4049.
Complete a separate
worksheet
for
renal
dialysis
department(s) and a separate worksheet
for home program dialysis department(s),
if applicable.
16
I-3
Read §4050. Complete a separate
worksheet for renal dialysis department(s)
and a separate worksheet for home
program dialysis department(s), if
applicable.
17
I-4
Read §4051.
Complete a separate
worksheet for renal dialysis department(s)
and a separate worksheet for home
program dialysis department(s), if
applicable.
18
I-5
Read §4052.
Complete only one
worksheet combining all renal dialysis
departments and home program dialysis
departments, if applicable.
Rev. 1
40-17
4001(Cont.)
F.
FORM CMS-2552-10
12-10
Title XVIII - For CMHC.--
Step
Worksheet
Instructions
19
J-1, Parts I and II
Read §§4053 - 4053.2. Complete entire
worksheet, if applicable.
20
J-2, Part I
Read §§4054 - 4054.1. Complete entire
worksheet, if applicable.
21
J-2, Part II
Read
§4054.2.
Complete
worksheet, if applicable.
22
J-3
Read §4055. Complete entire worksheet,
if applicable.
23
J-4
Read §4056. Complete lines 1-4 for title
XVIII only.
G.
entire
Titles XVIII and XIX - For Provider Based-Hospice.--
24
K-1
Read §4058. Complete entire worksheet,
if applicable.
25
K-2
Read §4059. Complete entire worksheet,
if applicable.
26
K-3
Read §4060. Complete entire worksheet,
if applicable.
27
K
Read §4057. Complete entire worksheet,
if applicable.
28
K-4, Parts I and II
Read §4061. Complete both worksheets,
if applicable.
29
K-5, Parts I, II & III
Read §§4062 - 4062.3.
worksheets, if applicable.
30
K-6
Read §4063. Complete entire worksheet,
if applicable.
40-18
Complete all
Rev. 1
12-10
H.
FORM CMS-2552-10
4001 (Cont.)
Titles V, XVIII, and XIX - For Rural Health Clinics/Federally Qualified Health
Clinics.--
Step
Worksheet
Instructions
31
M-1
Read §4066. Complete entire worksheet,
if applicable.
32
M-2
Read §4067. Complete entire worksheet,
if applicable.
33
M-3
Read §4068. Complete entire worksheet,
if applicable.
34
M-4
Read §4069. Complete entire worksheet,
if applicable.
35
M-5
Read §4070. Complete entire worksheet,
if applicable, for title XVIII only.
Rev. 1
40-19
4001(Cont.)
FORM CMS-2552-10
12-10
Part IV - Calculation of Reimbursement Settlement
Step
Worksheet
Instructions
1
E, Part A
Read §§4030 and 4030.1. Complete lines
1-71 of this worksheet for title XVIII for
each applicable provider component
subject to IPPS.
2
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E, Part A.
3
E, Part A
Complete the remainder
worksheet, lines 72-75.
4
E, Part B
Read §4030.2. Complete lines 1-40 for
title XVIII for each applicable provider
component.
5
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E, Part B.
6
E, Part B
Complete the remainder
worksheet, lines 41-44.
7
E-3, Part I
Read §§4033 and 4033.1. If applicable,
complete lines 1-18 for title XVIII for
each applicable provider component
subject to TEFRA.
8
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part I.
9
E-3, Part I
Complete the remainder
worksheet, lines 19-22.
10
E-3, Part II
Read §4033.2. If applicable, complete
lines 1-31 for title XVIII IPF PPS.
11
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part II.
12
E-3, Part II
Complete the remainder
worksheet, lines 32-35.
40-20
of
of
of
of
this
this
this
this
Rev. 1
12-10
FORM CMS-2552-10
4001 (Cont.)
Step
Worksheet
Instructions
13
E-3, Part III
Read §4033.3. If applicable, complete
lines 1-32 for title XVIII IRF PPS.
14
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part III.
15
E-3, Part III
Complete the remainder
worksheet, lines 33-36.
16
E-3, Part IV
Read §4033.4. If applicable, complete
lines 1-22 for title XVIII LTCH PPS.
17
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part IV.
18
E-3, Part IV
Complete the remainder
worksheet, lines 23-26.
19
E-3, Part V
Read §4033.5. If applicable, complete
lines 1-30 for title XVIII reasonable cost
reimbursed providers.
20
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part V.
21
E-3, Part V
Complete the remainder
worksheet, lines 31-34.
19
E-3, Part VI
Read §4033.6. If applicable, complete
lines 1-15 for title XVIII reasonable cost
reimbursed providers.
20
E-1, Part I
Read §4031.1. Complete this worksheet
for title XVIII services corresponding to
Worksheet E-3, Part VI.
21
E-3, Part VI
Complete the remainder
worksheet, lines 16-19.
22
E-3, Part VII
Read §4033.7. If applicable, complete the
entire worksheet for titles V and XIX
providers.
Rev. 1
of
of
of
of
this
this
this
this
40-21
4001(Cont.)
FORM CMS-2552-10
12-10
Part V - Additional Data
Step
Worksheet
Instructions
1
G
Read §4040. All providers maintaining
fund type accounting records must
complete this worksheet. Nonproprietary
providers which do not maintain fund
type records complete the General Fund
column only.
2
worksheet.
G-1
Read
§4040.1.
Complete
entire
3
worksheet.
G-2, Parts I & II
Read
§4040.2.
Complete
entire
4
worksheet.
G-3
Read
§4040.3.
Complete
entire
5
S-10
Read §4012. Acute care hospitals and
CAHs complete this worksheet.
6
E-1, Part II
Read §4031.2 Acute care hospitals and
CAHs complete this worksheet.
7
S, Parts I - III
Read §§4003.1 - 4003.3. Complete Part
III, then complete Parts I and II.
40-22
Rev. 1
08-11
4002.
FORM CMS-2552-10
4002
SEQUENCE OF ASSEMBLY
The following examples of assembly of worksheets are provided so all providers are consistent
in the order of submission of their annual cost report. All providers using Form CMS-2552-10
must adhere to this sequence. If worksheets are not completed because they are not applicable,
do not include blank worksheets in the assembly of the cost report.
4002.1 Sequence of Assembly for Hospital Health Care Complex Participating in Medicare.-Cost report worksheets are assembled in alpha-numeric sequence starting with the "S" series,
followed by A, B, C, etc.
Form CMS
Worksheet
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
S
S-2
S-3
S-4
S-5
S-6
S-7
S-8
S-9
S-10
A
A-6
A-7
A-8
A-8-1
A-8-2
A-8-3
B
B
B-1
B-2
C
C
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D
Rev. 2
Part
Health Care
Program (Title)
Component
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
Hospital-Based HHA
Renal Dialysis Dept
Hospital-Based CMHC
Hospital-Based SNF
Hospital-Based RHC/FQHC
Hospital-Based Hospice
Hospital & CAH
V
XIX
V
V
V
V
V
V
V
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Subprovider
Subprovider
Hospital
Hospital
Hospital
Hospital
Hospital
Subprovider
Subprovider
I - III
I & II
I-V
I - III
I - VI
I
II
I
II
II
I
II
III
IV
V
II
V
I
II
III
IV
V
II
III
40-23
4002 (Cont.)
FORM CMS-2552-10
Form CMS
Worksheet
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
D
D
D
D
D
D
D
D
D
D
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-1
D-2
D-2
D-2
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-3
D-4
D-5
D-5
D-5
E
E
E-1
E-1
E-1
E-1
E-1
E-1
40-24
Part
V
III
III
I
II
III
IV
V
II
V
I, II, & IV
I, II, & IV
I & III
I & III
I, II, & IV
I, II, & IV
I & III
I, II, & IV
I, II, & IV
I & III
I & III
I
II
III
I - IV
I
II
II
A
B
Part I
Part I
Part I
Part I
Part I
Part I
Health Care
Program (Title)
XVIII
XVIII
XVIII
XIX
XIX
XIX
XIX
XIX
XIX
XIX
V
V
V
V
XVIII
XVIII
XVIII
XIX
XIX
XIX
XIX
V, XVIII, & XIX
XVIII
XVIII
V
V
V
V
V
V
XVIII
XVIII
XVIII
XIX
XIX
XIX
XIX
XIX
XIX
XVIII
V, XVIII, & XIX
V, XVIII, & XIX
V, XVIII, & XIX
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
XVIII
08-11
Component
Subprovider
Swing Bed SNF
SNF
Hospital
Hospital
Hospital
Hospital
Hospital
Subprovider
Subprovider
Hospital
Subprovider
SNF
NF, ICF/MR
Hospital
Subprovider
SNF
Hospital
Subprovider
SNF
NF, ICF/MR
Hospital
Subprovider
Swing Bed SNF
Swing Bed NF
SNF
NF, ICF/MR
Hospital
Subprovider
Swing Bed SNF
Hospital
Subprovider
Swing Bed SNF
Swing Bed NF
SNF
NF, ICF/MR
Hospital
Subprovider
Hospital
Hospital
Hospital
IPF-Subprovider
IRF-Subprovider
Subprovider
Swing Bed SNF
SNF
Rev. 2
10-12
FORM CMS-2552-10
Form CMS
Worksheet
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
2552-10
E-1
E-2
E-2
E-2
E-2
E-2
E-3
E-3
E-3
E-3
E-3
E-3
E-3
G
G-1
G-2
G-3
H
H-1
H-2
H-3
H-4
H-5
I-1 - I-5
I-1 - I-5
J-1 - J-2
J-3
J-4
K
K-1
K-2
K-3
K-4
K-5
K-6
L
L
L-1
L-1
L-1
L-1
M-1
M-2
M-3
M-4
M-5
Rev. 3
Part
II
I-V
I - III or V
IV
VI
VII
VII
VII
I & II
I & II
I & II
I & II
Health Care
Program (Title)
Component
HIT
V
V
XVIII
XIX
XIX
XVIII
XVIII
XVIII
XVIII
V & XIX
V & XIX
V & XIX
Hospital and CAH
Swing Bed SNF
Swing Bed NF
Swing Bed SNF
Swing Bed SNF
Swing Bed NF
Hospital
Subprovider
LTCH
SNF
Hospital
NF, ICF/MR
SNF
V, XVIII, & XIX
V, XVIII, & XIX
XVIII
I & II
V, XVIII, & XIX
XVIII
I & II
I - III
I - III
I - III
I
II
III
III
4002.2 (Cont.)
XVIII, XIX
V, XVIII, & XIX
V, XVIII, & XIX
V, XVIII, & XIX
V, XVIII, & XIX
V, XVIII, & XIX
V, XVIII, &XIX
V, XVIII, &XIX
V, XVIII, &XIX
V, XVIII, &XIX
V, XVIII, &XIX
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Hospital-based HHA
Renal Dialysis
Home Program Dialysis
CMHC
CMHC
CMHC
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital-based Hospice
Hospital
Subprovider
Hospital
Hospital
Hospital
Subprovider
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
Hospital-based RHC/FQHC
40-25
4003
4003.
FORM CMS-2552-10
10-12
WORKSHEET S - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
COST REPORT CERTIFICATION AND SETTLEMENT SUMMARY
4003.1 Part I - Cost Report Status.--This section is to be completed by the provider and fiscal
intermediary (FI)/Medicare administrative contractor (MAC) (hereafter referred to as contractor)
as indicated on the worksheet.
Lines 1 - 3, column 1--The provider must check the appropriate box to indicate on line 1 or 2,
respectively, whether this cost report is being filed electronically or manually. For electronic
filing, indicate on the appropriate line the date and time corresponding to the creation of the
electronic file. This date and time remains as an identifier for the file by the contractor and is
archived accordingly. This file is your original submission and is not to be modified. If this is
an amended cost report, enter on line 3 the number of times the cost report has been amended.
Line 4, Column 1--The provider must enter an “F” if this is full cost report or an “L” for low
Medicare utilization (requires prior contractor approval, see Pub. 15-2, chapter 1, section 110).
Line 5, Column 1--Enter the Healthcare Cost Report Information System (HCRIS) cost report
status code on line 5, column 1 of Worksheet S that corresponds to the filing status of the cost
report: 1=As submitted; 2=Settled without audit; 3=Settled with audit; 4=Reopened; or
5=Amended.
Line 6, Column 2--Enter the date (mm/dd/yyyy) an accepted cost report was received from the
provider.
Line 7, Column 2--Enter the 5 position contractor number.
Lines 8 and 9, Column 2--If this is an initial cost report, enter “Y” for yes in the box on line 8. If
this is a final cost report, enter “Y” for yes in the box on line 9. If neither, enter “N”.
An initial report is the very first cost report for a particular provider CCN. A final cost report is
a terminating cost report for a particular provider CCN.
If the cost report is both initial and terminating in the same year, for example, the provider
started Medicare and decided to leave the program in the same year, and if the cost report is a
full Medicare utilization report, please submit to HCRIS an as submitted and a final settled
report. The as submitted extract should be the initial report, and the final settled should be the
final report.
If the cost report is both initial and terminating in the same year, and if the cost report is No or
Low Medicare utilization, please only submit to HCRIS a final settled with or without audit
report. This would be the only situation in which a HCRIS extract would be both initial and
final.
Line 10, Column 3--Enter the Notice of Program Reimbursement (NPR) date (mm/dd/yyyy).
The NPR date must be present if the cost report status code is 2 or 3.
Line 11, Column 3--Enter software vendor code of the cost report software used by the
contractor to process this HCRIS cost report file. Use “4” for HFS or “3” for KPMG.
Line 12, Column 3--If this is a reopened cost report (response to line 5, column 1 is “4”), enter
the number of times the cost report has been reopened. This field is only be completed if the cost
report status code in line 5, column 1 is 4.
4003.2 Part II - Certification.--This certification is read, prepared, and signed by an officer or
administrator of the provider after the cost report has been completed in its entirety.
40-26
Rev. 3
08-11
FORM CMS-2552-10
4003.2 (Cont.)
4003.3 Part III - Settlement Summary.--Enter the balance due to or due from the applicable
program for each applicable component of the complex. Transfer settlement amounts as follows:
FROM______
Hospital/
Hospital Component
Title V
Title XVIII
Part A
Title XVIII
Part B
HIT
Title XIX
Wkst. E-1,
Part II,
line 32
Wkst. E-3,
Part VII,
line 42
Hospital
Wkst. E-3,
Part VII,
line 42
Wkst. E,
Part A,
line 74
or
Wkst. E-3,
Part I,
line 21
or
Wkst. E-3,
Part IV,
line 25
or
Wkst. E-3,
Part V,
line 33
Wkst. E,
Part B,
line 43
Subprovider-IPF
Wkst. E-3,
Part VII,
line 42
Wkst. E-3,
Part II,
line 34
Wkst. E
Part B,
line 43
Wkst. E-3,
Part VII,
line 42
Subprovider-IRF
Wkst. E-3
Part VII,
line 42
Wkst. E-3,
Part III,
line 35
Wkst. E
Part B,
line 43
Wkst E-3,
Part VII
line 42
Subprovider-Other
Wkst. E series as applicable.
Swing Bed - SNF
Wkst. E-2,
col. 1,
line 22
Wkst. E-2,
col. 1,
line 22
Wkst. E-2,
col. 2,
line 22
Wkst. E-2,
col. 1,
line 22
Swing Bed - NF
Wkst. E-2,
col. 1,
line 22
N/A
N/A
Wkst. E-2
col. 1,
line 22
SNF
Wkst. E-3,
Part VII,
Line 42
Wkst. E-3,
Part VI,
line 18
Wkst. E,
Part B,
line 43
Wkst. E-3,
Part VII,
line 42
NF, ICF/MR
Wkst. E-3,
Part VII,
Line 42
N/A
N/A
Wkst. E-3,
Part VII
line 42
Rev. 2
40-27
08-11
FORM CMS-2552-10
4003.3 (Cont.)
FROM__________
Hospital/
Hospital Component
Title V
Title XVIII
Part A
Title XVIII
Part B
Title XIX
Home Health
Agency
Wkst. H-4,
Part II,
sum of cols.
1&2, line 34
Wkst. H-4,
Part II,
col. 1,
line 34
Wkst. H-4,
Part II,
col. 2,
line 34
Wkst. H-4,
Part II,
sum of cols.
1 & 2, line 34
Outpatient
Rehabilitation
Providers
Wkst.
J-3,
line 29
N/A
Wkst.
J-3,
line 29
Wkst.
J-3,
line 29
Rural Health Clinic/
Federally Qualified
Health Clinic
Wkst.
M-3
line 29
N/A
Wkst.
M-3
line 29
Wkst.
M-3
line 29
40-28
Rev. 2
10-12
FORM CMS-2552-10
4004
4004.
WORKSHEET S-2 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
IDENTIFICATION DATA
This worksheet consists of two parts:
Part I
Part II
-
Hospital and Hospital Health Care Complex Identification Data
Hospital and Hospital Health Care Complex Reimbursement Questionnaire
4004.1 Part I - Hospital and Hospital Health Care Complex Identification Data.-- The
information required on this worksheet is needed to properly identify the provider. The
responses to all lines are Yes or No unless otherwise indicated by the type of question.
Line Descriptions
Lines 1 and 2--Enter the street address, post office box (if applicable), the city, State, ZIP code,
and county of the hospital.
Lines 3 - 17--Enter on the appropriate lines and columns indicated the component names, CMS
certification numbers (CCN), core based statistical area (CBSA) codes (non-CBSA (rural) codes
are assembled by placing the digits “999” in front of the two digit State code, e.g., for the state
of Maryland the Non-CBSA code is 99921), provider type, and certification dates of the hospital
and its various components, if any. Indicate for each health care program (titles V, XVIII, or
XIX) the payment system applicable to the hospital and its various components by entering P, T,
O, or N in the appropriate column to designate PPS, TEFRA, OTHER, or NOT APPLICABLE,
respectively. The “OTHER” payment system includes critical access hospitals (CAHs) and cost
reimbursed providers.
Column 4--Indicate, as applicable, the number listed below which best corresponds with the type
of services provided.
1 = General Short Term
2 = General Long Term
3 = Cancer
4 = Psychiatric
5 = Rehabilitation
6 = Religious Non-Medical Health Care Institution
7 = Children
8 = Alcohol and Drug
9 = Other
If your hospital services various types of patients, indicate "General - Short Term" or "General Long Term," as appropriate.
NOTE: Long term care hospitals are hospitals organized to provide long term treatment
programs with average lengths of stay greater than 25 days. Some hospitals may be certified as
other than long term care hospitals, but also have average lengths of stay greater than 25 days.
If your hospital cares for only a special type of patient (such as cancer patients), indicate the
special group served. If you are not one of the hospital types described in items 1 through 8
above, indicate 9 for "Other".
Line 3--This is an institution which meets the requirements of §1861(e) or §1861(mm)(1) of the
Act and participates in the Medicare program or is a Federally controlled institution approved by
CMS.
Line 4--The distinct part inpatient psychiatric facility (IPF) is a portion of a general hospital
which has been issued a subprovider CCN because it offers a clearly different type of service
from the remainder of the hospital with such services reimbursed under inpatient psychiatric
PPS. (See 42 CFR 412.25) While an excluded unit (excluded from IPPS) in a hospital subject to
IPPS may not meet the definition of a subprovider, treat it as a subprovider for cost reporting
purposes.
Rev. 3
40-29
4004.1 (Cont.)
FORM CMS-2552-10
10-12
Line 5--The distinct part inpatient rehabilitation facility (IRF) is a portion of a general hospital
which has been issued a subprovider CCN because it offers a clearly different type of service
from the remainder of the hospital with such services reimbursed under inpatient rehabilitation
PPS. (See 42 CFR 412.25) While an excluded unit (excluded from IPPS) in a hospital subject to
IPPS may not meet the definition of a subprovider, treat it as a subprovider for cost reporting
purposes.
Line 6--This is a portion of a general hospital defined as non-Medicare certified not included in
lines 4 through 18 which offers a clearly different type of service from the remainder of the
hospital.
Line 7--Medicare swing-bed services are paid under the SNF PPS system (indicate payment
system as “P”). CAHs are reimbursed on a cost basis for swing-bed services and should indicate
“O” as the payment system. Rural hospitals with fewer than 100 beds may be approved by CMS
to use these beds interchangeably as hospital and skilled nursing facility beds with payment
based on the specific care provided. This is authorized by §1883 of the Act. (See CMS Pub. 151, §§2230-2230.6.)
Line 8--Swing bed-NF services are not payable under the Medicare program but are payable
under State Medicaid programs if included in the Medicaid State plan. This is a rural hospital
with fewer than 100 beds that has a Medicare swing bed agreement approved by CMS and that is
approved by the State Medicaid agency to use these beds interchangeably as hospital and other
nursing facility beds, with payment based on the specific level of care provided. This is
authorized by §1913 of the Act.
Line 9--This is a distinct part skilled nursing facility that has been issued an SNF identification
number and which meets the requirements of §1819 of the Act. For cost reporting periods
beginning on or after October 1, 1996, a complex cannot contain more than one hospital-based
SNF or hospital-based NF.
Line 10--This is a distinct part nursing facility which has been issued a separate identification
number and which meets the requirements of §1905 of the Act. (See 42 CFR 442.300 and 42
CFR 442.400 for standards for other nursing facilities, for other than facilities for the mentally
retarded, and for facilities for the mentally retarded.) If your State recognizes only one level of
care, i.e., skilled, do not complete any lines designated as NF and report all activity on the SNF
line for all programs. The NF line is used by facilities having two levels of care, i.e., either 100
bed facility all certified for NF and partially certified for SNF or 50 beds certified for SNF only
and 50 beds certified for NF only. The contractor will reject a cost report attempting to report
more than one nursing facility.
If the facility operates an Intermediate Care Facility/Mental Retarded (ICF/MR) subscript line 10
to 10.01 and enter the data on that line. Note: Subscripting is allowed only for the purpose of
reporting an ICF/MR.
Line 11--This is any other hospital-based facility not listed above. The beds in this unit are not
certified for titles V, XVIII, or XIX.
Line 12--This is a distinct part HHA that has been issued an HHA identification number and
which meets the requirements of §§1861(o) and 1891 of the Act. If you have more than one
hospital-based HHA, subscript this line, and report the required information for each HHA.
40-30
Rev. 3
10-12
FORM CMS-2552-10
4004.1 (Cont.)
Line 13--This is a distinct entity that operates exclusively for the purpose of providing surgical
services to patients not requiring hospitalization and which meets the conditions for coverage in
42 CFR 416, Subpart B. The ASC operated by a hospital must be a separately identifiable entity
which is physically, administratively, and financially independent and distinct from other
operations of the hospital. (See 42 CFR 416.30(f).) Under this restriction, hospital outpatient
departments providing ambulatory surgery (among other services) are not eligible. (See 42 CFR
416.120(a).)
Line 14--This is a distinct part hospice and separately certified component of a hospital which
meets the requirements of §1861(dd) of the Act. No payment designation is required in columns
6, 7, and 8.
Lines 15 and 16--Enter the applicable information for rural health clinics (RHCs) on line 15 and
for federally qualified health clinics (FQHCs) on line 16. These lines are used by RHCs and/or
FQHCs which have been issued a provider number and meet the requirements of §1861(aa) of
the Act. If you have more than one RHC, report them on subscripts of line 15. If you have more
than one FQHC, report them on subscripts of line 16. Report the required information in the
appropriate column for each. (See Exhibit 2, Table 4) RHCs and FQHCs may elect to file a
consolidated cost report pursuant to CMS Pub. 100-04, chapter 9, §30.8. Do not subscript this
line if you elect to file under the consolidated cost reporting method. See section 4010 for
further instructions.
Line 17--This line is used by hospital-based community mental health centers (CMHCs).
Subscript this line as necessary to accommodate multiple CMHCs (lines 17.00-17.09). Also
subscript this line to accommodate CORFs (lines 17.10-17.19), OPTs (lines 17.20-17.29), OOTs
(lines 17.30-17.39) and OSPs (lines 17.40-17.49). (See Exhibit 2, Table 4, Part III.)
Line 18--If this facility operates a renal dialysis facility (CCN 2300-2499), a renal dialysis
satellite (CCN 3500-3699), and/or a special purpose renal dialysis facility (CCN 3700-3799),
enter in column 2 the applicable CCN. Subscript this line as applicable.
Line 19--For any component type not identified on lines 3 through 19, enter the required
information in the appropriate column.
Line 20--Enter the inclusive dates covered by this cost report. In accordance with 42 CFR
413.24(f), you are required to submit periodic reports of your operations which generally cover a
consecutive 12 month period of your operations. (See CMS Pub. 15-2, §§102.1-102.3 for
situations where you may file a short period cost report.)
Line 21--Indicate the type of control or auspices under which the hospital is conducted as
indicated:
1 = Voluntary Nonprofit, Church
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Governmental, Federal
8 = Governmental, City-County
9 = Governmental, County
10 = Governmental, State
11 = Governmental, Hospital District
12 = Governmental, City
13 = Governmental, Other
Line 22--Does your facility qualify and is it currently receiving payments for disproportionate
share hospital adjustment, in accordance with 42 CFR 412.106? Enter on column 1 “Y” for yes
or “N” for no. Is this facility subject to the provisions of 42 CFR 412.106(c)(2) (Pickle
Amendment hospitals)? Enter in column 2 “Y” for yes or “N” for no.
Line 23--Indicate in column 1 the method used to capture Medicaid (title XIX) days reported on
lines 24 and/or 25 of this worksheet during the cost reporting period by entering a “1” if days are
based on the date of admission, “2” if days are based on census days (also referred to as the day
count), or “3”
Rev. 3
40-31
4004.1 (Cont.)
FORM CMS-2552-10
10-12
if the days are based on the date of discharge. Is the method of identifying the days in the
current cost reporting period different from the method used in the prior cost reporting period?
Enter in column 2 “Y” for yes or “N” for no.
NOTE: For lines 24 and 25, columns 1 through 6 are mutually exclusive. For example, if
patient days are entered in column 1, those days may not be entered in any other columns.
Line 24--If this is an IPPS provider, in accordance with 42 CFR 412.106(b)(4), enter the in-state
Medicaid paid days in column 1, the in-state Medicaid eligible but unpaid days in column 2, the
out-of-state Medicaid paid days in column 3, the out-of-state Medicaid eligible but unpaid days
in column 4, Medicaid HMO paid and eligible but unpaid days in column 5, and other Medicaid
days in column 6. For all columns include in these days the labor and delivery days. Do not
include swing-bed, observation or hospice days in any columns on this line.
Line 25--If this provider is an IRF, in accordance with 42 CFR 412.106(b)(4),enter the in-state
Medicaid paid days in column 1, the in-state Medicaid eligible but unpaid days in column 2, the
out-of-state Medicaid paid days in column 3, the out-of-state Medicaid eligible but unpaid days
in column 4, Medicaid HMO paid and eligible but unpaid days in column 5, and other Medicaid
days in column 6. For all columns include in these days the labor and delivery days.
Line 26--For the Standard Geographic classification (not wage), what is your status at the
beginning of the cost reporting period. Enter “1” for urban or “2” for rural.
Line 27--For the Standard Geographic classification (not wage), what is your status at the end of
the cost reporting period. Enter “1” for urban or “2” for rural. If applicable, enter the effective
date of the geographic reclassification in column 2.
Lines 28 - 34--Reserved for future use.
Line 35--If this is a sole community hospital (SCH), enter the number of periods (0, 1 or 2)
within this cost reporting period that SCH status was in effect. Enter the beginning and ending
dates of SCH status on line 36. Subscript line 36 if more than 1 period is identified for this cost
reporting period and enter multiple dates. Multiple dates are created where there is a break in the
date between SCH status, i.e., for calendar year provider SCH status dates are 1/1/20106/30/2010 and 9/1/2010-12/31/2010.
Line 37--If this is a Medicare dependent hospital (MDH), enter the number of periods within this
cost reporting period that MDH status was in effect. Enter the beginning and ending dates of
MDH status on line 38. Subscript line 38 if more than 1 period is identified for this cost
reporting period and enter multiple dates.
Lines 39 - 44--Reserved for future use.
Line 45--Does your facility qualify and receive capital payments for disproportionate share in
accordance with 42 CFR 412.320? Enter "Y" for yes and "N" for no.
Line 46--Are you eligible for the exception payment for extraordinary circumstances pursuant to
42 CFR 412.348(f)? Enter “Y” for yes or “N” for no. If yes, complete Worksheets L, Part III
and L-1.
Line 47--Is this a new hospital under 42 CFR 412.300(b) (PPS capital)? Enter “Y” for yes or
“N” for no for the respective programs.
Line 48--If line 47 is yes, do you elect full federal capital payment. Enter “Y” for yes or “N” for
no for the respective programs.
40-32
Rev. 3
10-12
FORM CMS-2552-10
4004.1 (Cont.)
Lines 49 - 55--Reserved for future use.
NOTE: CAHs complete question 107 in lieu of question 57.
Line 56--Is this a hospital involved in training residents in approved GME programs? Enter “Y”
for yes or “N” for no.
Line 57--If line 56 is yes, is this the first cost reporting period in which you are training residents
in approved programs. Enter “Y” for yes or “N” for no in column 1. If column 1 is yes, were
residents training during the first month of the cost reporting period. Enter “Y” for yes or “N”
for no in column 2. If column 2 is yes, complete Worksheet E-4. If column 2 is “N” complete
Worksheets D, Parts III and IV and D-2, Part II, if applicable.
Line 58--As a teaching hospital, did you elect cost reimbursement for teaching physicians as
defined in CMS Pub. 15-1, §2148? Enter “Y” for yes or “N” for no. If yes, complete Worksheet
D-5.
Line 59--Are you claiming costs of intern & resident in unapproved programs on line 100,
column 7, of Worksheet A? Enter “Y” for yes or “N” for no. If yes, complete Worksheet D-2,
Part I.
Line 60--Are you claiming nursing school and/or allied health costs for a program that meets the
provider-operated criteria under 42 CFR 413.85? Enter “Y” for yes or “N” for no. If yes, you
must identify such costs in the applicable column(s) of Worksheet D, Parts III and IV to
separately identify nursing and allied health (paramedical education) from all other medical
education costs.
Line 61--Did your hospital receive FTE slots under section 5503 of the ACA? Enter “Y” for yes
or “N” for no in column 1. If yes, complete columns 2 and 3. If “N” for no do not complete
columns 2 or 3. Effective for portions of cost reporting periods occurring on or after July 1,
2011, enter the average number of primary care FTE residents from the hospital’s 3 most recent
cost reports ending and submitted to the contractor before March 23, 2010. Enter the 3 year
primary care average for IME in column 2. Compute the IME 3 year average primary care FTE
counts from the rotation schedules for the 3 most recent cost reporting periods ending and
submitted to the contractor prior to March 23, 2010. This primary care average is based on the
hospital’s total primary care FTE count that would otherwise be allowable if not for the FTE
resident cap. Exclude OB/GYN FTE residents.
Enter the average number of primary care FTE residents for direct GME in column 3. This
primary care average is based on the hospital’s total unweighted primary care FTE count that
would otherwise be allowable if not for the FTE resident cap. If the hospital did not train any
OB/GYN residents in its 3 most recent cost reporting periods ending and submitted prior to
March 23, 2010, convert the weighted primary care FTE counts from line 3.19 of Worksheet E3, Part IV of Form CMS 2552-96, to unweighted FTE counts, compute a 3 year average, and
report the average in column 3. If the hospital did train OB/GYN FTE residents in its 3 most
recent cost reporting periods ending and submitted prior to March 23, 2010, subtract the
OB/GYN FTE counts from line 3.19 of Worksheet E-3, Part IV of Form CMS 2552-96, convert
the remaining primary care FTE counts to unweighted FTE counts, compute a 3 year average,
and report the average in column 3.
Lines 62 - 62.01--Affordable Care Act Provisions Affecting the Health Resources and Services
Administration (HRSA)--These provisions are effective for a five year period for the Health
Resources and Services Administration (HRSA) Primary Care Residency Expansion (PCRE)
program and the Teaching Health Center (THC) program.
Line 62--Effective for services rendered during September 30, 2010 through September 29,
2015, of the HRSA PCRE program, enter the number of FTE residents that your hospital trained
in this cost reporting period for which your hospital received HRSA PCRE funding. (Sections
4002 and 5301 of the ACA.)
Rev. 3
40-33
4004.1 (Cont.)
FORM CMS-2552-10
10-12
Line 62.01--Effective for services rendered during October 1, 2010, through September 30,
2015, enter the number of FTE residents that rotated from a Teaching Health Center (THC) into
your hospital during this cost reporting period under the HRSA THC program. (Section 5508 of
the ACA.)
Line 63--Has your facility trained residents in a non-provider setting during this cost reporting
period? Enter “Y” for yes or “N” for no in column 1. See Federal Register, Vol. 75, number
226, dated November 24, 2010, page 72139-40. If column 1 is “Y” for yes, complete lines 64
through 67 and applicable subscripts. If “N” for no, but your facility trained residents in a nonprovider setting during the base year period (cost reporting period that begins on or after July 1,
2009 and before June 30, 2010), complete lines 64 and 65 and applicable subscripts effective for
cost reporting periods beginning on or after July 1, 2010.
Lines 64 - 65--Section 5504 of the ACA Base Year FTE Residents in Nonprovider Settings--The
base year is your cost reporting period that begins on or after July 1, 2009 and before June 30,
2010.
Line 64--If line 63 is yes or your facility trained residents in the base year period, enter in
column 1, for cost reporting periods that begins on or after July 1, 2009, and before June 30,
2010 the number of unweighted nonprimary care FTE residents attributable to rotations that
occurred in all nonprovider settings. Enter in column 2 the number of unweighted nonprimary
care FTE residents that trained in your hospital. Include unweighted OB/GYN, dental and
podiatry FTEs on this line. Enter in column 3, the ratio of column 1 divided by the sum of
columns 1 and 2.
Line 65-- If line 63 is yes or your facility trained residents in the base year period, enter from
your cost reporting period that begins on or after July 1, 2009 and before June 30, 2010, the
number of unweighted primary care FTE residents for each primary care specialty program in
which you train residents. Use subscripted lines 65.01 through 65.50 for each additional primary
care program. 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
that occurred in nonprovider settings for each applicable program. Enter in column 4, the
number of unweighted primary care FTE residents in your hospital for each applicable program.
Enter in column 5 the ratio of column 3 divided by the sum of columns 3 and 4. If you operated
a primary care program that did not have FTE residents in a nonprovider setting, enter zero in
column 3 and complete all other columns for each applicable program.
NOTE: The sum of the FTE counts on line 64, columns 1 and 2, and line 65, columns 3 and 4,
should approximate the sum of the FTE counts on Form CMS 2552-96, Worksheet E3, part IV, lines 3.05 and 3.11 for your cost reporting period that begins on or after July
1, 2009 and before June 30, 2010.
Lines 66 and 67--Section 5504 of the ACA Current Year FTE Residents in Nonprovider
Settings-- Effective for cost reporting periods beginning on or after July 1, 2010.
Line 66--If line 63 is yes, enter in column 1 the unweighted number of nonprimary care FTE
residents attributable to rotations occurring in all non-provider settings. Enter in column 2 the
number of unweighted nonprimary care FTE residents in your hospital. Include unweighted
OB/GYN, dental and podiatry FTEs on this line. Enter in column 3 the ratio of column 1 divided
by the sum of columns 1 and 2.
Line 67-- If line 63 is yes, then, for each primary care residency program in which you are
training residents, 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
that occurred in nonprovider settings for each applicable program. Enter in column 4 the number
of unweighted primary care FTE residents in your hospital for each applicable program. Enter in
column 5 the ratio of column 3 divided by the sum of columns 3 and 4. Use subscripted lines
67.01 through 67.50 for each additional primary care program.
40-33.1
Rev. 3
10-12
FORM CMS-2552-10
4004.1 (Cont.)
This page is reserved for future use.
Rev. 3
40-33.2
4004.1 (Cont.)
FORM CMS-2552-10
10-12
If you operated a primary care program that did not have FTE residents in a nonprovider
setting, enter zero in column 3 and complete all other columns for each applicable program.
NOTE: The sum of the FTE counts on line 66, columns 1 and 2, and line 67, columns 3 and 4,
should approximate the sum of the FTE counts on Worksheet E-4, lines 6 and 10 for
this current cost reporting period.
Lines 68 - 69--Reserved for future use.
Line 70--Are you an IPF or do you contain an IPF subprovider? Enter in column 1 “Y” for yes
or “N” for no.
Line 71--If this facility is an IPF or contains an IPF subprovider (response to line 70, column 1 is
“Y” for yes), were residents training in this facility in the most recent cost report filed on or
before November 15, 2004? Enter in column 1 “Y” for yes or “N” for no. Is the facility
training residents in new teaching programs in accordance with §412.424(d)(1)(iii)(D)? Enter in
column 2 “Y” for yes or “N” for no. (Note: questions 1 and 2 must have opposite answers, i.e., if
column 1 is “Y”, then column 2 must be “N” and vice versa; columns 1 and 2 cannot be “Y”
simultaneously, columns 1 and 2 can be “N” simultaneously.) If yes, enter a “1”, “2”, or “3”,
respectively, in column 3 to correspond to the I&R academic year in the first 3 program years of
the first new program’s existence that begins during the current cost reporting period. If the
current cost reporting period covers the beginning of the fourth academic year of the first new
teaching program’s existence, enter the number “4” in column 3. If the current cost reporting
period covers the beginning of the fifth or subsequent academic years of the first new teaching
program’s existence, enter the number “5” in column 3.
Lines 72 - 74--Reserved for future use.
Line 75--Are you an IRF or do you contain an IRF subprovider? Enter in column 1 “Y” for yes
and “N” for no.
Line 76--If this facility is an IRF or contains an IRF subprovider (response to line 75, column 1
is “Y” for yes), did the facility train residents in teaching programs in the most recent cost
reporting period ending on or before November 15, 2004? Enter in column 1 “Y” for yes or
“N” for no. Is the facility training residents in new teaching programs in accordance with FR,
Vol. 70, No. 156, page 47929 dated August 15, 2005? Enter in column 2 “Y” for yes or “N” for
no. (Note: questions 1 and 2 must have opposite answers, i.e., if column 1 is “Y”, then column 2
must be “N” and vice versa; columns 1 and 2 cannot be “Y” simultaneously, columns 1 and 2
can be “N” simultaneously.) If yes, enter a “1”, “2”, or “3”, respectively, in column 3 to
correspond to the I&R academic year in the first 3 program years of the first new program’s
existence that begins during the current cost reporting period. If the current cost reporting period
covers the beginning of the fourth academic year of the first new teaching program’s existence,
enter the number “4” in column 3. If the current cost reporting period covers the beginning of the
fifth or subsequent academic years of the first new teaching program’s existence, enter the
number “5” in column 3.
Lines 77 - 79--Reserved for future use.
Line 80--Are you a freestanding long term care hospital (LTCH)? Enter in column 1 “Y” for yes
and “N” for no. LTCHs can only exist as independent/freestanding facilities. To be considered
as independent or a freestanding facility, a LTCH located within another hospital must meet the
separateness (from the host/co-located provider) requirements identified in 42 CFR 412.22(e.)
Lines 81 - 84--Reserved for future use.
Line 85--Is this a new hospital under 42 CFR 413.40(f)(1)(i) (TEFRA)? Enter “Y” for yes or
“N” for no in column 1.
40-34
Rev. 3
10-12
FORM CMS-2552-10
4004.1 (Cont.)
Line 86--Have you established a new “Other” subprovider (excluded unit) under 42 CFR 413.40
(f)(1)(ii)? Enter “Y” for yes or “N” for no in column 1. If there is more than one subprovider,
subscript this line. Do not complete this line.
Line 87 - 89--Reserved for future use.
Lines 90--Do you provide title V and/or XIX inpatient hospital services? Enter "Y" for yes or
"N" for no in the applicable column.
Line 91--Is this hospital reimbursed for title V and/or XIX through the cost report in full or in
part? Enter “Y” for yes or “N’ for no in the applicable column.
Line 92--If all of the nursing facility beds are certified for title XIX, and there are also title XVIII
certified beds (dual certified), are any of the title XVIII beds occupied by title XIX patients?
Enter “Y” for yes or “N” for no in the applicable column. You must complete a separate
Worksheet D-1 for title XIX for each level of care.
Line 93--Do you operate an ICF/MR facility for purposes of title XIX? Enter “Y” for yes or “N”
for no.
Line 94--Does title V and/or XIX reduce capital costs? Enter “Y” for yes or “N” for no in the
applicable column.
Line 95--If line 94 of the corresponding column is “Y” for yes, enter the percentage by which
capital costs are reduced.
Line 96--Does title V and/or XIX reduce operating costs? Enter “Y” for yes or “N” for no in the
applicable column.
Line 97--If line 96 of the corresponding column is “Y” for yes, enter the percentage by which
operating costs are reduced.
Lines 98 - 104--Reserved for future use.
Line 105--If this hospital qualifies as a CAH, enter “Y” for yes in column 1. Otherwise, enter
“N” for no, and skip to line 108. (See 42 CFR 485.606ff.)
Line 106--If this facility qualifies as a CAH, has it elected the all-inclusive method of payment
for outpatient services? Enter “Y” for yes or “N” for no. If yes, an adjustment for the
professional component is still required on Worksheet A-8-2.
NOTE: If the facility elected the all-inclusive method for outpatient services, professional
component amounts should be excluded from deductible and coinsurance amounts and
should not be included on E-1.
Line 107--If this facility qualifies as a CAH, is it eligible for 101 percent reasonable cost
reimbursement for I&R in approved training programs? Enter a “Y” for yes or an “N” for no in
column 1. If yes, the GME elimination is not made on Worksheet B, Part I, column 25 and the
program is cost reimbursed. If yes, complete Worksheet D-2, Part II.
If this facility qualifies as a CAH, do I&R in approved medical education programs train in the
CAH’s excluded IPF and/or IRF unit? Enter a “Y” for yes or an “N” for no in column 2. If yes,
complete Worksheet E-4. CAHs are reimbursed for GME in subproviders on Worksheet E-4;
and are reimbursed for GME in the rest of the CAH at 101 percent of reasonable cost. The CAH
must maintain adequate documentation to support the FTE resident count and time spent for the
excluded IPF and/or IRF units.
Rev. 3
40-35
4004.1 (Cont.)
FORM CMS-2552-10
10-12
Line 108--Is this a rural hospital qualifying for an exception to the certified registered nurse
anesthetist (CRNA) fee schedule? (See 42 CFR 412.113(c).) Enter “Y” for yes in column 1.
Otherwise, enter “N” for no.
Line 109--If this hospital qualifies as a critical access hospital (CAH) (response to line 105 is
yes) or is a cost reimbursed provider, are therapy services provided by outside suppliers? Enter
“Y” for yes or “N” for no under the corresponding physical, occupational, speech and/or
respiratory therapy services as applicable in columns 1 through 4.
Lines 110 - 114--Reserved for future use.
Line 115--Is this an all inclusive rate provider (see instructions in CMS Pub. 15-1, §2208). Enter
“Y” for yes or “N” for no in column 1. If yes, enter the applicable method (A, B, or E only) in
column 2. If column 2 is “E”, enter the inpatient Medicare calculation percentage in column 3.
Enter “93” for short-term hospitals where over 50 percent of all patients admitted stay less than
30 days or “98” for long-term hospitals where over 50 percent of all patients stay 30 days or
more. (See CMS Pub. 15-1, §2208.1.E.)
Line 116--Are you classified as a referral center? Enter “Y” for yes or “N” for no. See 42 CFR
412.96.
Line 117--Are you legally required to carry malpractice insurance? Enter “Y” for yes or “N” for
no. Malpractice insurance, sometimes referred to as professional liability insurance, is insurance
purchased by physicians and hospitals to cover the cost of being sued for malpractice.
Line 118--Is the malpractice insurance a claims-made or occurrence policy? A claims-made
insurance policy covers claims first made (reported or filed) during the year the policy is in force
for any incidents that occur that year or during any previous period during which the insured was
covered under a "claims-made" contract. The occurrence policy covers an incident occurring
while the policy is in force regardless of when the claim arising out of that incident is filed. If
the policy is claims-made, enter 1. If the policy is occurrence, enter 2.
Line 118.01--Enter the total amount of malpractice premiums paid in column 1, enter the total
amount of paid losses in column 2, and enter the total amount of self insurance paid in column 3.
Line 118.02--Indicate if malpractice premiums and paid losses are reported in a cost center
other than the Administrative and General cost center. If yes, provide a supporting schedule and
list the amounts applicable to each cost center.
Malpractice insurance premiums are money paid by the provider to a commercial insurer to
protect the provider against potential negligence claims made by their patients/clients.
Malpractice paid losses is money paid by the healthcare provider to compensate a patient/client
for professional negligence. Malpractice self-insurance is money paid by the provider where the
healthcare provider acts as its own insurance company (either as a sole or part-owner) to
financially protect itself against professional negligence. Often providers will manage their own
funds or purchase a policy referred to as captive insurance, which protects providers for excess
protection that may be unavailable or cost-prohibitive at the primary level.
Line 119--This question is eliminated and this line must not be used.
Line 120--If this is an SCH (or EACH), that qualifies for the outpatient hold harmless provision
in accordance with ACA section 3121, enter “Y” for yes or “N” for no in column 1. If this is a
rural hospital with 100 or fewer beds, that qualifies for the outpatient hold harmless provision in
accordance with ACA section 3121, enter “Y” for yes or “N” for no in column 2. ACA section
40-36
Rev. 3
10-12
FORM CMS-2552-10
4004.1 (Cont.)
3121, was amended by the Medicare and Medicaid Extenders Act (MMEA) of 2010, section
108; the Temporary Payroll Tax Cut Continuation Act of 2011, section 308; and the Middle
Class Tax Relief and Job Creation Act of 2012, section 3002. Note that for SCHs and EACHs
the outpatient hold harmless provision is effective for services rendered from January 1, 2010
through February 29, 2012, regardless of bed size and from March 1, 2012 through December
31, 2012, for SCHs and EACHs with 100 or fewer beds. Rural hospitals with 100 or fewer beds
are also extended through December 31, 2012. These responses impact the TOPs calculation on
Worksheet E, Part B, line 8.
Line 121--Did this facility incur and report costs in the “Implantable Devices Charged to
Patients” (line 72) cost center as indicated in the Federal Register, Vol. 73, number 161, dated
August 19, 2008, page 48462 under the following revenue codes: code 0275 - pacemaker, code
0276 - intraocular lens, code 0278 - other implants and code 0624 - Food and Drug
Administration (FDA) investigational devices. Enter “Y” for yes or “N” for no in column 1.
Lines 122 - 124--Reserved for future use.
Line 125--Does your facility operate a transplant center(s)? Enter “Y” for yes or “N” for no in
column 1. If yes, enter the all the applicable certification dates below.
Line 126--If this is a Medicare certified kidney transplant center, enter the certification date in
column 1 and termination date in column 2. Also complete Worksheet D-4.
Line 127--If this is a Medicare certified heart transplant center, enter the certification date in
column 1 and termination date in column 2. Also complete Worksheet D-4.
Line 128--If this is a Medicare certified liver transplant center, enter the certification date in
column 1 and termination date in column 2. Also complete Worksheet D-4.
Line 129--If this is a Medicare certified lung transplant center, enter the certification date in
column 1 and termination date in column 2. Also, complete Worksheet D-4.
Line 130--If Medicare pancreas transplants are performed, enter the more recent date of July 1,
1999 (coverage of pancreas transplants) or the certification date in column 1 for kidney
transplants and termination date in column 2. Also, complete Worksheet D-4.
Line 131--If this is a Medicare certified intestinal transplant center enter the certification date in
column 1 and termination date in column 2. Also, complete Worksheet D-4.
Line 132--If this is a Medicare certified islet transplant center enter the certification date in
column 1 and termination date in column 2. Also, complete Worksheet D-4.
Line 133--Use this line if your facility contains a Medicare certified transplant center not
specifically identified on lines 126 through 132. Enter the certification date in column 1 and
termination date in column 2. Subscript this line as applicable and complete a separate
Worksheet D-4 for each Medicare certified transplant center type.
Line 134--If this is an organ procurement organization (OPO), enter the OPO CCN number in
column 1 and termination date, if applicable, in column 2.
Lines 135 - 139--Reserved for future use.
Line 140--Are there any related organization or home office costs claimed as defined in CMS
Pub. 15-1, chapter 10? Enter “Y” for yes or “N” for no in column 1. If yes, complete Worksheet
A-8-1. If this facility is part of a chain and you are claiming home office costs, enter in column 2
the home office chain number; and enter the chain name, home office number, contractor
number, street
Rev. 3
40-37
4004.1 (Cont.)
FORM CMS-2552-10
10-12
address, post office box (if applicable), the city, State, zip code of the home office on lines 141
through 143. Also, enter on line 141, column 2, the contractor name, who receives the Home
Office Cost Statement and in column 3, the contractor number. See CMS Pub. 15-1, §2150 for a
definition of a chain organization.
Line 141--Enter the name of the Home Office.
Line 142--Enter the street address and P. O. Box (if applicable) of the Home Office.
Line 143--Enter the city, State and ZIP code of the Home Office.
Line 144--Are provider based physicians' costs included in Worksheet A? Enter “Y” for yes or
“N” for no. If yes, complete Worksheet A-8-2.
Line 145--If you are claiming costs for renal services on Worksheet A, line 74, are they inpatient
services only? Enter “Y” for yes or “N” for no. If yes, do not complete Worksheet S-5 and the
Worksheet I series.
Line 146--Have you changed your cost allocation methodology from the previously filed cost
report? Enter “Y” for yes or “N” for no. If yes, enter the approval date in column 2.
Line 147--Was there a change in the statistical basis? Enter “Y” for yes or “N” for no.
Line 148--Was there a change in the order of allocation? Enter “Y” for yes or “N” for no.
Line 149--Was there a change to the simplified cost finding method? Enter “Y” for yes or “N”
for no.
Lines 150 - 154--Reserved for future use.
Lines 155 - 161--If you are a hospital (public or non public) that qualifies for an exemption from
the application of the lower of cost or charges as provided in 42 CFR 413.13, indicate the
component and/or services for titles V, XVIII and XIX that qualify for the exemption by entering
in the corresponding box a “Y” for yes, if you qualify for the exemption or an “N” for no if you
do not qualify for the exemption. Subscript as needed for additional components. For title XVIII
providers, a response of “Y” does not subject the provider to LCC.
Lines 162 - 164--Reserved for future use.
Line 165--Is the hospital part of a multi-campus hospital that has one or more campuses in
different CBSAs? Enter “Y” for yes or “N” for no.
Line 166--If you responded “Y” for yes to question 165, enter information for each campus
(including the main campus) as follows: name in column 0, county in column 1, State in column
2, zip code in column 3, CBSA in column 4, and the FTE count for this campus in column 5. If
additional campuses exist, subscript this line as necessary.
Line 167--Is this hospital/campus a meaningful user of electronic health record (EHR)
technology in accordance section 1886(n) of the Social Security Act as amended by the section
4102 of the American Recovery and Reinvestment Act (ARRA) of 2009? Enter “Y” for yes or
“N” for no.
40-38
Rev. 3
10-12
FORM CMS-2552-10
4004.1 (Cont.)
Line 168--If this provider is a CAH (line 105 is “Y” for yes) and is also a meaningful EHR
technology user (line 167 is “Y” for yes) enter, if applicable, the reasonable acquisition cost
incurred for EHR assets either purchased or initially rented under a virtual purchase lease (see
PRM-1, §110.B.1.b) in the current cost reporting period. If applicable, also enter the undepreciated cost (i.e., net book value), as of the beginning of the current cost reporting period,
for assets purchased or initially rented under a virtual purchase lease in prior cost reporting
period(s) which were used for EHR purposes in the current cost reporting period. Do not enter
on this line any cost for EHR assets which was already claimed for the same assets in previous
cost reporting period(s). The reasonable acquisition cost incurred is for depreciable assets such
as computers and associated hardware and software necessary to administer certified EHR
technology. (See Federal Register, Vol. 75, number 144, dated July 28, 2010, pages 44461 and
42 CFR 495.106(a) and (c)(2).)
Additionally, if the amount on this line is greater than zero, submit a listing of the EHR assets
showing the following information for each asset: (1) nature of each asset and acquisition cost;
(2) an annotation whether the asset was purchased or leased under a virtual purchase lease (42
CFR 413.130(b)(8)); (3) date of purchase or date the virtual purchase lease was initiated; (4)
name(s) of original purchaser (e.g., CAH, CAH’s home office, group of unrelated providers);
(5) information regarding the asset’s use (i.e., indication whether the asset (hardware of
software) will be shared with CAH’s non-EHR systems); and (6) tag number and location
(department unit).
Line 169--If this is a §1886(d) provider that responded “N” for no to question 105 and “Y” for
yes to question 167, enter the transition factor to be used in the calculation of your HIT incentive
payment.
See Federal Register, Vol. 75, number 144, dated July 28, 2010, pages 44458-60. The transition
factor equals:
If a hospital first becomes a meaningful EHR user in fiscal year 2011, 2012 or 2013
• The first year transition factor is 1.00
• The second year transition factor is 0.75
• The third year transition factor is 0.50
• The fourth year transition factor is 0.25
• Any succeeding transition year is 0
If a hospital first becomes a meaningful EHR user in fiscal year 2014
• The first year transition factor is 0.75
• The second year transition factor is 0.50
• The third year transition factor is 0.25
• Any succeeding transition year is 0
If a hospital first becomes a meaningful EHR user in fiscal year 2015
• The first year transition factor is 0.50
• The second year transition factor is 0.25
• Any succeeding transition year is 0
Rev. 3
40-38.1
4004.1 (Cont.)
FORM CMS-2552-10
10-12
This page is reserved for future use.
40-38.2
Rev. 3
10-12
FORM CMS-2552-10
4004.2
4004.2
Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire.-The information required on Part II of this worksheet (formerly Form CMS-339) must be
completed by all hospitals submitting cost reports to the Medicare contractor under Title XVIII
of the Social Security Act (hereafter referred to as “The Act”). Its purpose is to assist you in
preparing an acceptable cost report, to minimize the need for direct contact between you and
your contractor, and to expedite review and settlement of cost reports. It is designed to answer
pertinent questions about key reimbursement concepts displayed in the cost reports and to gather
information necessary to support certain financial and statistical entries on the cost report. The
questionnaire is a tool used in arriving at a prompt and equitable settlement of your cost report.
Where the instructions for this worksheet direct you to submit documentation/information, mail
or otherwise transmit to the contractor immediately after submission of the ECR. The contractor
has the right under §§1815(a) and 1883(e) of the Act to request any missing documentation
required to complete the desk review.
To the degree that the information in the questionnaire constitutes commercial or financial
information which is confidential and/or is of a highly sensitive personal nature, the information
will be protected from release under the Freedom of Information Act. If there is any question
about releasing information, the contractor should consult with the CMS Regional Office.
NOTE: The responses on all lines are Yes or No unless otherwise indicated. If in accordance
with the following instructions, you are requested to submit documentation, indicate
the line number for each set of documents you submit.
Line Descriptions
Lines 1 through 21 are required to be completed by all hospitals.
Line 1--Indicate whether the hospital has changed ownership immediately prior to the beginning
of the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
enter the date the change of ownership occurred in column 2. Also, submit the name and address
of the new owner and a copy of the sales agreement with the cost report.
Line 2--Indicate whether the hospital has terminated participation in the Medicare program.
Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, enter the date of termination in
column 2, and “V” for voluntary or “I” for involuntary in column 3.
Line 3--Indicate whether the hospital is 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. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of
the individuals, the organizations involved, and a description of the transactions with the cost
report.
Rev. 3
40-39
4004.2 (Cont.)
FORM CMS-2552-10
10-12
Note: A related party transaction occurs when services, facilities, or supplies are furnished to the
provider by organizations related to the provider through common ownership or control. (See
Pub. 15-1, Chapter 10 and 42 CFR §413.17.)
Line 4--Indicate whether the financial statements were prepared by a Certified Public
Accountant. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, enter
“A” for audited, “C” for compiled, or “R” for reviewed in column 2. Submit a complete copy of
the financial statements (i.e., the independent public accountant’s opinion, the statements
themselves, and the footnotes) with the cost report. If the financial statements are not available
for submission with the cost report enter the date they will be available in column 3.
If you answer no in column 1, submit a copy of the financial statements you prepared, and
written statements of significant accounting policy and procedure changes affecting Medicare
reimbursement which occurred during the cost reporting period. You may submit the changed
accounting or administrative procedures manual in lieu of written statements.
Line 5--Indicate whether the total expenses and total revenues reported on the cost report differ
from those on the filed financial statements. Enter “Y” for yes or “N” for no in column 1. If you
answer “Y” in column 1, submit a reconciliation with the cost report.
Line 6--Indicate whether costs were claimed for Nursing School. Enter “Y” for yes or “N” for
no in column 1. If you answer “Y” in column 1, enter “Y” for yes or “N” for no in column 2 to
indicate whether the provider is the legal operator of the program .
Line 7--Indicate whether costs were claimed for Allied Health programs. Enter “Y” for yes or
“N” for no in column 1. If you answer “Y” in column 1, submit a list of the program(s) with the
cost report and annotate for each whether the provider is the legal operator of the program.
Note: For purposes of lines 6 and 7, the provider is the legal operator of a nursing school and/or
allied health programs if it meets the criteria in 42 CFR §413.85(f)(1) or (f)(2).
Line 8--Indicate whether approvals and/or renewals were obtained during the cost reporting
period for Nursing School and/or Allied Health programs. Enter “Y” for yes or “N” for no in
column 1. If you answer “Y” in column 1, submit a list of the program(s), and copies of the
approvals and/or renewals with the cost report.
Line 9--Indicate whether Intern-Resident costs were claimed on the current cost report. Enter
“Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit the current year
Intern-Resident Information System (IRIS) on diskette with the cost report.
Line 10--Indicate whether Intern-Resident program(s) have been initiated or renewed during the
cost reporting period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in
column 1, submit copies of the certification(s)/program approval(s) with the cost report. (See 42
CFR §413.79(l) for the definition of a new program.)
Line 11--Indicate whether Graduate Medical Education costs were directly assigned to cost
centers other than the Intern-Resident Services in an Approved Teaching Program on Worksheet
A of form CMS-2552-10. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in
column 1, submit a listing of the cost centers and amounts with the cost report.
40-40
Rev. 3
08-11
FORM CMS-2552-10
4004.2 (Cont.)
Line 12--Indicate whether you are seeking reimbursement for bad debts resulting from Medicare
deductible and coinsurance amounts which are uncollectible from Medicare beneficiaries. (See
42 CFR §413.89ff and Pub. 15-1, §§306 -324 for the criteria for an allowable bad debt.) Enter
“Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a completed
Exhibit 2 or internal schedules duplicating the documentation requested on Exhibit 2 to support
the bad debts claimed. If you are claiming bad debts for inpatient and outpatient services,
complete a separate Exhibit 2 or internal schedule for each category.
Exhibit 2 requires the following documentation:
Columns 1, 2, 3 - Patient Names, Health Insurance Claim (HIC) Number, Dates of Service
(From - To)--The documentation required for these columns is derived from the beneficiary’s
bill. Furnish the patient’s name, health insurance claim number and dates of service that
correlate to the filed bad debt. (See Pub. 15-1, §314 and 42 CFR §413.89.)
Column 4--Indigency/Welfare Recipient--If the patient included in column 1 has been deemed
indigent, place a check in this column. If the patient in column 1 has a valid Medicaid number,
also include this number in this column. See the criteria in Pub. 15-1, §§312 and 322 and 42
CFR §413.89 for guidance on the billing requirements for indigent and welfare recipients.
Columns 5 & 6--Date First Bill Sent to Beneficiary & Date Collection Efforts Ceased--This
information should be obtained from the provider’s files and should correlate with the
beneficiary name, HIC number, and dates of service shown in columns 1, 2 and 3 of this exhibit.
The dates in column 6 represents the date that the unpaid account is deemed worthless, whereby
all collection efforts, both internal and by an outside entity, ceased and there is no likelihood of
recovery of the unpaid account. (See CFR 413.89(f), and Pub. 15-1, §§308, 310, and 314.)
Column 7--Remittance Advice Dates--Enter in this column the remittance advice dates that
correlate with the beneficiary name, HIC No., and dates of service shown in columns 1, 2, and 3
of this exhibit.
Columns 8 & 9--Deductibles & Coinsurance--Record in these columns the beneficiary’s unpaid
deductible and coinsurance amounts that relate to covered services.
Column 10--Total Medicare Bad Debts--Enter on each line of this column, the sum of the
amounts in columns 8 and 9. Calculate the total bad debts by summing up the amounts on all
lines of Column 10. This “total” must agree with the bad debts claimed on the cost report.
Attach additional supporting schedules, if necessary, for bad debt recoveries.
Line 13--Indicate whether your bad debt collection policy changed during the cost reporting
period. Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, submit a
copy of the policy with the cost report.
Line 14--Indicate whether patient deductibles and/or copayments are waived. Enter “Y” for yes
or “N” for no in column 1. If you answer “Y” in column 1, ensure that they are not included on
the bad debt listings (i.e., Exhibit 2 or your internal schedules) submitted with the cost report.
Rev. 2
40-41
4004.2 (Cont.)
FORM CMS-2552-10
08-11
Line 15--Indicate whether total available beds have changed from the prior cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If you answer “Y” in column 1, provide an
analysis of available beds and explain any changes that occurred during the cost reporting period.
NOTE: For purposes of line 15, available beds are provider beds that are permanently
maintained for lodging inpatients. They must be available for use and housed in patient
rooms or wards (i.e., do not include beds in corridors or temporary beds). (See Pub. 151, §2200.2.C., Pub. 15-2, §4005.1, and CFR §412.105(b).)
Line 16--Indicate whether the cost report was prepared using the Provider Statistical &
Reimbursement Report (PS&R) only. Use columns 1 and 2 for Part A and columns 3 and 4 for
Part B. Enter “Y” for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y” enter
the paid through date of the PS&R in columns 2 and/or 4. Also, submit a crosswalk between
revenue codes and charges found on the PS&R to the cost center groupings on the cost report.
This crosswalk will reflect a cost center to revenue code match only.
Line 17--Indicate whether the cost report was prepared using the PS&R for totals and provider
records for allocation. Use columns 1 and 2 for Part A and columns 3 and 4 for Part B. Enter
“Y” for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y” enter the paid
through date of the PS&R used to prepare this cost report in columns 2 and/or 4. Also, submit a
detailed crosswalk between revenue codes, departments and charges on the PS&R to the cost
center groupings on the cost report. This crosswalk must show dollars by cost center and include
which revenue codes were allocated to each cost center. The total revenue on the cost report
must match the total charges on the PS&R (as appropriately adjusted for unpaid claims, etc.) to
use this method. Supporting workpapers must accompany this crosswalk to provide sufficient
documentation as to the accuracy of the provider records. If the contractor does not find the
documentation sufficient, the PS&R will be used in its entirety.
Line 18--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether
adjustments were made to the PS&R data for additional claims that have been billed but not
included on the PS&R used to file this cost report. Enter “Y” for yes or “N” for no in columns 1
and 3. If either column 1 or 3 is “Y”, include a schedule which supports any claims not included
on the PS&R. This schedule should include totals consistent with the breakdowns on the PS&R,
and should reflect claims that are unprocessed or unpaid as of the cut-off date of the PS&R used
to file the cost report.
Line 19--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether
adjustments were made to the PS&R data for corrections of other PS&R information. Enter “Y”
for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y”, submit a detailed
explanation and documentation which provides an audit trail from the PS&R to the cost report.
Line 20--If you entered “Y” on either line 16 or 17, columns 1 and/or 3, indicate whether other
adjustments were made to the PS&R data. Enter “Y” for yes or “N” for no in columns 1 and 3.
If either column 1 or 3 is “Y”, include a description of the other adjustments and documentation
which provides an audit trail from the PS&R to the cost report.
Line 21--Indicate whether the cost report was prepared using provider records only. Enter “Y”
for yes or “N” for no in columns 1 and 3. If either column 1 or 3 is “Y”, submit detailed
documentation of the system used to support the data reported on the cost report. If detail
documentation was previously supplied, submit only necessary updated documentation with the
cost report.
40-42
Rev. 2
12-10
FORM CMS-2552-10
4004.2 (Cont.)
The minimum requirements are:
•
Copies of input tables, calculations, or charts supporting data elements for PPS operating
rate components, capital PPS rate components and other PRICER information covering
the cost reporting period.
•
Internal records supporting program utilization statistics, charges, prevailing rates and
payment information broken into each Medicare bill type in a manner consistent with the
PS&R.
•
Reconciliation of remittance totals to the provider’s internal records.
•
Include the name of the system used and indicate how the system was maintained (vendor
or provider). If the provider maintained the system, include date of last software update.
Note: Additional information may be supplied such as narrative documentation, internal flow
charts, or outside vendor informational material to further describe and validate the reliability of
your system.
Lines 22 through 40 are required to be completed by cost-reimbursed and TEFRA hospitals only.
Line 22--Indicate whether assets have been relifed for Medicare purposes. Enter “Y” for yes or
“N” for no in column 1. If column 1 is “Y”, submit a detailed listing of these specific assets, by
class, as shown in the Fixed Asset Register with the cost report.
Note: “Class” means those depreciable asset groupings you use (e.g., land improvements,
moveable equipment, buildings, fixed equipment).
Line 23--Indicate whether changes occurred in the Medicare depreciation expense due to
appraisals made during the cost reporting period. Enter “Y” for yes or “N” for no in column 1.
If column 1 is “Y”, submit a copy of the Appraisal Report and Appraisal Summary by class of
asset with the cost report.
Line 24--Indicate whether new leases and/or amendments to existing leases were entered into
during the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is
“Y”, submit a listing of the new leases and/or amendments to existing leases if the annual rental
cost of each of these leases is $50,000 or greater with the cost report. The listing should include
the following information:
•
•
•
•
•
Identify if the lease is new or a renewal.
Parties to the lease.
Period covered by the lease.
Description of the asset being leased.
Annual charge by the lessor.
NOTE: Providers are required to submit copies of the lease, or significant extracts, upon
request from the contractor.
Rev. 1
40-43
4004.2 (Cont.)
FORM CMS-2552-10
12-10
Line 25--Indicate whether new capitalized leases were entered into during the cost reporting
period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a list of the
individual assets by class, the department assigned to, and respective dollar amounts if the annual
rental cost of these leases is $50,000 or greater with the cost report.
Line 26--Indicate whether assets subject to §2314 of DEFRA were acquired during the cost
reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
computation of the basis with the cost report.
Line 27--Indicate whether your capitalization policy changed during the cost reporting period.
Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a copy with the cost
report.
Line 28--Indicate whether new loans, mortgage agreements, or letters of credit were entered into
during the cost reporting period. Enter “Y” for yes or “N” for no in column 1. If column 1 is
“Y”, submit copies of the debt documents and amortization schedules with the cost report. Also,
state the purpose of the borrowing.
Line 29--Indicate whether you have a funded depreciation account and/or bond funds (Debt
Service Reserve Fund) treated as a funded depreciation account. Enter “Y” for yes or “N” for no
in column 1. If column 1 is “Y”, submit a detailed analysis of the funded depreciation account
for the cost reporting period with the cost report. (See Pub. 15-1, §226 and 42 CFR §413.153.)
Line 30--Indicate whether existing debt has been replaced prior to its scheduled maturity with
new debt. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a copy of the
new debt document and a schedule calculating the allowable cost. (See Pub. 15-1, §233.3 for
description of allowable cost.)
Line 31--Indicate whether debt has been recalled before its scheduled maturity without the
issuance of new debt. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
detailed analysis supporting the debt cancellation costs and treatment of these expenses on the
cost report. (See Pub. 15-1, §215 for description and treatment of debt cancellation costs.)
Line 32--Indicate whether you have entered into new agreements or if changes occurred in
patient care services furnished through contractual arrangements with suppliers of service. Enter
“Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit copies of the contracts in
those instances where the cost of the individual’s services exceeds $25,000 per year with the cost
report.
Where you do not have written agreements for purchased services, submit a description listing
the following information:
•
•
•
•
Duration of the arrangement.
Description of services.
Financial arrangement.
Name(s) of parties to the agreement furnishing the services.
Line 33--If you answered “Y” on line 32, were the requirements of Pub. 15-1, §2135.2 pertaining
to competitive bidding applied? Enter “Y” for yes or “N” for no in column 1. If column 1 is
“N”, submit an explanation with the cost report.
40-44
Rev. 1
10-12
FORM CMS-2552-10
4004.2 (Cont.)
Line 34--Indicate whether services are furnished at your facility under an arrangement with
provider-based physicians. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit Exhibit 1, where applicable.
You may submit computer generated substitutes for these schedules provided they contain, at a
minimum, the same information as in Exhibit 1. (This includes the signature on a substitute
Exhibit 1.)
Allocation agreements (Exhibit 1) are required if physician compensation is attributable to both
direct patient care and provider services. Allocation agreements are also required if all of the
provider-based physician’s compensation is attributable to provider services (i.e., departmental
supervision and administration, quality control activities, teaching and supervision of InternsResidents and/or Allied Health Students, and in the case of teaching hospitals electing cost
reimbursement for teaching physicians’ services, for compensation attributable to direct medical
and surgical services furnished to individual patients, and the supervision of intern and residents
furnishing direct medical and surgical services to individual patients. However, Exhibit 1 is not
required if all of the provider-based physician’s compensation is attributable to direct medical
and surgical services to individual patients.
Physicians’ compensation information is considered to be confidential, and therefore, qualifies
for exemption from disclosure under the Freedom of Information Act, and specifically under 5
U.S.C. 552(b)(4). The compensation information also qualifies for exemption from disclosure
under 5 U.S.C. 552(b)(6) which covers “personnel and medical files, the disclosure of which
would constitute a clearly unwarranted invasion of personal privacy.” An individual’s
compensation is a personal matter and its release would be an invasion of privacy. Accordingly,
CMS will not release, or make available to the public, compensation information collected.
Instructions for completing Exhibit 1:
Exhibit 1, Allocation of Physician Compensation Hours:
•
Complete this exhibit in accordance with CMS Pub. 15-1, §2182.3. The data elements
shown are physicians’ hours of service providing a breakdown between the professional
and provider component.
•
Prepare a physician time allocation for each physician by department, who receives
payment directly from you or a related organization for services rendered. This includes
physicians paid through affiliated agreements. A weighted average for the entire
department may be used where all physicians in the department are in the same specialty.
Where a weighted average is submitted, individual time allocations need not be
submitted. The physician or department head supplying this information must sign the
schedule.
Line 35--If you answered “Y” on line 34, indicate whether new agreements or amendments to
existing agreements were entered into during the cost reporting period. Enter “Y” for yes or “N”
for no in column 1. If column 1 is “Y”, submit copies of the new agreements or the amendments
to existing agreements with the cost report.
Rev. 3
40-45
4004.2 (Cont.)
FORM CMS-2552-10
10-12
Line 36--Indicate whether home office costs are claimed on the cost report. Enter “Y” for yes or
“N” for no in column 1.
Line 37--If you answered “Y” on line 36, indicate whether a home office cost statement was
prepared by the home office. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit a schedule displaying the entire chain’s direct, functional, and pooled costs as provided to
the designated home office contractor as part of the home office cost statement.
Line 38--If you answered “Y” on line 36, indicate whether the fiscal year end of the home office
is different from that of the provider. Enter “Y” for yes or “N” for no in column 1. If column 1
is “Y”, enter the fiscal year end of the home office in column 2.
Line 39--If you answered “Y” on line 36, indicate whether the provider renders services to other
components of the chain. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”,
submit a schedule listing the names of the entities, the services provided, and cost incurred to
provide these services with the cost report.
Line 40--If you answered “Y” on line 36, indicate whether the provider renders services to the
home office. Enter “Y” for yes or “N” for no in column 1. If column 1 is “Y”, submit a
schedule listing the services provided, and cost incurred to provide these services with the cost
report.
Cost Report Preparer Contact Information:
Line 41--Enter the first name, last name and the title/position held by the cost report preparer in
columns 1, 2, and 3, respectively.
Line 42--Enter the employer/company name of the cost report preparer.
Line 43--Enter the telephone number and email address of the cost report preparer.
NOTE: Exhibits 1 and 2 must be completed either manually (in hard copy) or via
separate electronic/digital media as this information is not captured in the ECR
file.
40-46
Rev. 3
12-10
FORM CMS-2552-10
4004.2 (Cont.)
EXHIBIT 1
Allocation of Physician
Compensation: Hours
Provider Name: ________________________________________
Provider Number:____________________
Department: ___________________________
Physician Name: _______________________________________
______________________________________________________________________________________________________
Cost Reporting Year:
Beginning___________________ Ending ___________________
___
___
___
___
Basis of Allocation: Time Study /__/; Other /__/; Describe:______________________________
______________________________________________________________________________________________________
Services
Total
Hours
______________________________________________________________________________________________________
1.
Provider Services - Teaching and Supervision of I/R's and other GME Related Functions.
_________
1A.
Provider Services - Teaching and Supervision of Allied Health Students
_________
1B.
Provider Services - Non Teaching Reimbursable Activities such as Departmental Administration,
Supervision of Nursing, and Technical Staff, Utilization Review, etc.
_________
1C.
Provider Services - Emergency Room Physician Availability
(Do not include minimum guarantee arrangements for Emergency Room Physicians.)
_________
1D.
Sub-Total - Provider Administrative Services (Lines 1, 1A, 1B, 1C).
_________
2.
Physician Services: Medical and Surgical Services to Individual Patients
_________
3.
Non-Reimbursable Activities: Research, Teaching of I/R's in Non-Approved Programs, Teaching
and Supervision of Medical Students, Writing for Medical Journals, etc.
_________
4.
Total Hours: (Lines 1D, 2, and 3)
_________
5.
Professional Component Percentage (Line 2 / Line 4)
_________
6.
Provider Component Percentage - (Line 1D / Line 4)
_________
_________________________________________
Signature: Physician or Physician Department Head
Rev. 1
______________
Date
40-47
4004.2 (Cont.)
FORM CMS-2552-10
12-10
EXHIBIT 2
LISTING OF MEDICARE BAD DEBTS AND APPROPRIATE SUPPORTING DATA
PROVIDER ____________________
NUMBER ______________________
FYE _________________________
(1)
Patient
Name
(2)
HIC. NO.
PREPARED BY __________________________________
DATE PREPARED ________________________________
INPATIENT __________ OUTPATIENT ______________
(3)
DATES OF
SERVICE
FROM
TO
(4)
INDIGENCY &
WEL. RECIP.
(CK IF APPL)
YES
(5)
DATE FIRST
BILL SENT TO
BENEFICIARY
(6)
DATE
COLLECTION
EFFORTS
CEASED
(7)
MEDICARE
REMITTANCE
ADVICE
DATES
(8)*
DEDUCT
(9)*
CO-INS
(10)
TOTAL
MEDICAID
NUMBER
* THESE AMOUNTS MUST NOT BE CLAIMED UNLESS THE PROVIDER BILLS FOR THESE SERVICES WITH THE INTENTION OF PAYMENT.
SEE INSTRUCTIONS FOR COLUMN 4 - INDIGENCY/WELFARE RECIPIENT, FOR POSSIBLE EXCEPTION
40-48
Rev. 1
12-10
FORM CMS-2552-10
4004.2 (Cont.)
Page 49 reserved for future use.
Rev. 1
4004.2 (Cont.)
FORM CMS-2552-10
40-49
12-10
Pages 50 through 54 are reserved for future use.
40-50
Rev. 1
10-12
4005.
FORM CMS-2552-10
4005
WORKSHEET S-3 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
STATISTICAL DATA AND HOSPITAL WAGE INDEX INFORMATION
This worksheet consists of five parts:
Part I
Part II
Part III
Part IV
Part V
-
Hospital and Hospital Health Care Complex Statistical Data
Hospital Wage Index Information
Hospital Wage Index Summary
Hospital Wage Related Costs
Hospital Contract Labor and Benefit Costs
4005.1 Part I - Hospital and Hospital Health Care Complex Statistical Data.--This part collects
statistical data regarding beds, days, FTEs, and discharges.
Column Descriptions
Column 1--Enter the Worksheet A line number that corresponds to the Worksheet S-3
component line description.
Column 2--Refer to 42 CFR 412.105(b) and Vol. 69 of the Federal Register 154, dated August
11, 2004, page 49093 to determine the facility bed count. Indicate the number of beds available
for use by patients at the end of the cost reporting period. A bed means an adult bed, pediatric
bed, birthing room, or newborn ICU bed (excluding newborn bassinets) maintained in a patient
care area for lodging patients in acute, long term, or domiciliary areas of the hospital. Beds in
labor room, birthing room, postanesthesia, postoperative recovery rooms, outpatient areas,
emergency rooms, ancillary departments, nurses' and other staff residences, and other such areas
which are regularly maintained and utilized for only a portion of the stay of patients (primarily
for special procedures or not for inpatient lodging) are not termed a bed for these purposes. (See
CMS Pub. 15-1, §§2200.2 C and 2205.)
Column 3--Enter the total bed days available. Bed days are computed by multiplying the number
of beds available throughout the period in column 2 by the number of days in the reporting
period. If there is an increase or decrease in the number of beds available during the period,
multiply the number of beds available for each part of the cost reporting period by the number of
days for which that number of beds was available.
Column 4--CAHs accumulate the aggregate number of hours all CAH patients spend in each
category on lines 1 and 8 through 12. This data is for informational purposes only.
Columns 5 through 7--Enter the number of inpatient days or visits, where applicable, for each
component by program. Do not include HMO days except where required (lines 2 through 4,
columns 6 and 7), organ acquisition, or observation bed days in these columns. Observation bed
days are reported in columns 7 (title XIX) and 8 (total), line 28. For LTCH, enter in column 6 on
the applicable line the number of covered Medicare days (from the PS&R) and enter in column
6, line 33 the number of noncovered days (from provider’s books and records) for Medicare
patients.
Report the program days for PPS providers (acute care hospital, IPF, IRF, and LTCH) in the cost
reporting period in which the discharge is reported. This also applies to providers under the
TEFRA/PPS blend. TEFRA providers should report their program days in the reporting period
in which they occur.
NOTE: Section 1886(d)(5)(F) of the Act provides for an additional Medicare payment for
hospitals serving a disproportionate share of low income patients. A hospital's
eligibility for these additional payments is partially based on its Medicaid utilization.
The count of Medicaid days used in the Medicare disproportionate share adjustment
computation includes days for Medicaid recipients who are members of an HMO as
well as out of State
Rev. 3
40-55
4005.1 (Cont.)
FORM CMS-2552-10
10-12
days, Medicaid secondary payer patient days, Medicaid eligible days for which no
payment was received, and baby days after mother's discharge. Medicaid HMO days
are reported on lines 2 through 4 in accordance with 42 CFR 412.106(b)(4)(ii).
Therefore, Medicaid patient days reported on line 1, column 7 do not include days for
Medicaid patients who are also members of an HMO.
Column 8--Enter the number of inpatient days for all classes of patients for each component.
Include organ acquisition and HMO days in this column. This amount will not equal the sum of
columns 5 through 7 when the provider renders services to other than titles V, XVIII, or XIX
patients.
Column 9--Enter the number of intern and resident full time equivalents (FTEs) in an approved
program determined in accordance with 42 CFR 412.105(f) for the indirect medical education
adjustment. The FTE residents reported by an IPF PPS facility or an IRF PPS facility (whether
freestanding or a unit reported on line 16 or 17, respectively, of an IPPS hospital’s cost report)
shall be determined in accordance with 42 CFR 412.424(d)(1)(iii) for IPFs and in accordance
with the Federal Register, Vol. 70, number 156, dated August 15, 2005, pages 47929-30 for
IRFs.
Columns 10 and 11--The average number of FTE employees for the period may be determined
either on a quarterly or semiannual basis. When quarterly data are used, add the total number of
hours worked by all employees on the first week of the first payroll period at the beginning of
each quarter, and divide the sum by 160 (4 times 40). When semiannual data are used, add the
total number of paid hours on the first week of the first payroll period of the first and seventh
months of the period. Divide this sum by 80 (2 times 40). Enter the average number of paid
employees in column 10 and the average number of nonpaid workers in column 11 for each
component, as applicable.
Columns 12 through 14--Enter the number of discharges including deaths (excluding newborn
and DOAs) for each component by program. A patient discharge, including death, is a formal
release of a patient. (See 42 CFR 412.4.) Enter the XVIII M+C HMO discharges in column 13,
line 2.
Column 15--Enter the number of discharges including deaths (excluding newborn and DOAs) for
all classes of patients for each component.
Line Descriptions
Line 1--In columns 5, 6, 7 and 8, enter the number of adult and pediatric hospital days excluding
the SNF and NF swing bed, observation bed, and hospice days. In columns 6 and 7 also exclude
HMO days. Do not include in column 6 Medicare Secondary Payer/Lesser of Reasonable
Cost (MSP/LCC) days. Include these days only in column 8. However, do not include
employee discount days in column 8.
Labor and delivery days (as defined in the instructions for line 32 of Worksheet S-3, Part I) must
not be included on this line.
Line 2--Enter in column 6 the title XVIII M+C days and days for individuals enrolled in section
1876 Medicare cost plans. Enter in column 7 the title XIX HMO days and other Medicaid
eligible days not included on line 1, column 7.
Line 3--Enter in column 6 the title XVIII M+C days and days for individuals enrolled in section
1876 Medicare cost plans which pertain to IPF subprovider patients. Enter in column 7 the title
XIX HMO days and other Medicaid eligible days not included on line 16, column 7.
Line 4--Enter in column 6 the title XVIII M+C days and days for individuals enrolled in section
1876 Medicare cost plans which pertain to IRF subprovider patients. Enter in column 7 the title
XIX HMO days and other Medicaid eligible days not included on line 17, column 7.
Line 5--Enter the Medicare covered swing bed days (which are considered synonymous with
SNF
40-56
Rev. 3
10-12
FORM CMS-2552-10
4005.1 (Cont.)
swing bed days) for all Title XVIII programs where applicable. See 42 CFR 413.53(a)(2).
Exclude all M+C days from column 6, include the M+C days in column 8.
Line 6--Enter the non-Medicare covered swing bed days (which are considered synonymous with
NF swing bed days) for all programs where applicable. See 42 CFR 413.53(a)(2).
Line 7--Enter the sum of lines 1, 5 and 6.
Lines 8 - 13--Enter the appropriate statistic applicable to each discipline for all programs.
Line 14--Enter the sum of lines 7 - 13 for columns 2 - 8, and for columns 12 - 15, enter the
amount from line 1. For columns 9 - 11, enter the total for each from your records.
Labor and delivery days (as defined in the instructions for line 32 of Worksheet S-3, Part I) must
not be included on this line.
Line 15--Enter the number of outpatient visits for CAHs by program and total. An outpatient
CAH visit is defined in 42 CFR 413.70(b)(3)(iii).
Line 16--Enter the applicable data for the IPF subprovider.
Line 17--Enter the applicable data for the IRF subprovider.
Line 18--Enter the applicable data for other than IPF or IRF subproviders. If you have more than
one subprovider, subscript this line.
Line 19--If your State recognizes one level of care, complete this line for titles V, XVIII, and
XIX, however, do not complete line 20. If you answered yes to line 92 of Worksheet S-2, Part I,
complete all columns.
Line 20--Enter nursing facility days if you have a separately certified nursing facility for Title
XIX or you answered yes to line 92 of Worksheet S-2, Part I. Make no entry if your State
recognizes only SNF level of care. If you operate an ICF/MR, subscript this line to 20.01 and
enter the ICF/MR days. Do not report any nursing facility data on line 20.01.
Line 21--Enter data for an other long term care facility.
Line 22--If you have more than one hospital-based HHA, subscript this line.
Line 23--Enter data for an ASC. If you have more than one ASC, subscript this line.
Line 24--Enter days applicable to hospice patients in a distinct part hospice.
Line 25--CMHCs enter the number of partial hospitalization days as applicable. For reporting of
multiple facilities follow the same format used on Worksheet S-2, Part I, line 17.
Line 26--Enter the number of outpatient visits for FQHC and RHC. If you have both or
multiples of one, subscript the line.
Line 28--Enter the total observation bed days in column 8. Divide the total number of
observation bed hours by 24 and round up to the nearest whole day. These total hours should
include the hours for observation of patients who are subsequently admitted as inpatients but
only the hours up to the time of admission as well as the hours for observation of patients who
are not subsequently admitted as inpatients but only the hours up to the time of discharge from
the facility. Observation bed days only need to be computed if the observation bed patients are
placed in a routine patient care area. The bed days are needed to calculate the cost of
observation beds since it cannot be separately costed
Rev. 3
40-57
4005.2
FORM CMS-2552-10
10-12
when the routine patient care area is used. If, however, you have a distinct observation bed area,
it must be separately costed (as are all other outpatient cost centers), and this computation is not
needed.
Line 29--Enter in column 6 the total number of ambulance trips, as defined by section 4531(a)(1)
of the BBA. Do not subscript this line.
Line 30--Enter in column 8 the employee discount days if applicable. These days are used on
Worksheet E, Part A, line 31 in the calculation of the DSH adjustment and Worksheet E-3, Part
III, line 3 in the calculation of the LIP adjustment.
Line 31--Enter in column 8 the employee discount days, if applicable, for IRF subproviders.
Line 32--Indicate in column 7 the count of labor/delivery days for Title XIX and in column 8 the
total count of labor/delivery days for the entire facility.
For the purposes of reporting on this line, labor and delivery days are defined as days during
which a maternity patient is in the labor/delivery room ancillary area at midnight at the time of
census taking, and is not included in the census of the inpatient routine care area because the
patient has not occupied an inpatient routine bed at some time before admission (see Pub. 15-1,
section 2205.2). In the case where the maternity patient is in a single multipurpose labor,
delivery and postpartum (LDP) room, hospitals must determine the proportion of each inpatient
stay that is associated with ancillary services (labor and delivery) versus routine adult and
pediatric services (post partum) and report the days associated with the labor and delivery
portion of the stay on this line. An example of this would be for a hospital to determine the
percentage of each stay associated with labor/delivery services and apply that percentage to the
stay to determine the number of labor and delivery days of the stay. Alternatively, a hospital
could calculate an average percentage of time maternity patients receive ancillary services in an
LDP room during a typical month, and apply that percentage through the rest of the year to
determine the number of labor and delivery days to report on line 32. Maternity patients must be
admitted to the hospital as an inpatient for their labor and delivery days to be included on line 32.
These days must not be reported on Worksheet S-3, Part I, line 1 or line 14.
Line 33--See instructions for columns 5 through 7 of this worksheet.
4005.2 Part II - Hospital Wage Index Information.--This worksheet provides for the collection
of hospital wage data which is needed to update the hospital wage index applied to the laborrelated portion of the national average standardized amounts of the prospective payment system.
It is important for hospitals to ensure that the data reported on Worksheet S-3, Parts II, III and IV
are accurate. Beginning October 1, 1993, the wage index must be updated annually. (See
§1886(d)(3)(E) of the Act.) Congress also indicated that any revised wage index must exclude
data for wages incurred in furnishing SNF services. Complete Worksheet S-3, Parts II, III and
IV for IPPS hospitals (see §1886(d)), any hospital with an IPPS subprovider, or any hospital that
would be subject to IPPS if not granted a waiver.
NOTE: Any line reference for Worksheets A and A-6 includes all subscripts of that line.
Column 2
Line 1--Enter from Worksheet A, column 1, line 200, the wages and salaries paid to hospital. All
salary amounts for paid vacation, holiday, sick, other paid-time-off (PTO), severance, and bonus
pay must be included in column 1 of Worksheet A. See Worksheet A instructions (§ 4013).
NOTE: Lines 4 and 22 apply to physician’s Part A administrative costs.
NOTE: Bonus pay includes award pay and vacation, holiday, and sick pay conversion (pay in
lieu of time off).
40-58
Rev. 3
10-12
FORM CMS-2552-10
4005.2 (Cont.)
NOTE: Capital related salaries, hours, and wage-related costs associated with lines 1 and 2 of
Worksheet A must not be included on Worksheet S-3, Parts II and III.
NOTE: Methodology for including vacation/sick/other PTO accruals in the wage index:
PTO salary cost--The required source for costs on Worksheet A is the General Ledger
(see Provider Reimbursement Manual, Part 2, section 4013 and 42 CFR 413.24(e)).
Worksheet S-3, Part II (wage index) data are derived from Worksheet A; therefore, the
proper source for costs for the wage index is also the General Ledger. A hospital’s
current year General Ledger includes both costs that are paid during the current year and
costs that are expensed in the current year but paid in the subsequent year (current year
accruals). Hospitals and contractors are to include on Worksheet S-3, Part II the current
year PTO cost incurred as reflected on the General Ledger; that is, both the current year
PTO cost paid and the current year PTO accrual. (Costs that are expensed in the prior
year but paid in the current year (prior year accruals) are not included on a hospital’s
current year General Ledger and should not be included on the hospital's current year
Worksheet S-3, Part II.)
PTO hours--The source for PTO paid hours on Worksheet S-3, Part II is the Payroll
Report. Hours are included on the Payroll Report in the period in which the associated
PTO expense is paid. Hospitals and contractors are to include on Worksheet S-3, Part II
the PTO hours that are reflected on the current year Payroll Report, which includes hours
associated with PTO cost that was expensed in the prior year but paid in the current year.
The time period must cover the weeks that best matches the provider’s cost reporting
period. (Hours associated with PTO cost expensed in the current year but not paid until
the subsequent year (current year PTO accrual) are not included on the current year
Payroll Report and should not be included on the hospital’s current year Worksheet S-3,
Part II.)
Although this methodology does not provide a perfect match between paid PTO cost and
paid PTO hours for a given year, it should approximate an actual match between cost and
hours. Over time, any variances should be minimal.
Lines 2 - 10--The amounts to be reported must be adjusted for vacation, holiday, sick, other paid
time off, severance, and bonus pay if not already included. Do not include in lines 2 through 8
the salaries for employees associated with excluded areas lines 9 and 10.
Line 2--Enter the salaries for directly-employed Part A non-physician anesthetist salaries (for
rural hospitals that have been granted CRNA pass through) to the extent these salaries are
included in line 1. Add to this amount the costs for CRNA Part A services furnished under
contract to the extent hours can be accurately determined. Report only the personnel costs
associated with these contracts. DO NOT include cost for equipment, supplies, travel expenses,
and other miscellaneous or overhead items. DO NOT include costs applicable to excluded areas
reported on lines 9 and 10. Additionally, contract CRNA cost must be included on line 11.
Report in column 5 the hours that are associated with the costs in column 4 for directly employed
and contract Part A CRNAs.
Do not include physician assistants, clinical nurse specialists, nurse practitioners, and nurse
midwives.
Line 3--Enter the non-physician anesthetist salaries included in line 1, subject to the fee schedule
and paid under Part B by the contractor. Do not include salary costs for physician assistants,
clinical nurse specialists, nurse practitioners, and nurse midwives.
Line 4--Enter the physician Part A administrative salaries, (excluding teaching physician
salaries), which are included in line 1. Also do not include intern and resident (I & R) salary on
this line. Report I & R salary on line 7. Subscript this line and report salaries for Part A
teaching physicians on line 4.01.
Rev. 3
40-59
4005.2 (Cont.)
FORM CMS-2552-10
10-12
Lines 5 and 6--Enter the total physician, physician assistant, nurse practitioner and clinical nurse
specialist salaries billed under Part B that are included in line 1. Under Medicare, these services
are related to patient care and billed separately under Part B. Also include physician salaries for
patient care services reported for rural health clinics (RHC) and Federally qualified health clinics
(FQHC) included on Worksheet A, column 1, lines 88 and/or 89 as applicable. Report on line 6
the non-physician salaries reported for Hospital-based RHC and FQHC services included on
Worksheet A, column 1, lines 88 and/or 89 as applicable. Do not include on these lines amounts
that are included on lines 9 and 10 for the SNF or excluded area salaries.
Line 7--Enter from Worksheet A the salaries reported in column 1 of line 21 for interns and
residents. Subscript this line and report salaries for contracted interns and residents in an
approved program on line 7.01. Report only the personnel costs associated with these contracts.
DO NOT include cost for equipment, supplies, travel expenses, and other miscellaneous or
overhead items. DO NOT include costs applicable to excluded areas reported on lines 9 and 10.
Additionally, contract intern and resident costs must be included on line 11. DO NOT include
contract intern and residents costs on line 13. Report in column 5 the hours that are associated
with the costs in column 4 for directly employed and contract interns and residents.
Line 8--If you are a member of a chain or other related organization as defined in CMS Pub 151, §2150, enter, from your records, the wages and salaries for home office related organization
personnel that are included in line 1.
Lines 9 and 10--Enter on line 9 the amount reported on Worksheet A, column 1 for line 44 for
the SNF. On line 10, enter from Worksheet A, column 1, the sum of lines 20, 23, 40 through 42,
45, 45.01, 46, 94, 95, 98 through 101, 105 through 112, 114, 115 through 117, and 190 through
194. DO NOT include on lines 9 and 10 any salaries for general service personnel (e.g.,
housekeeping) which, on Worksheet A, Column 1, may have been included directly in the SNF
and the other cost centers detailed in the instructions for Line 10.
Line 11--Enter the amount paid for services furnished under contract, rather than by employees,
for direct patient care, and top level management services as defined below. DO NOT include
cost for equipment, supplies, travel expenses, and other miscellaneous or overhead items (nonlabor costs). Do not include costs applicable to excluded areas reported on line 9 and 10.
Include costs for contract CRNA and intern and resident services (these costs are also to be
reported on lines 2 and 7.01 respectively). Include on this line contract pharmacy and laboratory
wage costs as defined below.
In general, for contract labor, the minimum requirement for supporting documentation is the
contract itself. If the wage costs, hours, and non-labor costs are not clearly specified in the
contract, then other documentation is necessary, such as a representative sample of invoices
which specify the wage costs, hours, and non-labor costs or a signed declaration from the vendor
in conjunction with a sample of invoices. Hospitals must be able to provide such documentation
when requested by the contractor. A hospital’s failure to provide adequate supporting
documentation may result in the cost being disallowed for the wage index.
Direct patient care services include nursing, diagnostic, therapeutic, and rehabilitative services.
Report only personnel costs associated with these contracts. DO NOT apply the guidelines for
contracted therapy services under §1861(v)(5) of the Act and 42 CFR 413.106. Eliminate all
supplies, travel expenses, and other miscellaneous items. Direct patient care contracted labor,
for purposes of this worksheet, DOES NOT include the following: services paid under Part B:
(e.g., physician clinical services, physician assistant services), management and consultant
contracts, billing services, legal and accounting services, clinical psychologist and clinical social
worker services, housekeeping services, security personnel, planning contracts, independent
financial audits, or any other service not directly related to patient care.
40-60
Rev. 3
10-12
FORM CMS-2552-10
4005.2 (Cont.)
Include the amount paid for top level management services, as defined below, furnished under
contract rather than by employees. Report only those personnel costs associated with the
contract. Eliminate all supplies, travel expenses, and other miscellaneous items. Contract
management is limited to the personnel costs for those individuals who are working at the
hospital facility in the capacity of chief executive officer, chief operating officer, chief financial
officer, or nursing administrator. The titles given to these individuals may vary from the titles
indicated above. However, the individual should be performing those duties customarily given
these positions.
For purposes of this worksheet, contract top level management services DO NOT include the
following: other management or administrative services (to be included on lines 12 or 28; see
instructions), physician Part A services, consultative services, clerical and billing services, legal
and accounting services, unmet physician guarantees, physician services, planning contracts,
independent financial audits, or any services other than the top level management contracts listed
above. Per instructions on Worksheet S-2, Part II, for direct patient care, pharmacy and
laboratory contracts, submit to your Medicare contractor the types of services, wages, and
associated hours; for top level management contracts, submit the aggregate wages and hours.
If you have no contracts for direct patient care or management services as defined above, enter a
zero in column 2. If you are unable to accurately determine the number of hours associated with
contracted labor, enter a zero in column 2.
Contract pharmacy services are furnished under contract, rather than by employees. DO NOT
include the following services paid under Part B (e.g., physician clinical services, physician
assistant services), management and consultant contracts, clerical and billing services, legal and
accounting services, housekeeping services, security personnel, planning contracts, independent
financial audits, or any other service not directly related to patient care. Report only personnel
costs associated with the contracts. DO NOT include costs for equipment, supplies, travel
expenses, or other miscellaneous items. Per instructions on Worksheet S-2, Part II, submit to
your contractor the following for direct patient care pharmacy contracts: the types of services,
wages, and associated hours.
Contract laboratory services are furnished under contract, rather than by employees. DO NOT
include the following services paid under Part B (e.g., physician clinical services, physician
assistant services), management and consultant contracts, clerical and billing services, legal and
accounting services, housekeeping services, security personnel, planning contracts, independent
financial audits, or any other service not directly related to patient care. Report only personnel
costs associated with the contracts. DO NOT include costs for equipment, supplies, travel
expenses, or other miscellaneous items. Per instructions on Worksheet S-2, Part II, submit to
your contractor the following for direct patient care laboratory contracts: the types of services,
wages, and associated hours.
Line 12--Enter the amount paid for contract management and administrative services
furnished under contract, rather than by employees. Include on this line contract management
and administrative services associated with cost centers other than those listed on lines 26
through 43 (and their subscripts) of this worksheet that are included in the wage index.
Examples of contract management and administrative services that would be reported on line 12
include department directors, administrators, managers, ward clerks, and medical secretaries.
Report only those personnel costs associated with the contract. DO NOT include on line 12 any
contract labor costs associated with lines 26 through 43 and subscripts for these lines. DO NOT
include the costs for contract top level management: chief executive officer, chief operating
officer, chief financial officer and nurse administrator; these services are included on line 11.
DO NOT include costs for equipment, supplies, travel expenses, or other miscellaneous items.
Line 13--Enter from your records the amount paid under contract (as defined on line 11) for Part
A physician services - administrative, excluding teaching physician services. DO NOT include
Rev. 3
40-61
4005.2 (Cont.)
FORM CMS-2552-10
10-12
contract I & R services (to be included on line 7). DO NOT include the costs for Part A
physician services from the home office allocation and/or from related organizations (to be
reported on line 15). Also, DO NOT include Part A physician contracts for any of the
management positions reported on line 11.
Line 14--Enter the salaries and wage-related costs (as defined on lines 17 and 18) paid to
personnel who are affiliated with a home office and/or related organization, who provide services
to the hospital, and whose salaries are not included on Worksheet A, column 1. In addition, add
the home office/related organization salaries included on line 8 and the associated wage-related
costs. This figure must be based on recognized methods of allocating an individual's home
office/related organization salary to the hospital. If no home office/related organization exists or
if you cannot accurately determine the hours associated with the home office/related organization
salaries that are allocated to the hospital, then enter a zero in column 1. All costs for any related
organization must be shown as the cost to the related organization
NOTE: Do not include any costs for Part A physician services from the home office allocation
and/or related organizations. These amounts are reported on line 15.
If a wage related cost associated with the home office is not “core” (as described in the
Worksheet S-3, Part IV) and is not a category included in “other” wage related costs on
line 18 (see Worksheet S-3, Part IV and line 18 instructions below), the cost cannot be
included on line 14. For example, if a hospital’s employee parking cost does not meet
the criteria for inclusion as a wage-related cost on line 18, any parking cost associated
with home office staff cannot be included on line 14.
Line 15--Enter from your records the salaries and wage-related costs for Part A physician
services - administrative, excluding teaching physician Part A services from the home office
allocation and/or related organizations.
Line 16--Enter from your records the salaries and wage-related costs for Part A teaching
physicians from the home office allocation and/or related organizations. Also report on this line
Part A teaching physicians salaries under contract.
Lines 17 - 25--In general, the amount reported for wage-related costs must meet the “reasonable
cost” provisions of Medicare. For pension and executive deferred compensation costs see the
instructions below in Part IV.
For those wage-related costs that are not covered by Medicare reasonable cost principles, a
hospital shall use generally accepted accounting principles (GAAP). For example, for purposes
of the wage index, disability insurance cost should be developed using GAAP. Hospitals are
required to complete Worksheet S-3, Part IV, a reconciliation worksheet to aid hospitals and
contractors in implementing GAAP when developing wage-related costs. Upon request by the
contractor or CMS, hospitals must provide a copy of the GAAP pronouncement, or other
documentation, showing that the reporting practice is widely accepted in the hospital industry
and/or related field as support for the methodology used to develop the wage-related costs. If a
hospital does not complete Worksheet S-3, Part IV, or, the hospital is unable, when requested, to
provide a copy of the standard used in developing the wage-related costs, the contractor may
remove the cost from the hospital’s Worksheet S-3 due to insufficient documentation to
substantiate the wage-related cost relevant to GAAP.
NOTE: All costs for any related organization must be shown as the cost to the related
organization. (For Medicare cost reporting principles, see Pub. 15 15-1, §1000. For
GAAP, see FASB 57.) If a hospital’s consolidation methodology is not in accordance
with GAAP or if there are any amounts in the methodology that cannot be verified by
the contractor, the contractor may apply the hospital’s cost to charge ratio to reduce the
related party expenses to cost.
40-62
Rev. 3
10-12
FORM CMS-2552-10
4005.2 (Cont.)
NOTE: All wage-related costs, including FICA, workers compensation, and unemployment
compensation taxes, associated with physician services are to be allocated according to
the services provided; that is, those taxes and other wage-related costs attributable to
Part A administrative services must be placed on line 22, to Part A teaching services
must be placed on line 22.01, and to Part B (patient care services) must be placed on
line 23. Line 17 must not include wage-related costs that are associated with physician
services.
Line 17--Enter the core wage-related costs from Worksheet S-3, Part IV, line 24. (See note
below for costs that are not to be included on line 17). Only the wage-related costs reported on
Worksheet S-3, Part IV, line 24 are reported on this line. (Wage-related costs are reported in
column 2, not column 1, of Worksheet A.)
NOTE: Do not include wage-related costs applicable to the excluded areas reported on lines 9
and 10. Instead, these costs are reported on line 19. Also, do not include the wagerelated costs for physicians Parts A and B, non-physician anesthetists Parts A and B,
interns and residents in approved programs, and home office personnel. (See lines 14,
15, and 20 through 25.)
Health Insurance and Health-Related Wage Related Costs:
Hospitals and contractors are not required to remove from domestic claims costs the personnel
costs associated with hospital staff who deliver services to employees. Additionally, health
related costs, that is, costs for employee physicals and inpatient and outpatient services that are
not covered by health insurance but provided to employees at no cost or at a discount, are to be
included as a core wage related cost.
Line 18--Enter the wage-related costs that are considered an exception to the core list. (See note
below for costs that are not to be included on line 18.) In order for a wage-related cost to be
considered an exception, it must meet all of the following tests:
a.
The cost is not listed on Worksheet S-3, Part IV,
b.
The wage-related cost has not been furnished for the convenience of the provider,
c.
The wage-related cost is a fringe benefit as defined by the Internal Revenue Service
and, where required, has been reported as wages to IRS (e.g., the unrecovered cost of
employee meals, education costs, auto allowances), and
d.
The total cost of the particular wage-related cost for employees whose services are
paid under IPPS exceeds 1 percent of total salaries after the direct excluded salaries are
removed (Worksheet S-3, Part III, column 4, line 3). Wage-related cost exceptions to
the core list are not to include those wage-related costs that are required to be reported
to the Internal Revenue Service as salary or wages (i.e., loan forgiveness, sick pay
accruals). Include these costs in total salaries reported on line 1 of this worksheet.
NOTE: Do not include wage-related costs applicable to the excluded areas reported on lines 9
and 10. Instead, these costs are reported on line 19. Also, do not include the wagerelated costs for physician Parts A and B, non-physician anesthetists Parts A and B,
interns and residents in approved programs, and home office personnel.
Line 19--Enter the total (core and other) wage-related costs applicable to the excluded areas
reported on lines 9 and 10.
Lines 20 - 25--Enter from your records the wage-related costs for each category of employee
listed. The costs are the core wage related costs plus the other wage-related costs. Do not
include wage-related costs for excluded areas reported on line 19. Subscript line 22 and report
the wage related costs for Part A teaching physicians reported on line 4.01, on line 22.01. On
line 23, do not include
Rev. 3
40-63
4005.2 (Cont.)
FORM CMS-2552-10
10-12
wage-related costs related to non-physician salaries reported for Hospital-based RHCs and
FQHCs services included on Worksheet A, column 1, lines 88 and/or 89, as applicable. These
wage-related costs are reported separately on line 24.
Lines 26 - 43--Enter the direct wages and salaries from Worksheet A column 1 for the
appropriate cost center identified on lines 26 through 43. These amounts must include amounts
paid for vacation, holiday, sick, and PTO and must be reported on Worksheet A, column 1.
These lines provide for the collection of hospital wage data for overhead costs to properly
allocate the salary portion of the overhead costs to the appropriate service areas for excluded
units. These lines are completed by all hospitals if the ratio of Part II, column 5, sum of lines 9
and 10 divided by the result of column 5, line 1 minus the sum of lines 2, 3, 4.01, 5, 6, 7, 7.01
and 8 equals or exceeds a threshold of 15 percent. However, all hospitals with a ratio greater
than 5 percent must complete line 7 of Part III for all columns. Calculate the percent to two
decimal places for purposes of rounding.
Lines 28, 33, and 35--Enter the amount paid for services performed under contract, rather than
by employees, for administrative and general, housekeeping, and dietary services, respectively.
DO NOT include costs for equipment, supplies, travel expenses, and other miscellaneous or
overhead items. Report only personnel costs associated with these contracts. Continue to report
on the standard lines (line 27, 32, and 34), the amounts paid for services rendered by employees
not under contract.
Line 28--A&G costs are expenses a hospital incurs in carrying out its administrative and/or
general management functions. Include on line 28 the contract services that are included on
Worksheet A, line 5 and subscripts, column 2 (“Administrative and General”). Contract
information and data processing services, legal, tax preparation, cost report preparation, and
purchasing services are examples of contract labor costs that would be included on Worksheet S3, Part II, line 28. Do not include on line 28 the costs for top level management contracts (these
costs are reported on line 11).
NOTE: Do not include overhead costs on lines 11 and 12.
Column 3--Enter on each line, as appropriate, the salary portion of any reclassifications made on
Worksheet A-6.
Column 4--Enter on each line the result of column 2 plus or minus column 3.
Column 5--Enter on each line the number of paid hours corresponding to the amounts reported
in column 4. Paid hours include regular hours (including paid lunch hours), overtime hours, paid
holiday, vacation and sick leave hours, paid time-off hours, and hours associated with severance
pay. For Part II, lines 1 through 15 (including subscripts), lines 26 through 43 (including
subscripts), and Part III, line 7, if the hours cannot be determined, then the associated salaries
must not be included in columns 2 through 4.
NOTE: The hours must reflect any change reported in column 3; For employees who work a
regular work schedule, on call hours are not to be included in the total paid hours (on
call hours should only relate to hours associated to a regular work schedule; overtime
hours are calculated as one hour when an employee is paid time and a half. No hours
are required for bonus pay. The intern and resident hours associated with the salaries
reported on line 7 must be based on 2080 hours per year for each full time intern and
resident employee. The hours reported for salaried employees who are paid a fixed
rate are recorded as 40 hours per week or the number of hours in your standard work
week.
NOTE: For workers who are contracted solely for the purpose of providing services on-call,
the wages and associated hours must be included on the appropriate contract labor line
on Worksheet S-3.
Column 6--Enter on all lines (except lines 17 through 25) the average hourly wage resulting from
dividing column 4 by column 5.
40-64
Rev. 3
10-12
FORM CMS-2552-10
4005.4
4005.3 Part III - Hospital Wage Index Summary.--This worksheet provides for the calculation
of a hospital’s average hourly wage (without overhead allocation, occupational mix adjustment,
and inflation adjustment) as well as analysis of the wage data.
Columns 1 through 6--Follow the same instructions discussed in Part II, except for column 6,
line 5.
Line 1--From Part II, enter the result of line 1 minus the sum of lines 2, 3, 4.01, 5, 6, 7, 7.01, and
8. Add to this amount lines: 28, 33, and 35.
Line 2--From Part II, enter the sum of lines 9 and 10.
Line 3--Enter the result of line 1 minus line 2.
Line 4--From Part II, enter the sum of lines 11, 12, 13, 14, and 15. (Line 16 is omitted from Part
III, line 4 because physicians' teaching services are excluded from the wage index.)
Line 5--From Part II, enter the sum of lines 17, 18, and 22. Enter on this line in column 6 the
wage-related cost percentage computed by dividing Part III, column 4, line 5, by Part III, column
4, line 3. Round the result to 2 decimal places.
Line 6--Enter the sum of lines 3 through 5.
Line 7--Enter from Part II above, the sum of lines 26 through 43. If the hospital’s ratio for
excluded area salaries to net salaries is greater than 5 percent, the hospital must complete all
columns for this line. (See instructions in Part II, lines 26 through 43 for calculating the
percentage.)
4005.4 Part IV - Wage Related Costs.--The hospital must provide the contractor with a
complete list of all core wage related costs included in Part II (section 4005.2), lines 17 and 19
through 25. This worksheet provides for the identification of such costs.
The hospital must determine whether each wage related cost “other than core”, reported on line
25, exceeds one (1) percent of the total adjusted salaries net of excludable salaries and meets all
of the following criteria:
•
•
•
•
•
The costs are not listed on lines 1 through 23, “Wage Related Costs Core”
If any of the additional wage related cost applies to the excluded areas of the hospital, the
cost associated with the excluded areas has been removed prior to making the 1 percent
threshold test.
The wage related cost has been reported to the IRS, as a fringe benefit if so required by
the IRS.
The individual wage related cost is not included in salaries reported on Worksheet S-3,
Part II, Column 3, Line 17.
The wage related cost is not being furnished for the convenience of the employer.
For wage related costs not covered by Medicare reasonable cost principles (excluding the
reporting of certain defined benefit pension costs; see instructions below), a hospital shall
use GAAP in reporting wage related costs. In addition, some costs such as payroll taxes, which
are reported as a wage related cost(s) on Worksheet S-3, Part IV, are not considered fringe
benefits for Medicare cost finding.
Enter on each line as applicable the corresponding amount from your accounting books and/or
records.
Line 3--Report pension cost for defined benefit pension plans than do not meet the applicable
requirements for a qualified pension plan under section 401(a) of the Internal Revenue Code.
Rev. 3
40-65
4005.4 (Cont.)
FORM CMS-2552-10
10-12
The policy adopted in the federal fiscal year (FFY) 2012 IPPS final rule (CMS-1518-F; 76 FR
51586 - 51590, August 18, 2011) does not change the reporting basis for these costs.
NOTE: These plans generally are not funded by a funding vehicle that is for exclusive benefit
of employees or their beneficiaries and qualifies for special tax benefits, such as tax
deferral of employer contributions. For such unfunded defined benefit plans, the costs
of these plans are reported on a cash basis which recognizes benefit payments made
during the current period. Typically these plans supplement the basic qualified
defined benefit plan or provide benefits to a select class of employees, such as
executives.
Line 4--Commencing with cost reporting periods used for the FFY 2013 wage index, report
pension cost for defined benefit pension plans which meet the applicable requirements for a
qualified pension plan under section 401(a) of the Internal Revenue Code for the wage index.
The allowable pension costs to be reported for these defined benefit pension plans shall be
determined in accordance with the policy adopted in the FY 2012 IPPS final rule (CMS-1518-F;
76 FR 51586 - 51590, August 18, 2011) and as discussed below. Enter the pension costs from
your records or from the Wage Index Pension Cost Schedule (Exhibit 3) below.
NOTE: The policy adopted in the FFY 2012 IPPS final rule replaces and supersedes the
provisions of PRM-1, section 2142.
Policy
Defined Benefit Pension Plan: A defined benefit pension plan is a type of deferred compensation
plan, which is established and maintained by the employer primarily to provide systematically
for the payment of definitely determinable benefits to its employees usually over a period of
years, or for life, after retirement. Pension plan benefits are generally measured by, and based
on, such factors as age of employees, years of service, and compensation received by employees.
This section applies only to defined benefit pension plans which meet the applicable
requirements for a qualified pension plan under section 401(a) of the Internal Revenue Code. A
qualified pension plan is for the exclusive benefit of employees or their beneficiaries and
qualifies for special tax benefits, such as tax deferral of employer contributions.
Pension Contributions: Pension costs for a defined benefit pension plan are allowable only to
the extent that costs are actually incurred by the provider Such costs are found to have been
incurred only if paid directly to participants or beneficiaries under the terms of the plan or paid
to a pension fund which meets the applicable tax qualification requirements under section 401(a)
of the Internal Revenue Code. For purposes of the wage index, provider pension payments shall
be measured on a cash-basis without regard to §2305 of PRM-1. Payment must be made by
check or other negotiable instrument, cash, or legal transfer of assets such as stocks, bonds, real
property, and etcetera. A contribution payment shall be deemed to occur on the date it is
credited to the fund established for the pension plan, or for provider payments made directly to a
plan participant or beneficiary, on the date the provider’s account is debited. Contributions
made under a pension plan that covers multiple providers or employers shall be allocated on a
basis consistent with plan records. If the plan records do not show a separate accounting of the
actuarially determined cost estimates, contribution deposits, and/or assets attributable to each
participating provider or employer, the allocation basis must represent a reasonable
approximation of the funding attributable to each employer.
Source of Documentation for Pension Contributions: Providers are required to obtain
contribution data from the pension trustee, insurance carrier, Schedule B or SB of IRS Form
5500, and if applicable, from accounting records showing the allocation of total plan
contributions to each participating provider. These records must be maintained as needed for
subsequent periods.
Reasonable Compensation: In order for pension costs to be allowable, the benefits payable
under the plan (attributable to employer contributions) together with all other compensation
paid to the employee must be reasonable in amount.
40-65.1
Rev. 3
10-12
FORM CMS-2552-10
4005.4 (Cont.)
Defined Benefit Pension Plan Costs for the Wage Index: The annual pension to be included in
the wage index shall be the average annual employer contributions made by or on behalf of the
provider (on a cash basis) to all defined benefit plans covered under this section during the
averaging period. Contribution payments must satisfy the allowability requirements outlined
above; see “Pension Contributions” and “Reasonable Compensation” above. A reversion of
plan assets shall be treated as a negative contribution payment and a negative pension cost
resulting from a reversion of plan assets shall offset a provider’s other wage related costs.
The averaging period is generally the 36 consecutive calendar month period centered on the
midpoint of the cost reporting period used for the wage index (the cost reporting period used for
the wage index shall hereafter be referred to as the wage index cost reporting period). If the
midpoint of the wage index cost reporting period is not the first day of a calendar month, use the
first day of the midpoint month or the first day of the following month as the midpoint. The same
averaging period must be used for all defined benefit plans sponsored by a provider.
A provider who adopts a new defined benefit pension plan and has no other defined benefit plan
in existence during the averaging period may elect to exclude from the averaging period all cost
reporting periods ending prior to the date the new plan was adopted. No defined benefit pension
cost is reportable for a wage index cost reporting period that is excluded from the averaging
period in accordance with this paragraph. An election to claim costs for a newly adopted plan
based on an averaging period of less than 36 months must be applied on a consistent basis for
all wage index cost reporting periods for which the 36 month averaging period contains the plan
effective date.
If the wage index cost reporting period does not represent a 12 month period, the annual pension
cost otherwise determined in accordance with this section shall be prorated to reflect the number
of months in the wage index cost reporting period.
NOTE: For the FY 2013 through FY 2022 wage index only, a provider may include a
prefunding installment as a component of pension cost regardless of whether or not the
plan(s) which gave rise to the prefunding
balance are still in existence. The annual
prefunding installment shall equal 1/10th of the prefunding balance. A prefunding
installment that is not reflected in the pension cost for a wage index cost reporting
period may not be reassigned and added to the pension cost reported for wage index
purposes in any subsequent period. The prefunding balance equals the excess, if any,
of (i) provider contributions made (on a cash-basis) to its defined benefit pension plans
during the look-back period over (ii) the pension costs included in the wage-index for
the same look-back period. A provider’s share of the total contributions made under a
pension plan that covers multiple providers or employers shall be determined on a
basis consistent with the methodology used to determine the wage index pension costs
for the cost reporting periods included in the prefunding balance. The look-back
period shall consist of consecutive provider cost reporting periods commencing no
earlier than October 1, 2002 and ending with the provider’s cost reporting period
immediately prior to the FY 2013 wage index cost reporting period. The look-back
period may not include any cost reporting period for which the provider is unable to
provide documentation of the contributions made or the pension costs included in the
wage index; all prior cost reporting periods must also be excluded in order to satisfy
the requirement that the look-back period consist of consecutive cost reporting
periods. A provider who establishes a prefunding balance must submit documentation
to the Medicare contractor to support the calculation of the prefunding balance and
annual prefunding installment.
Examples
Example 1 (prefunding balance and prefunding installment):
Rev. 3
• Provider’s FY 2013 wage index cost reporting period is 01/01/2010-12/31/2009.
The look-back period therefore ends with the cost reporting period ending
12/31/2008
40-65.2
4005.4 (Cont.)
FORM CMS-2552-10
10-12
(immediately prior to the FY 2013 wage index cost reporting period.) Assuming the
provider has always reported costs on a calendar year basis, the earliest possible
cost reporting period in the look-back period is the period commencing 01/01/2003
(first cost reporting period commencing on or after 10/01/2002).
• The provider is able to document its pension contributions (on a cash basis) and
the pension costs included in the wage index for all cost reporting periods except for
the 2004 year. Therefore, 2004 and all prior cost reporting periods must be excluded
from the look-back period. The data for 2005 through 2008 is as follows:
Cost Reporting Year Cash Basis Contributions
2005
2006
2007
2008
$400,000
$800,000
$0
$650,000
Wage-Index Pension Costs
$500,000
$0
$600,000
$700,000
• Because the pension cost reported in the wage index for 2005 was higher than the
cash contributions made during that same period, the provider may elect to drop
2005 (and all prior periods) from the look-back period.
• Although the contributions made in 2007 were also less than the pension cost
reported for that same period, the provider cannot exclude 2007 without also
excluding 2006 (look-back period must consist of consecutive cost reporting periods).
• Although the contributions made in 2008 were less than the pension cost reported
in that same period, the provider cannot exclude 2008 since the look-back period
must end with 2008 because that is the cost reporting period immediately prior to the
FY 2013 wage index cost reporting period.
• The prefunding balance based on a 2006-2008 look-back period is $150,000
($1,450,000 [$800,000+$0+$650,000] total contributions - $1,300,000 [$0 +
$600,000 + $700,000] in wage index pension costs reported for the same period).
The annual prefunding installment is $15,000 (1/10th of $150,000).
Example 2 (pension cost for a 12 month wage index cost reporting period):
• Provider’s FY 2013 wage index cost reporting period is 12 months (01/01/2009 –
12/31/2009); the midpoint of wage index cost reporting period is 07/01/2009; the 36
month averaging period is 01/01/2008 to 12/31/2010 (begins 18 months prior to
midpoint and ends 18 months following the midpoint).
• Contributions made in wage index cost reporting period 01/01/2009 –
12/31/2009 = $500,000.
•
Contributions made during 01/01/2008 – 12/31/2008 = $300,000.
•
Contributions made during 01/01/2010 – 12/31/2010 = $600,000.
•
Total contributions made during the 36 month averaging period = $1,400,000.
•
The provider has no prefunding balance or prefunding installment.
• The pension cost for the FY 2013 wage index cost reporting period is $466,667
($1,400,000 total contributions divided by 36 months in the averaging period
multiplied by 12 months in the wage index cost reporting period).
40-65.3
Rev. 3
10-12
FORM CMS-2552-10
4005.4 (Cont.)
Example 3 (pension cost for a 7 month wage index cost reporting period):
• Provider’s FY 2013 wage index cost reporting period is 7 months (01/01/2009 –
07/31/2009); the midpoint of the wage index cost reporting period is 04/15/2009;
since the midpoint must be adjusted to the first of the month (either preceding or
following); the provider elects to use 04/01/2009 as the midpoint; the 36 month
averaging period is 10/01/2007 to 09/30/2010 (begins 18 months prior to midpoint
and ends 18 months following the midpoint).
• Contributions made in wage index cost reporting period 01/01/2009 – 07/31/2009
= $300,000.
•
Contributions made during 10/01/2007 – 12/31/2008 = $500,000.
•
Contributions made during 08/01/2009 – 09/30/2010 = $600,000.
•
Total contributions made during the 36 month averaging period = $1,400,000.
• The provider has documented a prefunding balance
of $1,000,000; the annual
prefunding installment is therefore $100,000 (1/10th of prefunding balance).
• The pension cost for the FY 2013 wage index cost reporting period is $330,555
($272,222 average pension cost [$1,400,000 total contributions divided by 36 months
in the averaging period multiplied by 7 months in the in wage index cost reporting
period] plus $58,333 pro-rata prefunding installment [$100,000 annual prefunding
installment multiplied by 7/12ths to reflect a 7 month wage index cost reporting
period]).
Example 4 (pension cost for a new plan):
• Provider’s FY 2015 wage index cost reporting period is 12 months (01/01/2011 –
12/31/2011); the midpoint of the wage index cost reporting period is 07/01/2011; the
36 month averaging period is 01/01/2010 to 12/31/2012 (begins 18 months prior to
midpoint and ends 18 months following the midpoint).
• The provider adopted a new pension plan effective 07/01/2011 and had no other
pension plan in effect prior to that date; therefore, there is no prefunding balance or
prefunding installment.
•
Contributions made during 01/01/2010 - 12/31/2010 =$0 (no plan in existence)
• Contributions made in the wage index cost reporting period 01/01/2011 12/31/2011 = $500,000.
•
Contributions
•
Total contributions during the 36 month averaging period = $1,700,000.
made
during
01/01/2012
-
12/31/2012
=
$1,200,000.
• The provider did not report a pension cost attributable to the new plan based on a
36 month averaging period during any prior wage index cost reporting period;
therefore it may elect to exclude cost reporting periods ending prior to the
07/01/2011 plan effective date from the averaging period; the 36 month averaging
period is, therefore, shortened to 24 months and excludes the period 01/01/2010 to
12/31/2010. The pension cost for the FY 2015 wage index cost reporting period
would then be $850,000 ($1,700,000 total contributions divided by 24 months in the
averaging period multiplied by 12 months in the wage index reporting period).
Rev. 3
40-65.4
4005.4 (Cont.)
FORM CMS-2552-10
10-12
• Alternatively, the provider may have reported a pension cost for the FY 2014
wage index (2010 wage index cost reporting period) based on a full 36 month
averaging period of 01/01/2009 to 12/31/2011. The pension cost for that prior period
would have been $166,667 ($500,000 total contributions divided by 36 month
averaging period, multiplied by 12 months in wage index cost reporting period). If
the provider reported a pension cost for the new plan based on a full 36 month
averaging period for the FY 2014 wage index, it must also compute pension costs for
the FY 2015 wage index (2011 wage index cost reporting period) using a 36 month
averaging period. The pension cost for the 2011 wage index cost reporting period is
$566,667 ($1,700,000 total contributions divided by 36 months in averaging period,
multiplied by 12 months in the wage index cost reporting period).
NOTE: Fees paid to external organizations (for example, actuarial fees, claim administration
fees, IRS form preparation fees) for providing services that are directly associated with a
provider’s wage-related costs, including a provider’s defined benefit pension plan(s), may be
included in wage-related costs on Worksheet S-3, Part II for the period in which the expense is
incurred (see Worksheet S-3, Part IV, line 6). Such expenses are to be reported as additional
costs only if they are paid directly by the provider and NOT out of the plan assets.
Wage Index Pension Cost Schedule:
Use the following instructions and schedule (exhibit 3) to calculate your wage index pension cost
and enter the result of line 19 below on Worksheet S-3, Part IV, line 4.
Step 1:
Line 1--Enter the wage index FY for which pension costs are to be determined. This schedule
applies to wage index FYs starting with 2013.
Line 2--Enter the provider cost reporting period to be used for the wage index year in line 1.
This cost period must commence in the Medicare FY (10/1-9/30) four years prior to the wage
index year shown in line 1. For example, the provider cost reporting period for the FY 2013
wage index must commence in the Medicare FY ending September 30, 2009.
Line 3--Enter the midpoint of the provider cost reporting period shown in line 2. This should
always be the first day of a calendar month. If the midpoint occurs in the middle of a month,
enter either the first day of the midpoint month or the first day of the following month.
Line 4--Enter the date (1st of a month) that occurs 18 months prior to the midpoint date shown in
line 3. (Note: This date will not necessarily coincide with the beginning of a cost reporting
period.)
Line 5--Enter the date (last day of a month) that occurs 18 months after the midpoint date shown
in line 3. (Note: This date will not necessarily coincide with the end of a cost reporting period.)
Step 2:
STEP 2 IS OPTIONAL. Complete step 2 only if all of the following apply:
• The provider has a new defined benefit plan that was effective during the averaging
period determined in step 1;
• The provider had no other defined benefit plan in effect during the averaging period;
• The provider did not report pension costs for the new plan in a prior period based on a
36 month averaging period which included cost reporting periods ending prior to the
plan effective date;
• The provider elects to report costs for the new pension plan based on a shortened
averaging period excluding all cost reporting periods which ended prior to the plan
effective date.
40-65.5
Rev. 3
10-12
FORM CMS-2552-10
4005.4 (Cont.)
Line 6--Enter the effective date of the new plan that occurs within the averaging period
determined in step 1.
Line 7--Enter the first day of the provider's cost reporting period in which the plan was effective.
For example, if the plan was effective during the provider's cost reporting period that began on
01/01/2010, enter 01/01/2010.
Line 8--Enter the date from line 7 if it is the first of a calendar month; otherwise enter the first of
the month immediately preceding or following the date in line 7.
Step 3:
Line 9--Enter the beginning date of the averaging period from line 4 or line 8, as applicable.
Line 10--Enter the ending date of the averaging period from line 5.
Line 11--Complete the table to show the total provider contributions made (on a cash basis)
during the averaging period commencing on the date shown on line 9 and ending on the date
shown on line 10. Contributions may be grouped to correspond with the periods shown in
supporting documentation. Contributions made under a pension plan that covers multiple
providers or employers shall be allocated on a basis consistent with plan records. If the plan
does not provide for a separate accounting of the costs, contributions, and/or assets attributable
to each participating provider or employer, the allocation basis must represent a reasonable
approximation of the costs attributable to each employer. Supporting documentation must show
the amounts and dates of deposit for all contributions reported and the data to support the
allocation of total plan contributions, if applicable. Examples of acceptable documentation to
support the total deposits include pension trust or insurance statements, or Schedule SB of IRS
Form 5500.
Line 12--Enter the total number of calendar months included in the averaging period (enter "36"
unless Step 2 was completed for a new plan).
Line 13--Total the contributions listed in the table under line 11.
Line 14--The average monthly contribution during the averaging period is line 13 divided by line
12.
Line 15--Enter the number of (full or partial) months in the provider's cost reporting period
shown on line 2.
Line 16--The average pension contributions equals line 14 multiplied by line 15.
Step 4:
Line 17--If the provider has established a prefunding balance, enter the annual prefunding
installment from line 8 of the Pension Prefunding Worksheet. If the provider has not elected to
establish a pension prefunding balance, enter zero (0).
Line 18--The reportable prefunding installment is the amount shown on line 17 multiplied by line
15 divided by 12.
Line 19--The reportable pension cost for the wage index equals line 18 plus line 16. Enter the
result on Worksheet S-3, Part, IV, line 4.
Rev. 3
40-65.6
4005.4 (Cont.)
FORM CMS-2552-10
10-12
Exhibit 3
Wage Index Pension Cost Schedule
Provider Name: ________________________________________________________
Provider Number: __________
Step 1: Determine the 3-Year Averaging Period
1.
2.
3.
4.
5
Wage Index fiscal year ending.
Provider cost reporting period used for Wage Index year shown on Line 1.
from: ________
Midpoint of provider's cost reporting period shown on line 2. (adjust response to first of month)
Date beginning the 3-year averaging period. (subtract 18 months from midpoint shown on line 3)
Date ending the 3-year averaging period. (add 18 months to midpoint shown on line 3)
_ _________
to: __________
__________
__________
__________
Step 2: Adjust Averaging Period for a New Plan (See instructions)
(Leave this section blank if the provider has not elected to use an adjusted averaging period)
6.
7.
8.
Effective date of pension plan.
First day of the provider cost reporting period containing the pension plan effective date.
Starting date of the adjusted averaging period. (date on line 7 if first of the month, otherwise adjust
response to first of month) ________
_________
_________
If this date occurs after the period shown on line 2 (Step 1), stop here and see instructions. No cost is reportable for
a period which is excluded from the averaging period.
Step 3: Average Pension Contributions During the Averaging Period
9.
10.
11.
Beginning date of averaging period from Line 4 or Line 8.
__________
Ending date of averaging period from Line 5.
__________
Enter provider contributions made during the averaging period shown on lines 9 & 10. Add additional lines as necessary
if more than 15 contributions are made during the cost reporting period.
(Data may be grouped within the averaging period to agree with documentation records (enter beginning date of grouped
date range))
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
12.
13.
14.
15.
16.
Deposit Date(s)
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
Contributions
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Deposit Date(s)
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
Total number of months included in the averaging period.
Total contributions made during averaging period.
Average monthly contribution. (line 13 divided by line 12)
Number of months in provider cost reporting period on line 2.
Average pension contributions. (line 14 multiplied by line 15)
Contributions
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
__________
__________
__________
__________
__________
Step 4: Total Pension Cost for Wage Index
17.
Annual prefunding installment from line 8 of pension prefunding worksheet, if applicable.
18.
Reportable prefunding installment. (line 17 multiplied by line 15 divided by 12)
__________
19.
Total Pension Cost for Wage Index. (line 16 plus line 18) __________
Prepared By: ________________________________________________________
40-65.7
___________
Date: __________
Rev. 3
10-12
FORM CMS-2552-10
4005.5
(Continuation of Worksheet S-3, Part IV Instructions)
Line 21--Report costs of executive deferred compensation plans and awards for executives. The
policy adopted in the FFY 2012 IPPS final rule (CMS-1518-F; 76 FR 51586 - 51590, August 18,
2011) does not change the reporting basis for these costs. Examples of executive deferred
compensation include special stock option or bonus plans and sum certain postemployment
awards that are not available to other employees.
NOTE:
Costs reported on Line 21 excludes costs of executive deferred compensation that are
defined contribution pension plans, tax-sheltered annuity plans, nonqualified defined
benefit plans and qualified defined benefit plans that are available to other employees
that is reportable on Lines 1 through 4, respectively.
4005.5 Part V - Contract Labor and Benefit Costs.--This section identifies the contract labor
costs and benefit costs for the hospital complex and applicable subproviders and units.
Definitions:
Contract Labor Costs--Enter the amount paid for services furnished under contract, rather than
by employees, for direct patient care, and top level management services as defined in the
instructions for Worksheet S-3, Part II, line 11. The amount of Contract Labor report on S-3,
Part II, line 11 should agree with the amount reported on S-3, Part V, line 2. This is only for the
hospital (not including excluded areas). The remainder of S-3, Part V should reflect Contract
Labor as defined on S-3, Part II, line 11 (direct patient care and top level management for all of
the excluded areas) with the aggregate total reported on line 1.
Benefit Costs--Enter the amount of employee benefit costs, also referred to as wage-related
costs. Worksheet S-3, Part IV provides a list of core wage-related costs. The core wage-related
costs reported on S-3, Part IV, line 24, which is spread on S-3, Part II, lines 17 and 19-25, must
be reported by component on S-3, Part V. The amount reported on S-3, Part V, line 1 must
agree to the allowable amount reported on S-3, Part IV, line 24. S-3, Part V, line 2 must agree
to the amount reported on S-3, Part II, line 17. Each excluded area must contain their share of
wage related costs so that lines 19 through 25 on S-3, Part II will agree to S-3, Part V, lines 3
through 18.
Indentify the contract labor costs and benefit costs for each component on the applicable line.
Rev. 3
40-65.8
4006
4006.
FORM CMS-2552-10
WORKSHEET S-4 STATISTICAL DATA
HOSPITAL-BASED
10-12
HOME
HEALTH
AGENCY
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are
required to maintain statistical records for proper determination of costs payable under titles V,
XVIII, and XIX. The statistics required on this worksheet pertain to a hospital-based home health
agency. The data maintained is dependent upon the services provided by the agency, number of
program home health aide hours, total agency home health aide hours, program unduplicated
census count, and total unduplicated census count. In addition, FTE data are required by
employee staff, contracted staff, and total. Complete a separate S-4 for each hospital-based
home health agency.
Line 1--Enter the number of hours applicable to home health aide services.
Line 2--Enter the unduplicated count of all individual patients and title XVIII patients receiving
home visits or other care provided by employees of the agency or under contracted services
during the reporting period. Count each individual only once. However, because a patient may
be covered under more than one health insurance program, the total census count (column 5, line
2) may not equal the sum of columns 1 through 4, line 2. For purposes of calculating the
unduplicated census, if a beneficiary has received healthcare in more than one CBSA, you must
prorate the count of that beneficiary so as not to exceed a total of (1). A provider is to also query
the beneficiary to determine if he or she has received healthcare from another provider during the
year, e.g., Maine versus Florida for beneficiaries with seasonal residence.
Lines 3 - 18--Lines 3 through 18 provide statistical data related to the human resources of the
HHA. The human resources statistics are required for each of the job categories specified in
lines 3 through 18.
Enter the number of hours in your normal work week.
Report in column 1 the full time equivalent (FTE) employees on the HHA’s payroll. These are
staff for which an IRS Form W-2 is used.
Report in column 2 the FTE contracted and consultant staff of the HHA.
Compute staff FTEs for column 1 as follows. Add all hours for which employees were paid and
divide by 2080 hours. Round to two decimal places, e.g., .04447 is rounded to .04. Compute
contract FTEs for column 2 as follows. Add all hours for which contracted and consultant staff
worked and divide by 2080 hours.
If employees are paid for unused vacation, unused sick leave, etc., exclude these paid hours from
the numerator in the calculations.
Line 19--Enter in column 1 the number of CBSAs that you serviced during this cost reporting
period.
Line 20--Identify each CBSA where the reported HHA visits are performed by entering the 5
digit CBSA code and Non-CBSA (rural) code as applicable. Subscript the lines to accommodate
the number of CBSAs you service. Rural CBSA codes are assembled by placing the digits “999”
in front of the two digit State code, e.g., for the State of Maryland the rural CBSA code is 99921.
PPS Activity Data--Applicable for Medicare Services.
In accordance with 42 CFR §413.20 and §1895 of the Social Security Act, home health agencies
transitioned from a cost based reimbursement system to a prospective payment system (PPS)
effective for home health services rendered on or after October 1, 2000.
40-66
Rev. 3
12-10
FORM CMS-2552-10
4006 (Cont.)
The statistics required on this worksheet pertain to home health services furnished on or after
October 1, 2000. The data to be maintained, depending on the services provided by the agency,
includes the number of aggregate program visits furnished in each episode of care payment
category for each covered discipline, the corresponding aggregate program charges imposed in
each episode of care payment category for each covered discipline, total visits and total charges
for each episode of care payment category, total number of episodes and total number of outlier
episodes for each episode of care payment category, and total medical supply charges for each
episode of care payment category.
HHA Visits--See Pub. 15-2, chapter 32, §3205, page 32-13 for the definition of an HHA visit.
Episode of Care--Under home health PPS the 60 day episode is the basic unit of payment where
the episode payment is specific to one individual beneficiary. Beneficiaries are covered for an
unlimited number of non-overlapping episodes. The duration of a full length
episode will be 60
days. An episode begins with the start of care date and must end by the 60th day from the start of
care.
Less than a full Episode of Care--When 4 or fewer visits are provided by the HHA in a 60 day
episode period, the result is a low utilization payment adjustment (LUPA). In this instance the
HHA will be reimbursed based on a standardized per visit payment.
An episode may end before the 60th day in the case of a beneficiary elected transfer, or a
discharge and readmission to the same HHA (including for an intervening inpatient stay). This
type of situation results in a partial episode payment (PEP) adjustment.
Use lines 21 through 32 to identify the number of visits and the corresponding visit charges for
each discipline for each episode payment category. Lines 33 and 35 identify the total number of
visits and the total corresponding charges, respectively, for each episode payment category. Line
36 identifies the total number of episodes completed for each episode payment category. Line 37
identifies the total number of outlier episodes completed for each episode payment category.
Outlier episodes do not apply to 1) Full Episodes without Outliers and 2) LUPA Episodes. Line
38 identifies the total medical supply charges incurred for each episode payment category.
Column 5 displays the sum total of data for columns 1 through 4. The statistics and data
required on this worksheet are obtained from the provider statistical and reimbursement (PS&R)
report.
When an episode of care is initiated in one fiscal year and concludes in the subsequent fiscal
year, all statistical data (i.e., cost, charges, counts, etc…) associated with that episode of care will
appear on the PS&R of the fiscal year in which the episode of care is concluded. Similarly, all
data required in the cost report for a given fiscal year must only be associated with services
rendered during episodes of care that conclude during the fiscal year. Title XVIII visits reported
on this worksheet will not agree with the title XVIII visits reported on Worksheet H-3, sum of
columns 2 and 3, line 14.
Columns 1 through 4--Enter data pertaining to title XVIII patients only. Enter, as applicable, in
the appropriate columns 1 through 4, lines 21 through 32, the number of aggregate program
visits furnished in each episode of care payment category for each covered discipline and the
corresponding aggregate program visit charges imposed for each covered discipline for each
episode of care payment category. The visit counts and corresponding charge data are mutually
exclusive for all episode of care payment categories. For example, visit counts and the
corresponding charges that appear in column 4 (PEP only Episodes) will not include any visit
counts and corresponding charges that appear in column 3 (LUPA Episodes) and vice versa.
This is true for all episode of care payment categories in columns 1 through 4.
Rev. 1
40-67
4006 (Cont.)
FORM CMS-2552-10
12-10
Line 33--Enter in columns 1 through 4 for each episode of care payment category, respectively,
the sum total of visits from lines 21, 23, 25, 27, 29 and 31.
Line 34--Enter in columns 1 through 4 for each episode of care payment category, respectively,
the charges for services paid under PPS and not identified on any previous lines.
Line 35--Enter in columns 1 through 4 for each episode of care payment category, respectively,
the sum total of visit charges from lines 22, 24, 26, 28, 30, 32 and 34.
Line 36--Enter in columns 1 through 4 for each episode of care payment category, respectively,
the total number of episodes (standard/non-outlier) of care rendered and concluded in the
provider’s fiscal year.
Line 37--Enter in columns 2 and 4 for each episode of care payment category identified,
respectively, the total number of outlier episodes of care rendered and concluded in the
provider’s fiscal year. Outlier episodes do not apply to columns 1 and 3 (Full Episodes without
Outliers and LUPA Episodes, respectively).
NOTE: Lines 36 and 37 are mutually exclusive.
Line 38--Enter in columns 1 through 4 for each episode of care payment category, respectively,
the total non-routine medical supply charges for services rendered and concluded in the
provider’s fiscal year.
Column 5--Enter on lines 21 through 37, respectively, the sum total of amounts from columns 1
through 4.
40-68
Rev. 1
12-10
4007.
FORM CMS-2552-10
WORKSHEET S-5 STATISTICAL DATA
HOSPITAL
RENAL
4007
DIALYSIS
DEPARTMENT
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are
required to maintain statistical records for proper determination of costs payable under the
Medicare program. The statistics reported on this worksheet pertain to the renal dialysis
department. The data maintained, depending on the services provided by the hospital, includes
patient data, the number of treatments, number of stations, and home program data.
If you have more than one renal dialysis department, submit one Worksheet S-5 combining all of
the renal dialysis departments’ data. You must also have on file (as supporting documentation),
a Worksheet S-5 for each renal dialysis department and the appropriate workpapers. File this
documentation with exception requests in accordance with CMS Pub. 15-1, §2720. Also enter
on the combined Worksheet S-5 the applicable data for each renal dialysis satellite for which you
are separately certified (that is, a satellite for which you were issued a satellite CCN).
Column Descriptions
Columns 1 and 2--Include in these columns information regarding outpatient hemodialysis
patients. Do not include information regarding intermittent peritoneal dialysis. In column 2,
report information if you are using high flux dialyzers.
Columns 3 through 6--Report information concerning the provider’s training and home
programs. Do not include intermittent peritoneal dialysis information in columns 3 and 5.
Line Descriptions
Line 1--Enter the number of patients receiving dialysis at the end of the cost reporting period.
Line 2--Enter the average number of times patients receive dialysis per week. For CAPD and
CCPD patients, enter the number of exchanges per day.
Line 3--Enter the average time for furnishing a dialysis treatment.
Line 4--Enter the average number of exchanges for CAPD.
Line 5--Enter the number of days dialysis is furnished during the cost reporting period.
Line 6--Enter the number of stations used to furnish dialysis treatments at the end of the cost
reporting period.
Line 7--Enter the number of treatments furnished per day per station. This number represents the
number of treatments that the facility can furnish not the number of treatments actually
furnished.
Line 8--Enter your utilization. Compute this number by dividing the number of treatments
furnished by the product of lines 5, 6, and 7. This percentage cannot exceed 100 percent.
Line 9--Enter the number of times your facility reuses dialyzers. This number is the average
number of times patients reuse a dialyzer. If none, enter zero.
Line 10--Enter the percentage of patients that reuse dialyzers.
Line 11--Enter the number of patients who are awaiting a transplant at the end of the cost
reporting period.
Rev. 1
40-69
4007 (Cont.)
FORM CMS-2552-10
12-10
Line 12--Enter the number of patients who received a transplant during the fiscal year.
Line 13--Enter the direct product cost net of discount and rebates for Epoetin (EPO). Include all
EPO cost for patients receiving outpatient, home (method I or II), or training dialysis treatments.
This amount includes EPO cost furnished in the renal department or any other department if
furnished to an end stage renal disease dialysis patient. Report on this line the amount of EPO
cost included in line 74 of Worksheet A.
Line 14--Based on the instructions contained on line 13, enter the amount of Epoetin included on
line 94 (home dialysis program) from Worksheet A.
Line 15--Enter the number of EPO units furnished relating to the renal dialysis department.
Line 16--Enter the number of EPO units furnished relating to the home dialysis program.
Line 17--Enter the direct product cost net of discount and rebates for Darbepoetin Alfa (Aranesp)
Include all Aranesp cost for patients receiving outpatient, home (method I or II), or training
dialysis treatments. This amount includes Aranesp cost furnished in the renal department or any
other department if furnished to an end stage renal disease dialysis patient. Report on this line
the amount of Aranesp cost included in line 74 of Worksheet A.
Line 18--Based on the instructions contained on line 17, enter the dollar amount of Aranesp
included on line 94 (home dialysis program) from Worksheet A.
Line 19--Enter the number of micrograms (mcgrs) of Aranesp furnished relating to the renal
dialysis department.
Line 20--Enter the number of micrograms of Aranesp furnished relating to the home dialysis
program.
Line 21--Identify how physicians are paid for medical services provided to Medicare
beneficiaries. Under the monthly capitation payment (MCP) methodology, contractors pay
physicians for their Part B medical services. Under the initial method, the renal facility pays for
physicians’ Part B medical services. The facility’s payment rate is increased in accordance with
42 CFR 414.313. There are a limited number of facilities electing this method.
40-70
Rev. 1
08-11
4008.
FORM CMS-2552-10
4008
WORKSHEET S-6 - HOSPITAL-BASED COMMUNITY MENTAL HEALTH
CENTER AND OTHER OUTPATIENT REHABILITATION PROVIDER
STATISTICAL DATA
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), maintain
statistical records for proper determination of costs payable under the Medicare program. The
statistics reported on this worksheet pertain to hospital-based community mental health centers
(CMHCs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient rehabilitation
facilities (ORFs) which generally furnishes outpatient physical therapy (OPT), outpatient
occupational therapy (OOT), or outpatient speech pathology (OSP). If you have more than one
hospital-based component, complete a separate worksheet for each facility.
Additionally, only CMHCs are required to complete the corresponding Worksheet J series.
However, all CMHCs, CORFs, ORFs, OPTs, OOTs, and OSPs must complete the applicable
Worksheet A cost center for the purpose of overhead allocation.
This worksheet provides statistical data related to the human resources of the community mental
health center. FTE data is required by employee staff, contracted staff, and total. The human
resources statistics are required for each of the job categories specified on lines 1 through 17.
Enter any additional categories needed on line 18.
Enter the number of hours in your normal work week in the space provided.
Report in column 1 the full time equivalent (FTE) employees on the CMHC or outpatient
rehabilitation provider's payroll. These are staff for which an IRS Form W-2 was issued.
Report in column 2 the FTE contracted and consultant staff of the CMHC or outpatient
rehabilitation provider.
Compute staff FTEs for column 1 as follows. Add hours for which employees were paid divided
by 2080 hours, and round to two decimal places, e.g., round .04447 to .04. Compute contract
FTEs for column 2 as follows. Add all hours for which contracted and consultant staff worked
divided by 2080 hours, and round to two decimal places.
If employees are paid for unused vacation, unused sick leave, etc., exclude the paid hours from
the numerator in the calculations.
Rev. 2
40-71
4009
4009.
FORM CMS-2552-10
08-11
WORKSHEET S-7 - PROSPECTIVE PAYMENT FOR SKILLED NURSING
FACILITIES STATISTICAL DATA
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are
required to maintain statistical records for proper determination of costs payable under the
Medicare program. Public Law 105-33 (Balanced Budget Act of 1997) requires that all SNFs be
reimbursed under PPS for cost reporting periods beginning on and after July 1, 1998.
Line 1--If this facility contains a hospital-based SNF, if all patients were covered under managed
care or if there was no Medicare utilization, enter “Y” for yes. If the response is yes, do not
complete the rest of this worksheet.
Line 2--Does this hospital have an agreement under either section 1883 or 1913 of the Act for
swingbeds? Enter “Y” for yes or “N” for no in column 1. If yes, enter arrangement date
(mm/dd/yyyy) in column 2.
Column Descriptions for Lines 3 Through 200
Column 1--The case mix resource utilization group (RUGs) designations are already entered in
this column.
Column 2--Enter the number of days associated with SNF services. All SNF payment data will
be reported as a total amount paid under the RUG PPS payment system on Worksheet E-3, Part
VI, line 1 and will be generated from the PS&R or your records.
Column 3--Enter the number of days associated with the swing beds. All swingbed SNF
payment data will be reported as a total amount paid under the RUG PPS payment system on
Worksheet E-2, line 1 and will be generated from the PS&R or your records.
Column 4--Enter the sum total of columns 2 and 3.
Line 201--Enter in column 1, the CBSA code in effect at the beginning of the cost reporting
period. Enter in column 2, the CBSA code in effect on or after October 1 of the current cost
reporting period, if applicable.
Lines 202 through 206--A notice published in the August 4, 2003, Federal Register, Vol. 68,
No. 149 provided for an increase in RUG payments to hospital based SNFs for payments on or
after October 1, 2003. Congress expects this increase to be used for direct patient care and
related expenses. Lines 202 through 206 are idetnified as following: 202 - Staffing, 203 Recruitment, 204 - Retention of Employees, 205 - Training, and 206 - Other. Enter in column 1
the direct patient care expenses and related expenses in accordance with the above referenced
Federal Register citation. Enter in column 2 the ratio, expressed as a percentage, of total
expenses for each category to total SNF revenue from Worksheet G-2, Part I, line 7, column 3.
For each line, indicate in column 3 whether the increased RUG payments received reflects
increases associated with direct patient care and related expenses by responding “Y” for yes.
Indicate “N” for no if there was no increase in spending in any of these areas. If the increased
spending is in an area not previously identified in areas one through four, identify on the “Other
(Specify)” line(s), the cost center(s) description and the corresponding information as indicated
above.
40-72
Rev. 2
10-12
4010.
FORM CMS-2552-10
4010
WORKSHEET S-8 - HOSPITAL-BASED RURAL HEALTH CLINIC/FEDERALLY
QUALIFIED HEALTH CENTER STATISTICAL DATA
In accordance with 42 CFR 413.20(a), 42 CFR 413.24(a), and 42 CFR 413.24(c), you are
required to maintain separate statistical records for proper determination of costs payable under
the Medicare program. The statistics reported on this worksheet pertain to provider-based rural
health clinics (RHCs) and provider-based federally qualified health centers (FQHCs). If you
have more than one of these clinics, complete a separate worksheet for each facility. RHCs and
FQHCs may elect to file a consolidated cost report pursuant to CMS Pub. 100-4, chapter 9,
§30.8.
Lines 1 and 2--Enter the full address of the RHC/FQHC.
Line 3--For FQHCs only, enter your appropriate designation of “R” for rural or “U” for urban.
See §505.2 of the RHC/FQHC Manual for information regarding urban and rural designations.
If you are uncertain of your designation, contact your contractor. RHCs do not complete this
line.
Lines 4 - 9--In column 1, enter the applicable grant award number(s). In column 2, enter the
date(s) awarded.
Line 10--If the facility provides other than RHC or FQHC services (e.g., laboratory or physician
services), answer “Y” for yes and enter the type of operation on subscripts of line 11, otherwise
enter “N” for no.
Line 11 --Enter in columns 1 through 14 the starting and ending hours in the applicable columns
for the days that the facility is available to provide RHC/FQHC services. Enter the starting and
ending hours in the applicable columns 1 through 14 for the days that the facility is available to
provide other than RHC/FQHC services. When entering time do so as military time, e.g., 2:00
p.m. is 1400.
Line 12--Have you received an approval for an exception to the productivity standards? Enter a
“Y” for yes or an “N” for no.
Line 13--Is this a consolidated cost report as defined in the Rural Health Clinic Manual? If yes,
enter in column 2 the number of providers included in this report, complete line 14, and complete
only one worksheet series M for the consolidated group. If no, complete a separate Worksheet S8 for each component accompanied by a corresponding Worksheet M series.
Line 14--Identify provider’s name and CCN number filing the consolidated cost report.
Line 15--Are you claiming allowable GME costs as a result of your substantial payment for
interns and residents. Enter a “Y” for yes or an “N” for no in column 1. If yes, enter in the
appropriate column the number of program visits (columns 2-4) and total visits (column 5)
performed by interns and residents.
Rev. 3
40-73
4011
4011.
FORM CMS-2552-10
10-12
WORKSHEET S-9 - HOSPICE IDENTIFICATION DATA
In accordance with 42 CFR 418.310 hospice providers of service participating in the Medicare
program are required to submit annual information for health care services rendered to Medicare
beneficiaries. Also, 42 CFR 413.24(f) requires cost reports from providers on an annual basis.
The data submitted on the cost reports supports management of Federal programs. The statistics
required on this worksheet pertain to a hospital-based hospice. Complete a separate Worksheet
S-9 for each hospital-based hospice.
4011.1
Part I - Enrollment Days.--
NOTE: Columns 1 and 2 contain the days identified in column 3 and 4. Column 3 and 4
identify the SNF and NF days out of the total for title XVIII and XIX.
Lines 1 - 4--Enter on lines 1 through 4 the enrollment days applicable to each type of care.
Enrollment days are unduplicated days of care received by a hospice patient. A day is recorded
for each day a hospice patient receives one of four types of care. Where a patient moves from
one type of care to another, count only one day of care for that patient for the last type of care
rendered. For line 4, an inpatient care day should be reported only where the hospice provides or
arranges to provide the inpatient care.
Line 5--Enter the total of columns 1 through 6 for lines 1 through 4.
For the purposes of the Medicare and Medicaid hospice programs, a patient electing hospice can
receive only one of the following four types of care per day:
Continuous Home Care Day - A continuous home care day is a day on which the hospice
patient is not in an inpatient facility. A day consists of a minimum of 8 hours and a maximum of
24 hours of predominantly nursing care. Note: Convert continuous home care hours into
days so that a true accountability can be made of days provided by the hospice.
Routine Home Care Day - A routine home care day is a day on which the hospice patient is at
home and not receiving continuous home care.
Inpatient Respite Care Day - An inpatient respite care day is a day on which the hospice
patient receives care in an inpatient facility for respite care.
General Inpatient Care Day - A general inpatient care day is a day on which the hospice
patient receives care in an inpatient facility for pain control or acute or chronic symptom
management which cannot be managed in other settings.
COLUMN DESCRIPTIONS
Column 1--Enter only the unduplicated Medicare days applicable to the four types of care. Enter
on line 5 the total unduplicated Medicare days.
Column 2--Enter only the unduplicated Medicaid days applicable to the four types of care. Enter
on line 5 the total unduplicated Medicaid days.
Column 3--Enter only the unduplicated days applicable to the four types of care for all Medicare
hospice patients residing in a skilled nursing facility. Enter on line 5 the total unduplicated days.
Column 4--Enter only the unduplicated days applicable to the four types of care for all Medicaid
hospice patients residing in a nursing facility. Enter on line 5 the total unduplicated days.
40-74
Rev. 3
08-11
FORM CMS-2552-10
4011.2
Column 5--Enter in column 5 only the days applicable to the four types of care for all other non
Medicare or Medicaid hospice patients. Enter on line 5 the total unduplicated days.
Column 6--Enter the total days for each type of care, (i.e., sum of columns 1, 2 and 5). The
amount entered in column 6, line 5 should represent the total days provided by the hospice.
NOTE: Convert continuous home care hours into days so that column 6, line 5 reflects the
actual total number of days provided by the hospice.
4011.2
Part II - Census Data.--
NOTE: Columns 1 and 2 contain the days identified in columns 3 and 4. Columns 3 and 4
identify the SNF and NF days out of the total for title XVIII and XIX.
Line 6--Enter the total number of patients receiving hospice care within the cost reporting period
for the appropriate payer source.
The total under this line should equal the actual number of patients served during the cost
reporting period for each program. Thus, if a patient’s total stay overlapped two reporting
periods, the stay should be counted once in each reporting period. The patient who initially
elects the hospice benefit, is discharged or revokes the benefit, and then elects the benefit again
within a reporting period is considered to be a new admission with a new election and should be
counted twice.
A patient transferring from another hospice is considered to be a new admission and would be
included in the count. If a patient entered a hospice under a payer source other than Medicare
and then subsequently elects Medicare hospice benefit, count the patient once for each pay
source.
The difference between line 6 and line 9 is that line 6 should equal the actual number of patients
served during the reporting period for each program, whereas under line 9, patients are counted
once, even if their stay overlaps more than one reporting period.
Line 7--Enter the total title XVIII Unduplicated Continuous Care hours billable to Medicare.
When computing the Unduplicated Continuous Care hours, count only one hour regardless of
number of services or therapies provided simultaneously within that hour.
Line 8--Enter the average length of stay for the reporting period. Include only the days for which
a hospice election was in effect. The average length of stay for patients with a payer source
other than Medicare and Medicaid is not limited to the number of days under a hospice election.
Line 5 divided by Line 6.
The statistics for a patient who had periods of stay with the hospice under more than one
program is included in the respective columns. For example, patient A enters the hospice under
Medicare hospice benefit, stays 90 days, revokes the election for 70 days (and thus goes back
into regular Medicare coverage), then reelects the Medicare hospice benefits for an additional 45
days, under a new benefit period and dies (patient B).
Medicare patient C was in the program on the first day of the year and died on January 29 for a
total length of stay of 29 days. Patient D was admitted with private insurance for 27 days, then
their private insurance ended and Medicaid covered an additional 92 days. Patient E, with
private insurance, received hospice care for 87 days. The average length of stay (LOS) (assuming
these are the only patients the hospice served during the cost reporting period) is computed as
follows:
Rev. 2
40-75
4011.2 (Cont.)
FORM CMS-2552-10
Medicare Days (90 & 45 & 29)
Patient (A, B & C)
Medicare Patients
08-11
164 days
Average LOS Medicare
/3
---54.67 Days
Medicaid Days Patient D (92)
Medicaid Patient
Average LOS Medicaid
92 Days
1
92 Days
Other (Insurance) Days (87 & 27)
Other Payments (D & E)
Average LOS (Other)
114 Days
2
54 Days
All Patients (90+45+29+92+87+27)
Total number of patients
Average LOS for all patients
370 Days
6
61.67 Days
Enter the hospice’s average length of stay, without regard to payer source, in column 6, line 8.
Line 9--Enter the unduplicated census count of the hospice for all patients initially admitted and
filing an election statement with the hospice within a reporting period for the appropriate payer
source. Do not include the number of patients receiving care under subsequent election periods
(See CMS Pub. 21, Section 204). However, the patient who initially elects the hospice benefit, is
discharged or revokes the benefits, and elects the benefit again within the reporting period is
considered a new admission with each new election and should be counted twice.
The total under this line should equal the unduplicated number of patients served during the
reporting period for each program. Thus, you would not include a patient if their stay was
counted in a previous cost reporting period. If a patient enters a hospice source other than
Medicare and subsequently becomes eligible for Medicare and elects the Medicare hospice
benefit, then count that patient only once in the Medicare column, even though he/she may have
had a period in another payer source prior to the Medicare election. A patient transferring from
another hospice is considered to be a new admission and is included in the count.
40-76
Rev. 2
10-12
FORM CMS-2552-10
4012
4012.
Worksheet S-10 - Hospital Uncompensated and Indigent Care Data--Section 112(b) of
the Balanced Budget Refinement Act (BBRA) requires that short-term acute care hospitals
(§1886(d) of the Act) submit cost reports containing data on the cost incurred by the hospital for
providing inpatient and outpatient hospital services for which the hospital is not compensated.
Charity care charge data, as referenced in section 4102 of American Recovery and Reinvestment
Act of 2009, may be used to calculate the EHR technology incentive payments made to §1886(d)
hospitals and critical access hospitals (CAHs). CAHs, as well as §1886(d) hospitals, are
required to complete this worksheet. Note that this worksheet does not produce the estimate of
the cost of treating uninsured patients required for disproportionate share payments under the
Medicaid program.
Definitions:
Uncompensated care--Defined as charity care and bad debt which includes non-Medicare bad
debt and non-reimbursable Medicare bad debt. Uncompensated care does not include courtesy
allowances or discounts given to patients.
Charity care--Health services for which a hospital demonstrates that the patient is unable to pay.
Charity care results from a hospital's policy to provide all or a portion of services free of charge
to patients who meet certain financial criteria. For Medicare purposes, charity care is not
reimbursable and unpaid amounts associated with charity care are not considered as an allowable
Medicare bad debt. (Additional guidance provided in the instruction for line 20.)
Non-Medicare bad debt--Health services for which a hospital determines the non-Medicare
patient has the financial capacity to pay, but the non-Medicare patient is unwilling to settle the
claim. (Additional guidance provided in the instruction for line 25.)
Non-reimbursable Medicare bad debt--The amount of allowable Medicare coinsurance and
deductibles considered to be uncollectible but are not reimbursed by Medicare under the
requirements of §413.89 of the regulations and of Chapter 3 of the Provider Reimbursement
Manual Part 1. (Additional guidance provided in the instruction for line 25.)
Net revenue--Actual payments received or expected to be received from a payer (including coinsurance payments from the patient) for services delivered during this cost reporting period.
Net revenue will typically be charges (gross revenue) less contractual allowance. (Applies to
lines 2, 9, and 13.)
Instructions:
Cost to charge ratio:
Line 1--Enter the cost-to-charge ratio resulting from Worksheet C, Part I, line 202, column 3
divided by Worksheet C, Part I, line 202, column 8.
For all inclusive rate providers that do not complete Worksheet C, Part I, enter your cost-tocharge ratio as calculated in accordance with CMS Pub. 15-1, section 2208.
Medicaid
NOTE: The amount on line 18 should not include the amounts on lines 2 and 5. That is, the
amounts on lines 2 and 5 are mutually exclusive from the amount on line 18.
Line 2--Enter the inpatient and outpatient payments received or expected for Title XIX covered
services delivered during this cost reporting period. Include payments for an expansion SCHIP
program, which covers recipients who would have been eligible for coverage under Title XIX.
Include payments for all covered services except physician or other professional services, and
include payments received from Medicaid managed care programs. If not separately identifiable,
Rev. 3
40-77
4012 (Cont.)
FORM CMS-2552-10
10-12
disproportionate share (DSH) and supplemental payments should be included in this line. For
these payments, report the amount received or expected for the cost reporting period, net of
associated provider taxes or assessments.
Line 3--Enter “Y” for yes if you received or expect to receive any DSH or supplemental
payments from Medicaid relating to this cost reporting period. Otherwise enter “N” for no.
Line 4--If you answered yes to question 3, enter “Y” for yes if all of the DSH or supplemental
payments you received from Medicaid are included in line 2. Otherwise enter “N” for no and
complete line 5.
Line 5--If you answered no to question 4, enter the DSH or supplemental payments the hospital
received or expects to receive from Medicaid relating to this cost reporting period that were not
included in line 2, net of associated provider taxes or assessments.
Line 6--Enter all charges (gross revenue) for Title XIX covered services delivered during this
cost reporting period. These charges should relate to the services for which payments were
reported on line 2.
Line 7--Calculate the Medicaid cost by multiplying line 1 times line 6.
Line 8--Enter the difference between net revenue and costs for Medicaid by subtracting the sum
of lines 2 and 5 from line 7. If line 7 is less than the sum of lines 2 and 5, then enter zero.
State Children’s Health Insurance Program:
Line 9--Enter all payments received or expected for services delivered during this cost reporting
period that were covered by a stand-alone SCHIP program. Stand-alone SCHIP programs cover
recipients who are not eligible for coverage under Title XIX. Include payments for all covered
services except physician or other professional services, and include any payments received from
SCHIP managed care programs.
Line 10--Enter all charges (gross revenue) for services delivered during this cost reporting period
that were covered by a stand-alone SCHIP program. These charges should relate to the services
for which payments were reported on line 9.
Line 11--Calculate the stand-alone SCHIP cost by multiplying line 1 times line 10.
Line 12--Enter the difference between net revenue and costs for stand-alone SCHIP by
subtracting line 9 from line 11. If line 11 is less than line 9, then enter zero.
Other state or local indigent care program:
Line 13--Enter all payments received or expected for services delivered during this cost
reporting period for patients covered by a state or local government indigent care program (other
than Medicaid or SCHIP), where such payments and associated charges are identified with
specific patients and documented through the provider's patient accounting system. Include
payments for all covered services except physician or other professional services, and include
payments from managed care programs.
Line 14--Enter all charges (gross revenue) for services delivered during this cost reporting period
for patients covered by a state or local government program, where such charges and associated
payments are documented through the provider's patient accounting system. These charges
should relate to the services for which payments were reported on line 13.
40-78
Rev. 3
10-12
FORM CMS-2552-10
4012 (Cont.)
Line 15--Calculate the costs for patients covered by a state or local government program by
multiplying line 1 times line 14.
Line 16--Calculate the difference between net revenue and costs for patients covered by a state
or local government program by subtracting line 13 from line 15. If line 15 is less than line 13,
then enter zero.
Uncompensated care:
Line 17--Enter the value of all non-government grants, gifts and investment income received
during this cost reporting period that were restricted to funding uncompensated or indigent care.
Include interest or other income earned from any endowment fund for which the income is
restricted to funding uncompensated or indigent care.
Line 18--Enter all grants, appropriations or transfers received or expected from government
entities for this cost reporting period for purposes related to operation of the hospital, including
funds for general operating support as well as for special purposes (including but not limited to
funding uncompensated care). Include funds from the Federal Section 1011 program, if
applicable, which helps hospitals finance emergency health services for undocumented aliens.
While Federal Section 1011 funds were allotted for federal fiscal years 2005 through 2008, any
unexpended funds will remain available after that time period until fully expended even after
federal fiscal year 2008. If applicable, report amounts received from charity care pools net of
related provider taxes or assessments. Do not include funds from government entities designated
for non-operating purposes, such as research or capital projects.
Line 19--Calculate the total unreimbursed cost for Medicaid, SCHIP and state and local indigent
care programs by entering the sum of lines 8, 12 and 16.
Line 20--Enter the total initial payment obligation of patients who are given a full or partial
discount based on the hospital’s charity care criteria (measured at full charges), for care
delivered during this cost reporting period for the entire facility. For uninsured patients,
including patients with coverage from an entity that does not have a contractual relationship with
the provider (column 1), this is the patient’s total charges. For patients covered by a public
program or private insurer with which the provider has a contractual relationship (column 2),
these are the deductible and coinsurance payments required by the payer. Include charity care
for all services except physician and other professional services. Do not include charges for
either uninsured patients given discounts without meeting the hospital's charity care criteria or
patients given courtesy discounts. Charges for non-covered services provided to patients eligible
for Medicaid or other indigent care program (including charges for days exceeding a length of
stay limit) can be included, if such inclusion is specified in the hospital's charity care policy and
the patient meets the hospital's charity care criteria.
Line 21--Calculate the cost of initial obligation of patients approved for charity care by
multiplying line 1 times line 20. Use column 1 for uninsured patients, including patients with
coverage from an entity that does not have a contractual relationship with the provider, and use
column 2 for patients covered by a public program or private insurer with which the provider has
a contractual relationship.
Line 22--Enter payments received or expected from patients who have been approved for partial
charity care for services delivered during this cost reporting period. Include such payments for
all services except physician or other professional services. Payments from payers should not be
included on this line. Use column 1 for uninsured patients, including patients with coverage
from an entity that does not have a contractual relationship with the provider, and use column 2
for patients covered by a public program or private insurer with which the provider has a
contractual relationship.
Rev. 3
40-79
4012 (Cont.)
FORM CMS-2552-10
10-12
Line 23--Calculate the cost of charity care by subtracting line 22 from line 21. Use column 1 for
uninsured patients, including patients with coverage from an entity that does not have a
contractual relationship with the provider, and use column 2 for patients covered by a public
program or private insurer with which the provider has a contractual relationship.
Line 24--Enter “Y” for yes if any charges for patient days beyond a length-of-stay limit imposed
on patients covered by Medicaid or other indigent care program are included in the amount
reported in line 20, column 2, and complete line 25. Otherwise enter “N” for no.
Line 25--If you answered yes to question 24, enter charges for patient days beyond a length-ofstay limit imposed on patients covered by Medicaid or other indigent care program for services
delivered during this cost reporting period. The amount must match the amount of such charges
included in line 20, column 2.
Line 26--Enter the total facility (entire hospital complex) charges for bad debts (bad debt
expense) written off or expected to be written off on balances owed by patients for services
delivered during this cost reporting period. Include such charges for all services except
physician and other professional services. Include the sum of all Medicare allowable bad debts
appearing in the Worksheet E, H, I, J, and M series including: E, Part A, line 64; E, Part B, line
34; E-2, line 17; E-3, Part I, line 11; E-3, Part II, line 23; E-3, Part III, line 24; E-3, Part IV, line
14; E-3, Part V, line 25; E-3, Part VI, line 8; Part VII, line 34; H-4, Part II, line 27; I-5, line 5; J3, line 21; and M-3, line 23. For privately insured patients, do not include bad debts that were
the obligation of the insurer rather than the patient.
Line 27--Enter the total facility (entire hospital complex) Medicare reimbursable (also referred to
adjusted) bad debts as the sum of Worksheet E, Part A, line 65; E, Part B, line 35; E-2, line 17,
columns 1 and 2; E-3, Part I, line 12; E-3, Part II, line 24; E-3, Part III, line 25; E-3, Part IV, line
15; E-3, Part V, line 26; E-3, Part VI, line 10; H-4, Part II, line 27; I-5, line 5; J-3, line 21; and
M-3, line 23.
Line 28--Calculate the non-Medicare and non-reimbursable Medicare bad debt expense by
subtracting line 27 from line 26.
Line 29--Calculate the cost of non-Medicare and non-reimbursable Medicare bad debt expense
by multiplying line 1 times line 28.
Line 30--Calculate the cost of non-Medicare uncompensated care by entering the sum of lines
23, column 3 and line 29.
Line 31--Calculate the cost of unreimbursed and uncompensated care and by entering the sum of
lines 19 and 30.
40-80
Rev. 3
10-12
4013.
FORM CMS-2552-10
4013
WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
In accordance with 42 CFR 413.20, the methods of determining costs payable under title XVIII
involve using data available from the institution's basic accounts, as usually maintained, to arrive
at equitable and proper payment for services. Worksheet A provides for recording the trial
balance of expense accounts from your accounting books and records. It also provides for the
necessary reclassifications and adjustments to certain accounts. The cost centers on this
worksheet are listed in a manner which facilitates the transfer of the various cost center data to
the cost finding worksheets (e.g., on Worksheets A, B, C, and D, the line numbers are
consistent). While providers are expected to maintain their accounting books and general ledger
in a manner consistent with the standard cost centers/departments identified on this worksheet,
not all of the cost centers listed apply to all providers using these forms. For example, IPPS
providers may contain a Burn Intensive Care Unit, where CAHs may not furnish this type of
service.
Do not include on this worksheet items not claimed in the cost report because they conflict with
the regulations, manuals, or instructions but which you wish nevertheless to claim and contest.
Enter amounts on the appropriate settlement worksheet (Worksheet E, Part A, line 75;
Worksheet E, Part B, line 44; Worksheet E-2, line 23; and Worksheet E-3, Parts I, II, III, IV, V,
VI, and VII lines 22, 35, 36, 26, 34, 19, and 43, respectively). For provider based-facilities enter
the protested amounts on line 35 of Worksheet H-4, Part II for home health agencies; line 30 of
Worksheet J-3 for CMHCs; and line 30 of Worksheet M-3 for RHC/FQHC providers.
If the cost elements of a cost center are separately maintained on your books, maintain a
reconciliation of the costs per the accounting books and records to those on this worksheet. This
reconciliation is subject to review by your contractor.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
you need to use additional or different cost center descriptions, add (subscript) additional lines to
the cost report. Where an added cost center description bears a logical relationship to a standard
line description, the added label must be inserted immediately after the related standard line.
The added line is identified as a numeric subscript of the immediately preceding line. For
example, if two lines are added between lines 7 and 8, identify them as lines 7.01 and 7.02. If
additional lines are added for general service cost centers, add corresponding columns for cost
finding.
Also, submit the working trial balance of the facility with the cost report. A working trial
balance is a listing of the balances of the accounts in the general ledger to which adjustments are
appended in supplementary columns and is used as a basic summary for financial statements.
Do not use lines 24 through 29, 47 through 49, 77 through 87, 102 through 104, 119 through
189, and 195 through 199.
Rev. 3
40-81
4013 (Cont.)
FORM CMS-2552-10
10-12
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care providers on the Medicare cost reports. Form CMS-2552-10 provides for
preprinted cost center descriptions on Worksheet A. In addition, a space is provided for a cost
center code. The preprinted cost center labels are automatically coded by CMS approved cost
reporting software. These cost center descriptions are hereafter referred to as the standard cost
centers. Additionally, nonstandard cost center descriptions have been identified through analysis
of frequently used labels.
The use of this coding methodology allows providers to continue to use labels for cost centers
that have meaning within the individual institution. The five digit cost center codes that are
associated with each provider label in their electronic file provide standardized meaning for data
analysis. You are required to compare any added or changed label to the descriptions offered on
the standard or nonstandard cost center tables. A description of cost center coding and the table
of cost center codes are in §4095, table 5.
Columns 1, 2, and 3--The expenses listed in these columns must be the same as listed in your
accounting books and records and/or trial balance.
List on the appropriate lines in columns 1, 2, and 3 the total expenses incurred during the cost
reporting period. These expenses are detailed between salaries (column 1) and other than
salaries (column 2). Include in column 1 as applicable all salary amounts for paid vacation,
holiday, sick, other paid-time-off (PTO), severance, and bonus pay. The sum of columns 1 and 2
equals the sum of column 3. Record any needed reclassifications and/or adjustments in columns
4 and 6, as appropriate.
Column 4--With the exception of the reclassification of capital related costs which are
reclassified via Worksheet A-7, all reclassifications in this column are made via Worksheet A-6.
Worksheet A-6 need not be completed by all providers and is completed only to the extent that
the reclassifications are needed and appropriate in the particular circumstance. Show reductions
to expenses as negative numbers.
The net total of the entries in column 4 must equal zero on line 200.
Column 5--Adjust the amounts entered in column 3 by the amounts in column 4 (increase or
decrease) and extend the net balances to column 5. Column 5, line 200 must equal column 3,
line 200.
Column 6--Enter on the appropriate lines in column 6 the amounts of any adjustments to
expenses indicated on Worksheet A-8, column 2. The total on Worksheet A, column 6, line 200,
equals Worksheet A-8, column 2, line 50.
Column 7--Adjust the amounts in column 5 by the amounts in column 6 (increase or decrease),
and extend the net balances to column 7.
Transfer the amounts in column 7 to the appropriate lines on Worksheet B, Part I, column 0.
40-82
Rev. 3
08-11
FORM CMS-2552-10
4013 (Cont.)
Line Descriptions
The trial balance of expenses is broken down into general service, inpatient routine service,
ancillary service, outpatient service, other reimbursable, special purpose, and nonreimbursable
cost center categories to facilitate the transfer of costs to the various worksheets. The line
numbers on Worksheet A are used on subsequent worksheets, for example, the categories of
ancillary service cost centers, outpatient service cost centers, and other reimbursable cost centers
appear on Worksheet C, Part I, using the same line numbers as on Worksheet A.
NOTE: The category titles do not have line numbers. Only cost centers, data items, and totals
have line numbers.
Lines 1 - 23--These lines are for the General Service cost centers. These costs are expenses
incurred in operating the facility as a whole that are not directly associated with furnishing
patient care such as, but not limited to mortgage, rent, plant operations, administrative salaries,
utilities, telephone charges, computer hardware and software costs, etcetera. General Service
cost centers furnish services to both general service areas and to other cost centers in the
provider.
Lines 1 and 2--The capital cost centers on lines 1 and 2 include depreciation, leases and rentals
for the use of facilities and/or equipment, and interest incurred in acquiring land or depreciable
assets used for patient care.
NOTE: Do not include in these cost centers costs incurred for the repair or maintenance of
equipment or facilities; amounts specifically included in rentals or lease payments for
repair and/or maintenance agreements; interest expense incurred to borrow working
capital or for any purpose other than the acquisition of land or depreciable assets used
for patient care; general liability insurance or any other form of insurance to provide
protection other than the replacement of depreciable assets; or taxes other than those
assessed on the basis of some valuation of land or depreciable assets used for patient
care. However, if no amount of the lease payment is identified in the lease agreement
for maintenance, you are not required to carve out a portion of the lease payment to
represent the maintenance portion. Thus, the entire lease payment is considered a
capital-related cost subject to the provisions of 42 CFR 413.130(b).
When you are dealing with a related organization, you are essentially dealing with yourself and
Medicare considers the costs to you equal to the cost to the related organization. Therefore, for
costs applicable to services, facilities, and supplies furnished by organizations related by
common ownership or control (see 42 CFR 413.17 and Pub. 15-1, chapter 10), the reimbursable
cost includes the costs for these items at the cost to the supplying organization unless the
exception provided in 42 CFR 413.17(d) and CMS Pub. 15-1, §1010 is applicable, not to exceed
the price of comparable services, facilities, or supplies that could be purchased elsewhere in the
open market.
Rev. 2
40-83
4013 (Cont.)
FORM CMS-2552-10
08-11
The policy of cost incurred from related organizations applies to capital related and non-capital
related costs. If you include costs incurred by a related organization on your cost report, the
nature of the costs (e.g., capital-related or operating costs) do not change. Treat capital-related
costs incurred by the related organization as capital-related costs to you.
If the price of comparable services, facilities, or supplies that could be purchased elsewhere in
the open market is lower than the cost to the supplying related organization; if the exception in
CFR 413.17(d) and CMS Pub. 15-1, §1010 applies; or if the supplying organization is not related
to you, then no part of the charge to you is a capital related cost unless the services, facilities, or
supplies are capital-related in nature.
In the case of leased equipment, the fact that the lease or rental is for a depreciable asset is
sufficient for consideration as a capital-related item, but a distinction must be made between the
lease of equipment and the purchase of services. A lease of equipment is considered a capitalrelated cost while a purchase of service is considered an operating cost. Generally, for the
agreement to be considered a lease or rental (and therefore a capital-related cost), the agreement
must convey to the provider the possession, use, and enjoyment of the asset. Each agreement
must be examined on its own merits. Factors that would weigh in favor of treating a particular
agreement as a lease of equipment include the following:
•
The equipment is operated by personnel employed by the provider or an organization
related to the provider within the meaning of Pub. 15-1, chapter 10.
•
The physicians who perform the services with or interpret the tests from the equipment
are associated with the provider.
•
The agreement is memorialized in one document rather than in two or more documents
(e.g., one titled a "Lease Agreement" and one titled a "Service Agreement").
•
The document memorializing the agreement is titled a “lease agreement.” If one or more
of the documents memorializing the agreement are titled “Service Agreements,” this
indicates a purchase of services.
•
The provider holds the certificate of need (CON) for the services furnished with the
equipment.
•
The basis for determining the lease payment is units of time and is not volume sensitive
(e.g., numbers of scans).
•
The provider attends to such matters as utilization review, quality assurance, and risk
management for the services involving the equipment.
•
The provider schedules the patients for services involving the equipment.
•
The provider furnishes any supplies required to be used with the equipment.
•
The provider’s access to the equipment is not subject to interruption without notice or
interruption on very short notice.
If the supplying organization is not related to you (see 42 CFR 413.17), no part of the charge to
you is a capital-related cost unless the services, facilities, or supplies are capital-related in nature.
40-84
Rev. 2
08-11
FORM CMS-2552-10
4013 (Cont.)
Under certain circumstances, costs associated with minor equipment are considered capitalrelated costs. See CMS Pub. 15-1, §106 for three methods of writing off the cost of minor
equipment. Amounts treated as expenses under method (a) are not capital-related costs because
they are treated as operating expenses. Amounts included in expense under method (b) are
capital-related costs because such amounts represent the amortization of the cost of tangible
assets over a projected useful life. Amounts determined under method (c) are capital-related
costs because method (c) is a method of depreciation.
Section 1886(g) of the Act, as implemented by 42 CFR, Part 412, Subpart M, requires that the
reasonable cost-based payment methodology for hospital inpatient capital-related costs be
replaced with an inpatient prospective payment methodology for hospitals paid under IPPS,
effective for cost reporting periods beginning on or after October 1, 1991. Hospitals and hospital
distinct part units (IPFs, IRFs, and LTCH) excluded from IPPS pursuant to 42 CFR, Part 412,
Subpart B, are paid for capital-related costs under their respective PPS payment systems. Also,
CAHs are reimbursed on a reasonable cost basis under 42 CFR 413.70.
Lines 1 and 2--Capital costs are defined as all allowable capital-related costs for land and
depreciable assets, with additional recognition of costs for capital-related items and services that
are legally obligated by an enforceable contract (See Pub. 15-1, §2800.) Betterment or
improvement costs related to capital are included in capital assets. (See 42 CFR 412.302.)
Capital costs incurred as a result of extraordinary circumstances are included in capital. (See 42
CFR 412.348(g).) Direct assignment of capital costs must be done in accordance with CMS Pub.
15-1, §§2307 and 2313.
Capital costs include the following:
1. Allowable depreciation on assets based on the useful life guidelines used to determine
depreciation expense in the hospital’s base period, which cannot be subsequently changed.
2. Allowable capital-related interest expense. Except as provided in subsections a
through c below, the amount of allowable capital-related interest expense recognized as capital is
limited to the amount the hospital was legally obligated to pay.
a. An increase in interest expense is recognized if the increase is due to periodic
fluctuations of rates in variable interest rate loans or to periodic fluctuations of rates at the time
of conversion from a variable rate loan to a fixed rate loan when no other changes in the terms of
the loan are made.
b. If the terms of a debt instrument are revised, the amount of interest recognized
associated with the original capital cannot exceed the amount that would have been recognized
during the same period prior to the revision of the debt instrument.
c. Investment income (excluding income from funded depreciation accounts and
other exclusions from investment income offset cited in CMS Pub. 15-1, §202.2) is used to
reduce capital interest expense based in each cost reporting period.
Rev. 2
40-85
4013 (Cont.)
3.
FORM CMS-2552-10
08-11
Allowable capital-related lease and rental costs for land and depreciable assets.
a. The cost of lease renewals and the acquisition of assets continuously leased (e.g.,
capitalized leases) are recognized provided that the same asset remains in use, the asset has a
useful life of at least 3 years, and the annual lease payment is $1000 or more for each item or
service.
b. If a hospital-owned asset is sold or given to another party and that same asset is
then leased back by the hospital, the amount of allowable capital-related costs recognized as
capital costs is limited to the amount allowed for that asset in the last cost reporting period
during which it was owned by the hospital.
4. The appropriate portion of the capital-related costs of related organizations under 42
CFR 413.17 that would be recognized as capital costs if these costs had been incurred directly by
the hospital.
Unless there is a change of ownership, the hospital must continue the same cost finding methods
for capital costs. This includes its practices for the direct assignment of capital-related costs and
its cost allocation bases in. If there is a change of ownership, the new owners may request that
the contractor approve a change in order to be consistent with their established cost finding
practices.
If a hospital desires to change its cost finding method for the direct assignment of capital costs,
the request for change must be made in writing to the contractor prior to the beginning of the cost
reporting period for which the change is to apply. The request must include justification as to
why the change will result in more accurate and more appropriate cost finding. The contractor
does not approve the change unless it determines that there is reasonable justification for the
change.
Line 3--In accordance with 42 CFR 412.302(b)(4), enter all other capital-related costs, including
but not limited to taxes, insurance, and license and royalty fees on depreciable assets. This line
also includes any directly allocated home office other capital cost. After reclassifications in
column 4 and adjustments in column 6, the balance in column 7 must equal zero. This line
cannot be subscripted.
PPS providers paid 100 percent Federal complete line 3, column 2 and Worksheet A-7, Parts I (if
applicable), II and III.
40-86
Rev. 2
08-11
FORM CMS-2552-10
4013 (Cont.)
Line 4--Enter on this line incurred employee benefit costs, including human resources costs,
which cannot be placed in the various cost centers along with the associated salaries.
Line 5--Enter administrative and general (A & G) costs on this line. A&G includes a wide
variety of provider administrative costs such as but not limited to cost of executive staff, legal
and accounting services, facility administrative services (not already included in other general
services cost centers), etcetera. If this line is componentized into more than one cost center,
eliminate line 5. Componentized A & G lines must begin with subscripted line 5.01 and
continue in sequential and consecutive order except where this manual specifies otherwise.
Line 6--Maintenance and repairs are any activity to maintain the facility and grounds such as, but
not limited to, costs of routine painting, plumbing and electrical repairs, mowing and snow
removal.
Line 7--Operation of plant includes the cost such as, but not limited to, the internal hospital
environment including air conditioning (both heating and cooling systems and ventilation) and
other mechanical systems.
Line 8--Laundry and linen services includes the cost of routine laundry and line services whether
performed in-house or by outside contractors.
Line 9--Housekeeping includes the cost of routine housekeeping activities such as mopping,
vacuuming, cleaning restrooms, lobbies, waiting areas and otherwise maintaining patient and
non-patient care areas.
Line 10--Dietary includes the cost of preparing meals for patients.
Line 11--Cafeteria includes the cost of preparing food for provider personnel, physicians
working at the provider, visitors to the provider.
Line 12--Maintenance of personnel includes the cost of room and board furnished to employees.
(See Pub. 15-1, §704.3.)
Line 13--Nursing administration normally includes only the cost of nursing administration. The
salary cost of direct nursing services, including the salary cost of nurses who render direct
service in more than one patient care area, is directly assigned to the various patient care cost
centers in which the services were rendered. Direct nursing services include gross salaries and
wages of head nurses, registered nurses, licensed practical and vocational nurses, aides, orderlies,
and ward clerks.
However, if your accounting system fails to specifically identify all direct nursing services to the
applicable patient care cost centers, then the salary cost of all direct nursing service is included in
this cost center.
Line 14--Central services and supply includes the costs of supplies and services which are
requested by departments throughout the provider, including medical supplies charged to
patients.
Rev. 2
40-87
4013(Cont.)
FORM CMS-2552-10
08-11
Line 15--Pharmacy includes the cost of drugs and pharmacy supplies requested by patient care
departments and drugs charged to patients.
Line 16--Medical records and medical records library includes the direct costs of the medical
records cost center including the medical records library. The general library and the medical
library are not included in this cost center but are reported in the A & G cost center.
Line 17--Social service includes the cost of explaining health care resources and policies to
patients, family and professional staff; assistance in planning for post-hospital patient needs;
assisting patients and families receive needed follow-up care by referral to health care resources
and providing advocacy through appropriate organizations.
Line 19--The services of a nonphysician anesthetist generally are paid for by the Part B
contractor based on a fee schedule rather than on reasonable cost basis through the cost report.
As such, the salary and fringe benefit costs included on line 19 generally are not reimbursed
through the cost report.
NOTE: Any costs are included on this line are limited to salary and employee benefit costs.
However, payment for the nonphysician anesthetists on a fee basis may not apply to a qualified
rural hospital or CAH if the facility employed or contracted with not more than one FTE (2080
hours) nonphysician anesthetist and, if (1) the hospital had 800 or fewer surgical procedures
(including inpatient and outpatient procedures) requiring anesthesia services and (2) each
nonphysician employed by or under contract with the hospital has agreed not to bill under Part B
of title XVIII for professional services furnished. 42 CFR 412.113(c)(2)(i)
Payment under the fee schedule applies to qualified hospitals and CAHs unless the hospital
establishes, before the beginning of each calendar year, that it did not exceed 800 surgical
procedures requiring anesthesia in the previous year. 42 CFR 412.113(c)(2)(ii)
Hospitals which do not qualify for the exception and are therefore subject to the fee schedule
payment method must remove the salary and fringe benefit costs from line 19. The total amount
is reported on Worksheet A-8, line 28 and in column 6, line 19 of this worksheet. This removes
these costs from the cost reported in column 7.
40-88
Rev. 2
08-11
FORM CMS-2552-10
4013 (Cont.)
Lines 20 and 23--If you operate an approved nursing or allied health education program that
meets the criteria of 42 CFR 413.85 and 412.113(b), both classroom and clinical portions of the
costs are allowable as pass-through costs as defined in 42 CFR 413.85.
Classroom costs are those costs associated with formal, didactic instruction on a specific topic or
subject in a classroom that meets at regular, scheduled intervals over a specific time period (e.g.,
semester or quarter) and for which a student receives a grade.
Clinical training is defined as involving the acquisition and use of the skills of a nursing or allied
health profession or trade in the actual environment in which these skills will be used by the
student upon graduation. While it may involve occasional or periodic meetings to discuss or
analyze cases, critique performance, or discuss specific skills or techniques, it involves no
classroom instruction.
If you do not operate the program, the classroom portion of the costs is not allowable as a passthrough cost and therefore not reported on lines 20 and 23 of the Form CMS-2552-10. This cost
may, however, be allowable as routine service operating cost. (See Pub. 15-1, §404.2.) The
clinical portions of these costs are allowable as pass-through costs if the following conditions as
set forth in 42 CFR 413.85 are met:
1. The hospital must have claimed and have been paid for clinical costs
(described above) during its latest cost reporting period that ended on or before October
1, 1989.
2. The proportion of the hospital’s total allowable costs that is attributable to the clinical
training costs of the approved program and allowable under 42 CFR 413.85 during a cost
reporting period does not exceed the proportion of total allowable costs that were attributable to
the clinical training costs during the hospital’s most recent cost reporting period ending on or
before October 1, 1989.
3. The hospital receives a benefit for the support it furnishes to the education program
through the provision of clinical services by nursing and allied health students participating in
the program.
4. The clinical training costs must be incurred by the provider or by an educational
institution related to the provider by common ownership or control as defined by 42 CFR
413.17(b) and Pub. 15-1, §1002 (cost to related organizations). Costs incurred by a third party,
regardless of its relationship to either the provider or the educational institution, are not allowed.
5. The costs incurred by the hospital for the program do not exceed the costs that would
have been incurred by the hospital if the program had been operated by the hospital.
6. The clinical training must occur on the premises of the hospital; i.e., in the hospital
itself or in the physical area immediately adjacent to the hospital buildings or in other areas and
structures located within 250 yards of the main buildings.
Rev. 2
40-89
4013 (Cont.)
FORM CMS-2552-10
08-11
Line 20--Enter the cost for the nursing school.
Line 21--Enter the cost of intern and resident salaries and salary-related fringe benefits. Do not
include salary and salary-related fringe benefits applicable to teaching physicians which are
included in line 22.
Line 22--Enter the other costs applicable to interns and residents in an approved teaching
program.
Line 23--For this line establish a separate cost center for each paramedical education program
(e.g., one for medical records or hospital administration). If additional lines are needed,
subscript line 23 consecutively and sequentially. If the direct costs are included in the costs of an
ancillary cost center, reclassify them on Worksheet A-6 to line 23. Appropriate statistics are
required on Worksheet B-1 to ensure that overhead expenses are properly allocated to this cost
center. Identify all other medical education costs on line 23.99. These costs, if present and
applicable, may be used on worksheets D, Parts III and IV.
Lines 24 - 29--Reserved for future use.
Lines 30 - 46--These lines are for the inpatient routine service cost centers.
Line 30--The purpose of this cost center is to accumulate the incurred routine service cost
applicable to adults and pediatrics (general routine care) in a hospital. Do not include incurred
costs applicable to subproviders or any other cost centers which are treated separately.
Lines 31 - 35--Use lines 31 through 35 to record the cost applicable to intensive care type
inpatient hospital units. (See 42 CFR 413.53(b) and (d) and Pub. 15-1, § 2202.7.) Label line 35
appropriately to indicate the purpose for which it is being used.
Lines 36 - 39--Reserved for future use.
Line 40--Use this line to record the IPF service costs of a subprovider. Hospital units that are
excluded units from IPPS are treated as subproviders for cost reporting purposes.
Line 41--Use this line to record the IRF service costs of a subprovider. Hospital units that are
excluded units from IPPS are treated as subproviders for cost reporting purposes.
Line 42--Use this line to record the inpatient routine service costs of other subproviders as
applicable.
Line 43--Use this line to record the costs associated with the nursery.
Line 44--Use this line to record the costs of SNFs certified for titles V, XVIII, or XIX if your
State accepts one level of care.
Line 45--Use this line to record the cost of NFs certified for title V or title XIX but not certified
as an SNF for title XVIII. Subscript this line to record the cost of ICF/MR. Do not report
nursing facility costs on this subscripted line.
40-90
Rev. 2
08-11
FORM CMS-2552-10
4013 (Cont.)
Line 46--Use this cost center to accumulate the direct costs incurred in maintaining long term
care services not specifically required to be included in other cost centers. A long term care unit
refers to a unit where the average length of stay for all patients is greater than 25 days. The beds
in this unit are not certified for title XVIII.
Lines 47-49--Reserved for future use.
Lines 50 - 76--Use for ancillary service cost centers.
Line 57--Use this line to record direct costs associated with computed tomography (CT) services.
Line 58--Use this line to record direct costs associated with magnetic resonance imaging (MRI)
services.
Line 59--Use this line to record direct costs associated with cardiac catheterization services.
Line 60--Use this line to record direct costs associated with laboratory services.
Line 61--Use this line to record costs when a pathologist continues to bill non-program patients
for clinical laboratory tests and is compensated by you for services related to such tests for
program beneficiaries. When you pay the pathologist an amount for administrative and
supervisory duties for the clinical laboratory for program beneficiaries only, include the cost in
this cost center.
NOTE: No overhead expenses are allocated to this cost center since it relates to services for
program beneficiaries only. The cost reporting treatment is similar to that of services
furnished under arrangement to program beneficiaries only. (See CMS Pub. 15-1,
§2314.) These costs are apportioned among the various programs on the basis of
program charges for provider clinical laboratory tests for all programs for which you
reimburse the pathologist.
Line 62--Include the direct expenses incurred in obtaining blood directly from donors as well as
obtaining whole blood and packed red blood cells from suppliers. Do not include in this cost
center the processing fee charged by suppliers. The processing charge is included in the blood
storing, processing, and transfusion cost center. Identify this line with the appropriate cost center
code (06250) (Table 5 - electronic reporting specifications) for the cost of administering blood
clotting factors to hemophiliacs. (See §4452 of BBA 1997, OBRA 1989 & 1993.)
Line 63--Include the direct expenses incurred for processing, storing, and transfusing whole
blood, packed red blood cells, and blood derivatives. Also include the processing fee charged by
suppliers.
Rev. 2
40-91
4013 (Cont.)
FORM CMS-2552-10
08-11
Line 71--The cost of medical supplies charged to patients is for low cost medical supplies
generally not traceable to individual patients. Do not include high cost implantable devices on
this line. The cost of this cost center generally is not the direct cost of the cost center, but rather
allocated to this cost center on Worksheet B from cost center 14 (central service and supply)
based on the recommended statistic of costed requisitions. Where providers directly assign costs
to this cost center, such amounts must be reported in this cost center on Worksheet A. (See Pub.
15-1, §2307.)
Line 72--Include the expense of implantable devices charged to patients. All providers who
responded “Y” to question 121 on Worksheet S-2, Part I must complete this line. The types of
items includable on this line are high cost implantable devices that remain in the patient upon
discharge and are chargeable and traceable to individual patients. Do not include low cost
medical supplies on this line. When determining what costs are reported in this cost center,
providers should use costs associated with implantable devices bearing revenue codes identified
in the FR, Vol. 73, No. 161, page 48462, dated August 19, 2008. This amount is generally not
input on Worksheet A, but rather allocated to this cost center on Worksheet B from cost center
14 (central service and supply) based on the recommended statistic of costed requisitions.
Where providers directly assign costs to this cost center, such amounts must be reported in this
cost center on Worksheet A. (See Pub. 15-1, §2307.) Identify this line with the appropriate cost
center code according to Table 5 in §4095 of the electronic reporting specifications.
NOTE: Hospitals maintain the option to directly assign costs to a specific cost center (Pub. 151, §2307) or, if such costs are overhead costs, they can be placed in the appropriate
overhead cost center and allocated to the applicable cost centers. This applies
generally to all cost centers, but is re-emphasized for medical supplies charged to
patients (line 71) and implantable devices charged to patients (line 72).
Line 74--If you furnish renal dialysis treatments, account for such costs by establishing this
separate ancillary service cost center. In accumulating costs applicable to the cost center, include
no other ancillary services even though they are routinely administered during the course of the
dialysis treatment. However, if you physically perform a few minor routine laboratory services
associated with dialysis in the renal dialysis department, such costs remain in the renal dialysis
cost center. Outpatient maintenance dialysis services are reimbursed under the composite rate
reimbursement system. For purposes of determining overhead attributable to the drugs Epoetin
and Aranesp, include the cost of the drug in this cost center. The drug costs will be removed on
worksheet B-2 after stepdown.
NOTE: ESRD physician supervisory services are not included as your costs under the
composite rate reimbursement system. Supervisory services are included in the
physician’s monthly capitation rate.
40-92
Rev. 2
10-12
FORM CMS-2552-10
4013 (Cont.)
Line 75--Enter the cost of ASCs that are not separately certified as a distinct part but which have
a separate surgical suite. Do not include the costs of the ancillary services provided to ASC
patients. Include only the surgical suite costs (i.e., those used in lieu of operating or recovery
rooms).
Lines 77 - 87--Reserved for future use.
Lines 88 - 93--Use these lines for outpatient service cost centers.
NOTE: For lines 88 through 90 and 93 any ancillary service billed as clinic, RHC, and FQHC
services must be reclassified to the appropriate ancillary cost center, e.g., radiologydiagnostic, laboratory.
Line 88--Use this line to report the costs of provider-based RHCs. If more than one is
maintained, subscript the line. See Table 5 in §4095 for the proper cost center code for RHCs.
In accordance with CMS Pub. 100-02, chapter 13, §30.4A, compensation paid to a physician for
RHC services rendered in a hospital-based RHC is cost-reimbursed. Where the physician
agreement compensates for RHC services as well as non-RHC services, or services furnished in
the hospital, the related compensation must be eliminated on Worksheet A-8 and billed to the
Part B contractor. If not specified in the agreement, a time study must be used to allocate the
physician compensation.
Line 89--Use this line to report the costs of provider-based FQHCs. If more than one is
maintained, subscript the line. See Table 5 in §4095 for the proper cost center code for FQHCs.
In accordance with CMS Pub. 100-02, chapter 13, §30.4A, compensation paid to a physician for
FQHC services rendered in a hospital-based FQHC is cost-reimbursed. Where the physician
agreement compensates for FQHC services as well as non-FQHC services, or services furnished
in the hospital, the related compensation must be eliminated on Worksheet A-8 and billed to the
Part B contractor. If not specified in the agreement, a time study must be used to allocate the
physician compensation.
Rev. 3
40-93
4013 (Cont.)
FORM CMS-2552-10
10-12
Line 90--Enter the cost applicable to the clinic not included on lines 88 and 89. If you have two
or more clinics which are separately costed, separately report each such clinic. Subscript this
line to report each clinic. If you do not separately cost each clinic, you may combine the cost of
all clinics on the clinic line.
Line 91--Enter the costs of the emergency room cost center.
Line 92--Do not use this line on this worksheet. If you have a distinct part area specifically
designated for observation (e.g., where observation patients are not placed in a general acute care
area bed), report this on a subscripted line 92.01.
NOTE: It is possible to have both a distinct observation bed area and a non-distinct area (for
example, where your distinct part observation bed area is only staffed from 7:00 a.m. 10:00 p.m. Patients entering your hospital needing observation bed care after 10:00
p.m. and before 7:00 a.m. are placed in a general inpatient routine care bed). If
patients entering the distinct part observation bed area are charged differently than the
patients placed in the general inpatient routine care bed, separate the costs into distinct
observation bed costs and non-distinct observation bed costs. However, if the charge
is the same for both patients, report all costs and charges as distinct part observation
beds.
Line 93--Use this line to report the costs of other outpatient services not previously identified on
lines 88 through 90. If more than one other service is offered, subscript the line. See Table 5 in
§4095 for the proper cost center code for this line.
Lines 94 - 98 and 100--Use these lines for other reimbursable cost centers (other than HHA and
CMHC).
Line 94--Use this line to accumulate the direct costs incurred for self-care home dialysis. For
purposes of determining overhead attributable to the drugs Epoetin and Aranesp, include the cost
of the drug in this cost center. The drug costs will be removed on worksheet B-2 after stepdown.
A Medicare beneficiary dialyzing at home has the option to deal directly with the Medicare
program and make individual arrangements for securing the necessary supplies and equipment to
dialyze at home. Under this arrangement, the beneficiary is responsible for dealing directly with
the various suppliers and the Medicare program to arrange for payment. The beneficiary is also
responsible to the suppliers for the deductible and 20 percent Medicare coinsurance requirement.
You do not receive composite rate payment for a patient who chooses this option. However, if
you provide any direct home support services to a beneficiary who selects this option, you are
reimbursed on the same reasonable cost basis for these services as for other outpatient services.
These costs are entered on line 93 and are notated as cost reimbursed. You may service
Medicare beneficiaries who elect this option and others who deal directly with you. In this case,
set up two home program dialysis cost centers (using a subscript for the second cost center) to
properly classify costs between the two categories of beneficiaries (those subject to cost
reimbursement and those subject to the composite rate).
40-94
Rev. 3
08-11
FORM CMS-2552-10
4013 (Cont.)
Line 95--Report all ambulance costs on this line for both owned and operated services and
services under arrangement. No subscripting is allowed for this line.
Lines 96 and 97--Use these lines to report durable medical equipment rented or sold,
respectively. Enter the direct expenses incurred in renting or selling durable medical equipment
(DME) items to patients. Also, include all direct expenses incurred by you in requisitioning and
issuing DME to patients.
For a hospital-based SNF, report support surfaces by subscripting line 97 and use the proper cost
center code.
Line 99--This cost center accumulates the direct costs for outpatient rehabilitation providers
(CORFs and OPTs) and CMHCs. However, only CMHCs complete the J series worksheets.
Use lines 99 - 99.09 for CMHCs, 99.10 - 99.19 for CORFs, 99.20 - 99.29 for OPTs, lines 99.30 99.39 for OOTs, and lines 99.40 - 99.49 for OSPs. If you have multiple components, subscript
this line using the proper cost center code.
Line 100--Use this line if your hospital operates an intern and resident program not approved by
Medicare.
Line 101--This cost center accumulates costs specific to HHA services. If you have more than
one certified hospital-based HHA, subscript line 101 for each HHA.
Provider-based HHAs are operated and managed in a variety of ways within the context of the
health care complexes of which they are components. In some instances, there are discrete
management and administrative functions pertaining to the HHA, the cost of which is readily
identifiable from the books and records.
In other instances, the administration and management of the provider-based HHA is integrated
with the administration and management of the health care complex to such an extent that the
cost of administration and management of the home health agency can be neither identified nor
derived from the books and records of the health care complex. In other instances, the cost of
administration and management of the HHA is integrated with the administration and
management of the health care complex, but the cost of the HHA administration and
management can be derived through cost finding. However, in most cases, even when the cost
of HHA administration and management can be either identified or derived, the extent to which
the costs are applicable to the services furnished by the provider-based HHA is not readily
identifiable.
Even when the costs of administration and management of a provider-based HHA can be
identified or derived, such costs do not generally include all of the general service costs (i.e.,
overhead costs) applicable to the HHA. Therefore, allocation of general service costs through
cost finding is necessary for the determination of the full costs of the provider-based HHA.
When the provider-based HHA can identify discrete management and administrative costs from
its books and records, these costs are included on line 101.
Rev. 2
40-95
4013 (Cont.)
FORM CMS-2552-10
08-11
Similar situations occur for the services furnished by the provider-based HHA. For example, in
some instances, physical therapy services are furnished by a discrete HHA physical therapy
department. In other instances, physical therapy services are furnished to the patient of the
provider-based HHA by an integrated physical therapy department of a hospital health care
complex in such a manner that the direct costs of furnishing the physical therapy services to the
patients of the provider-based HHA cannot be readily identified or derived. In other instances,
physical therapy services are furnished to patients of the provider-based HHA by an integrated
physical therapy department of a hospital health care complex in such a manner that the costs of
physical therapy services furnished to patients of the provider-based HHA can be readily
identified or derived.
When you maintain a separate therapy department for the HHA apart from the hospital therapy
department furnishing services to other patients of the hospital health care complex or when you
are able to reclassify costs from an integrated therapy department to an HHA therapy cost center,
make a reclassification entry on Worksheet A-6 to the appropriate HHA therapy cost center.
Make a similar reclassification to the appropriate line for other ancillaries when the HHA costs
are readily identifiable.
NOTE: This cost report provides separate HHA cost centers for all therapy services. If
services are provided to HHA patients from a shared hospital ancillary cost center,
make the cost allocation on Worksheet H-1, Part II.
Lines 102 - 104--Reserved for future use.
Lines 105 - 117--Use these lines for special purpose cost centers. Special purpose cost centers
include kidney, heart, liver, lung, pancreas, intestinal, and islet acquisition costs as well as costs
of other organ acquisitions which are nonreimbursable but which CMS requires for data
purposes, cost centers which must be reclassified but which require initial identification, and
ASC and hospice costs which are needed for rate setting purposes.
NOTE: Prorate shared acquisition costs (e.g., coordinator salaries, donor awareness programs)
among the type of organ acquisitions. Generally, this is done based on the number of
organs procured. Further, if multiple organs have been procured from a community
hospital or an independent organ procurement organization, prorate the cost among the
type of acquisitions involved.
These cost centers include the cost of services purchased under arrangement or billed directly to
the hospital in connection with the acquisition of organs. Such direct costs include but are not
limited to:
•
Fees for physician services (preadmission for transplant donor and recipient tissue-typing
and all tissue-typing services performed on cadaveric donors);
•
Cost for organs acquired from other providers or organ procurement organizations;
•
Transportation costs of organs;
•
Organ recipient registration fees;
40-96
Rev. 2
12-10
FORM CMS-2552-10
•
Surgeons' fees for excising cadaveric donor organs; and
•
Tissue-typing services furnished by independent laboratories.
4013 (Cont.)
NOTE: No amounts or fees paid to a donor, their estate, heirs, or assigns in exchange for an
organ or for the right to remove or transplant an organ are included in organ
acquisition costs. Also, such amounts or fees are not included in any other revenue
producing or general service cost center.
Only hospitals which are certified transplant centers are reimbursed directly by the
Medicare program for organ acquisition costs. All such costs are accumulated on
Worksheet D-4.
Hospitals which are not certified transplant centers are not reimbursed by the Medicare program
for organ acquisition costs. Such hospitals sell any organs excised to a certified transplant center
or an organ procurement organization. The costs are accumulated in the applicable organ
acquisition cost center and flow through cost finding to properly allocate overhead costs to this
cost center. However, only a certified transplant center completes Worksheet D-4.
Line 105--Record any costs in connection with kidney acquisitions. This cost center flows
through cost finding and accumulates any appropriate overhead costs.
Line 106--Record any costs in connection with heart acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 107--Record any costs in connection with liver acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 108--Record any costs in connection with lung acquisitions. This cost center flows through
cost finding and accumulates any appropriate overhead costs.
Line 109--Record any costs in connection with pancreas acquisitions. This cost center flows
through cost finding and accumulates any appropriate overhead costs.
Line 110--Record any costs in connection with intestinal acquisitions. This cost center flows
through cost finding and accumulates any appropriate overhead costs.
Line 111--Record the costs associated with the acquisition of the pancreas that is used to isolate
the islet cells that are used for transplant. Do not include in this cost any costs associated with the
isolation of the islet cells as these costs will be included as an add-on to the DRG payment. (See
CR 5505, dated March 2, 2007).
Line 112--Record any costs related to organ acquisitions, which are not already recorded on lines
105 through 111 and subscripts. This cost center flows through cost finding and accumulates
any appropriate overhead costs.
Line 113--Enter all interest paid by the facility. After reclassifications in column 4 and
adjustments in column 6, the balance in column 7 must equal zero. This line cannot be
subscripted.
NOTE: If capital-related and working capital interest are commingled on this line, reclassify
working capital interest to A & G expense. Reclassify capital-related interest to lines 1
and 2, as appropriate, in accordance with the instructions for those lines.
Rev. 1
40-97
4013 (Cont.)
FORM CMS-2552-10
12-10
Line 114--Include only utilization review costs of the hospital-based SNF. All costs are either
reclassified or adjusted in total depending on the scope of the review. If the scope of the review
covers all patients, all allowable costs are reclassified in column 4 to A & G expenses (line 5). If
the scope of the review covers only Medicare patients or Medicare, title V, and title XIX
patients, then (1) in column 4, reclassify to A & G expenses all allowable costs other than
physicians' compensation and (2) deduct in column 6 the compensation paid to the physicians for
their personal services on the utilization review committee. The amount reported on Worksheet
E-2, column 1, line 7 must equal the amount adjusted on Worksheet A-8.
Line 115--Enter the direct costs of an ASC as defined in 42 CFR 416.2. An ASC operated by a
hospital must be a separately identifiable entity, physically, administratively, and financially
independent and distinct from other operations of the hospital. In addition, the ASC must have
an agreement with CMS as required by 42 CFR 416.25. Under this restriction, hospital
outpatient departments providing ambulatory surgery (among other services) are not eligible to
be classified as ASCs. Those ASCs which meet the definition in 42 CFR 416.2 and are currently
treated as an outpatient cost center on the hospital’s Medicare cost report are reimbursed through
a prospectively determined standard overhead amount. For cost reporting purposes, an eligible
ASC is treated as a nonreimbursable cost center to ensure that overhead costs are properly
allocated since the cost is not reimbursable in this cost report.
Line 116--42 CFR Part 418 provides for coverage of hospice care for terminally ill Medicare
beneficiaries who elect to receive care from a participating hospice.
Line 117--Enter other special purpose cost centers not previously identified. Review Table 5 in
§4095 for the proper cost center code.
Lines 119 - 189--Reserved for future use.
Lines 190 - 194--Record the costs applicable to nonreimbursable cost centers to which general
service costs apply. If additional lines are needed for nonreimbursable cost centers other than
those shown, subscript one or more of these lines with a numeric code. The subscripted lines
must be appropriately labeled to indicate the purpose for which they are being used. However,
when the expense (direct and all applicable overhead) attributable to any nonallowable cost area
is so insignificant as not to warrant establishment of a nonreimbursable cost center and the sum
total of all such expenses is so insignificant as not to warrant the establishment of a composite
nonreimbursable cost center, these expenses are adjusted on Worksheet A-8. (See CMS Pub. 151, §2328.)
Line 194--Establish a nonreimbursable cost center to accumulate the cost incurred by you for
services related to the physicians’ private practice. Such costs include depreciation costs for the
space occupied, movable equipment used by the physicians’ offices, administrative services,
medical records, housekeeping, maintenance and repairs, operation of plant, drugs, medical
supplies, and nursing services. Do not include costs applicable to services rendered to hospital
patients by hospital-based physicians since such costs may be included in hospital costs.
Lines 195 - 199--Reserved for future use.
Line 200--Sum of lines 118 through 199.
40-98
Rev. 1
08-11
4014.
FORM CMS-2552-10
4014
WORKSHEET A-6 - RECLASSIFICATIONS
This worksheet provides for the reclassification of certain costs to effect proper cost allocation
under cost finding. For each reclassification adjustment, assign an alpha character in column 1
to identify each reclassification entry, e.g., A, B, C.
DO NOT USE NUMERIC
DESIGNATIONS. All reclassification entries must have a corresponding Worksheet A line
number reference in columns 3 and 7. In column 10, indicate the column of Worksheet A-7
impacted by the reclassification, where applicable. If more than one column on Worksheet A-7
is impacted by one reclassification, report each entry as a separate line to properly report each
column impacted on Worksheet A-7. If you directly assign the capital-related costs, i.e.,
insurance, taxes, and other, reclassify these costs to line 3. Do not reclassify other capital-related
costs reported or reclassified to line 3 of Worksheet A back to the other capital lines 1-2 of
Worksheet A. This is accomplished through Worksheet A-7.
Submit with the cost report copies of any workpapers used to compute the reclassifications
effected on this worksheet.
Identify any reclassifications made as salary and other costs in the appropriate column.
However, when transferring to Worksheet A, transfer the sum of the two columns.
If there is any reclassification to general service cost centers for compensation of provider-based
physicians, make the appropriate adjustment for RCE limitation on Worksheet A-8-2. (See
§4018.)
Examples of reclassifications that may be needed are:
•
Reclassification of related organization rent expenses included in the A & G cost center
which are applicable to lines 1 and 2 of Worksheet A. See instructions for Worksheet A8-1 for treatment of rental expenses for related organizations.
•
Reclassification of interest expense included on Worksheet A, column 3, line 113, which
is applicable to funds borrowed for A & G purposes (e.g., operating expenses) or for the
purchase of buildings and fixtures or movable equipment. Allocate interest on funds
borrowed for operating expenses with A & G expenses.
•
Reclassification of employee benefits expenses (e.g., personnel department, employee
health service, hospitalization insurance, workers compensation, employee group
insurance, social security taxes, unemployment taxes, annuity premiums, past service
benefits, and pensions) included in the A & G cost center.
•
Reclassification of utilization review cost applicable to the hospital-based SNF to A & G
costs. If the scope of the utilization review covers the entire population, reclassify the
total allowable utilization review cost included on Worksheet A, column 3, line 114.
However, if the scope of the utilization review in the hospital-based SNF covers only
Medicare patients or Medicare and title XIX patients, only the allowable utilization
review costs included on Worksheet A, column 3, line 114 (other than the compensation
of physicians for their personal services on utilization review committees) are reclassified
to A & G costs.
The appropriate adjustment for physicians’ compensation is made on Worksheet A-8. For
further explanations concerning utilization review in skilled nursing facilities, see CMS Pub. 151, §2126.2.
•
•
Reclassification of any dietary cost included in the dietary cost center which is applicable
to the cafeteria, nursery, and to any other cost centers such as gift, flower, coffee shops,
and canteen.
Reclassification of any direct expenses included in the central service and supply cost
center which are directly applicable to other cost centers such as intern-resident service,
intravenous therapy, and oxygen (inhalation) therapy.
Rev. 2
40-99
4014 (Cont.)
FORM CMS-2552-10
08-11
•
Reclassification of any direct expenses included in the laboratory cost center which are
directly applicable to other cost centers such as whole blood and packed red blood cells
or electrocardiology.
•
Reclassification of any direct expenses included in the radiology-diagnostic cost center
which are directly applicable to other cost centers such as radiology-therapeutic,
radioisotope, or electrocardiology.
•
When you purchase services (e.g., physical therapy) under arrangements for Medicare
patients but do not purchase such services under arrangements for non-Medicare patients,
your books reflect only the cost of the Medicare services. However, if you do not use the
grossing up technique for purposes of allocating overhead and if you incur related direct
costs applicable to both Medicare and non-Medicare patients (e.g., paramedics or aides
who assist a physical therapist in performing physical therapy services), reclassify the
related costs on Worksheet A-6 from the ancillary service cost center. Allocate them as
part of A & G expense. However, when you purchase services that include performing
administrative functions such as completion of medical records, training, etc. as described
in CMS Pub. 15-1, §1412.5, the overall charge includes the provision of these services.
Therefore, for cost reporting purposes, these related services are NOT reclassified to A &
G.
•
If a beneficiary receives outpatient renal dialysis for an extended period of time and you
furnish a meal, the cost of this meal is not an allowable cost for Medicare. Make an
adjustment on Worksheet A-8. However, the dietary counseling cost attributable to a
dialysis patient is an allowable cost. Reclassify this cost from the dietary cost center, line
10, to the renal dialysis cost center, line 74.
•
When interns and residents are employed to replace anesthetists, you must reclassify the
related direct costs from the intern and resident cost center to the anesthesiology cost
center. (See 49 FR 208 dated January 3, 1984.)
NOTE: These interns and residents do not qualify for the indirect medical education
adjustment and must be excluded for the intern and resident FTE for that purpose.
(See 42 CFR 412.113(c).)
•
If you incur costs for an unpaid guarantee for emergency room physician availability,
attach a separate worksheet showing the computation of the necessary reclassification.
(See CMS Pub. 15-1, §2109.)
•
Reclassification of the costs of malpractice insurance premiums, self-insurance fund
contributions, and uninsured malpractice losses incurred either through deductible or
coinsurance provisions, as a result of an award in excess of reasonable coverage limits, or
as a government provider to the A & G cost center.
40-100
Rev. 2
08-11
FORM CMS-2552-10
4015.
WORKSHEET A-7 - RECONCILIATION OF CAPITAL COST CENTERS
4015
This worksheet consists of three parts:
Part I
Part II Part III -
Analysis of Changes in Capital Asset Balances.
Reconciliation of amounts from worksheet A, column 2, lines 1 and 2.
Reconciliation of Capital Cost Centers.
See the instructions for Worksheet A for a definition of capital. All providers must complete
Parts I, II, and III.
NOTE: Include assets which are directly allocated to the provider from the home office or
related organization and the related other capital costs in Parts I and II of this
worksheet.
The intent of Worksheet A-7, Part I, is to reflect assets which relate to the hospital.
However, examine the cost finding elections made at the time you submit the cost
report to consider the cost finding treatment of SNF, HHA, hospice, subproviders,
CORF, CMHC, the physician office building, and any other nonallowable cost centers.
Where you have elected to cost find any of these areas through the cost report, related
assets must be included in Worksheet A-7, Part I, as appropriate, to properly allocate
the related insurance, taxes, etc.
4015.1 Part I - Analysis of Changes in Capital Asset Balances.--This part enables the
Medicare program to analyze the changes that occurred in your capital asset balances during the
current reporting period. Complete this worksheet only once for the entire hospital complex
(certified and non-certified components). However, only include in Part I assets that relate to
hospital services or are commingled and cannot be separated.
Columns 1 and 6--Enter the balance recorded in your books of accounts at the beginning of your
cost reporting period (column 1) and at the end of your cost reporting period (column 6). You
must submit a reconciliation demonstrating that the amount reported on Part I, column 6, line 10,
agrees with the total fixed assets on Worksheet G, plus any directly allocated assets from the
home office or related organization, less any assets not allocated through the cost finding method
on Worksheet B. Include fully depreciated assets still used for patient care.
Columns 2 - 4--Enter the cost of capital assets acquired by purchase in column 2 and the fair
market value at date acquired of donated assets in column 3. Enter the sum of columns 2 and 3
in column 4.
NOTE: The amounts in Part I, column 2, must also include transfers of assets from a change of
ownership.
Column 5--Enter the cost or other approved basis of all capital assets sold, retired, or disposed of
in any other manner during your cost reporting period.
Column 6--Enter the sum of columns 1 and 4 minus column 5.
Column 7--Enter the initial acquisition cost of fully depreciated assets for each category. An
asset that is fully depreciated and continues to be used in the facility must be recorded in this
column. There will be no depreciation expense recorded after the asset is fully depreciated.
Rev. 2
40-101
4015.2
FORM CMS-2552-10
08-11
Line Descriptions
Line 7--If you acquired certified HIT assets and are an EHR technology meaningful user
(Worksheet S-2, Part I, line 167 is yes) in accordance with ARRA 2009, section 4102, enter the
corresponding amounts on this line.
Line 9--If you have included in lines 1 through 7 of Part I any of the following, enter those
amounts on line 9.
•
Capitalized a lease in accordance with generally accepted accounting principles (GAAP)
and included it in the assets reported on Worksheet G,
•
Excess of amounts paid for the acquisition of assets over their fair values or the amount
recognized under §2314 of DEFRA for transactions after July 18, 1984, or
•
Construction in progress at the end of the cost reporting period.
Line 10--Enter line 8 minus line 9.
4015.2 Part II - Reconciliation of Amounts From Worksheet A, Column 2, Lines 1 and 2.-The purpose of this worksheet is to segregate and specifically identify the depreciation and
capital related costs which are directly assigned to Worksheet A, column 2, lines 1 and 2.
Columns 9 - 14--Enter in columns 9 through 14, the depreciation and other capital related costs.
(Do not report in columns 12 through 14 any amounts previously reported in Part III, columns 5
through 7). The sum of columns 9 through 14 of this part, which is reported in column 15, lines
1 and 2 must agree with the amounts reported on Worksheet A, column 2, lines 1 and 2.
4015.3 Part III - Reconciliation of Capital Cost Centers.--Use this part to allocate allowable
insurance, taxes, and other capital expenditures (not including depreciation, lease, and interest
expense) to the capital-related cost centers. This part also summarizes the amounts in the
capital-related cost centers on Worksheet A, lines 1 and 2, column 7.
Lines 1 and 2--The allowable costs for other capital-related expenses (including but not limited
to taxes, insurance, and license and royalty fees on depreciable assets) are apportioned by
applying the ratio of the hospital's capital related building and fixtures and capital related
movable equipment gross asset value to total asset value in each cost reporting period. These
lines compute the appropriate gross asset ratios used in allocating other capital-related costs in
columns 5 through 7.
Line 3--Enter the sum of lines 1 and 2. Column 4 must equal 1.000000.
Columns 1 - 4, Lines 1 and 2--Use these columns and lines to compute ratios of capital related
building and fixtures and capital related movable equipment gross asset values to total gross
asset values. Use these ratios on columns 5 through 7 to allocate other capital costs (insurance,
taxes, and other) to the capital-related cost center lines (Worksheet A, lines 1 and 2).
Column 1--Enter on line 1 your gross asset value (asset value before accumulated depreciation)
for buildings and fixtures (which also includes old land and land improvements). Enter on line 2
your gross asset value for movable equipment.
NOTE: Part III, column 1, line 3, must agree with the sum of Part I, column 6, line 8.
Column 2--Enter in column 2, line as appropriate, any amounts that you have included in column
1, lines 1 and 2, and which were reported on line 8 of Part I, as appropriate.
Column 3--Enter column 1 less column 2.
40-102
Rev. 2
08-11
FORM CMS-2552-10
4015.2 (Cont.)
Column 4--Enter on lines 1 and 2 the amount in column 3, lines as applicable, divided by the
amount in column 3, line 3. Round the resulting ratio to six decimal places.
Columns 5 - 7--These columns provide for the allocation of other capital-related costs (taxes,
insurance, and other) to the capital-related cost center lines (Worksheet A, lines 1 and 2).
Line 3--Enter in column 5 capital expenditures relating to insurance. Enter in column 6 capital
expenditures relating to State and local taxes on property and equipment. Enter in column 7
other capital expenditures (not including taxes, insurance, depreciation, lease, and interest
expense). Enter in column 8 the sum of the amounts reported in columns 5 through 7.
Lines 1 and 2--Apply the ratios developed in column 4, line as applicable, to allocate the other
capital costs reported in line 3.
Column 8--Line 3 must be equal to or less than the amount on Worksheet A, line 3, column 3.
The amount reported becomes the reclassification entry on Worksheet A, column 4 which will
zero-out the balance on line 3. If you directly assign other capital related costs, see Part II for
proper disclosure of these costs.
Columns 9 - 15--These lines summarize the amounts in the capital-related cost centers
(Worksheet A, lines 1 and 2, column 7).
NOTE: The amount entered in these columns must be net of reclassifications and adjustments
identified on Worksheets A-6, A-8 and A-8-1.
Column 9--Enter the amount reported in Part II above, from column 9, lines 1 and 2, adjusted by
the amounts identified on Worksheets A-6, A-8 and A-8-1.
Column 10--Enter the amount reported in Part II, column 10, lines 1 and 2, relating to capitalrelated lease expense, adjusted by the amounts identified on Worksheets A-6, A-8, and A-8-1.
(See CMS Pub. 15-1, §2806.1.) Report insurance, taxes, and license and royalty fees associated
with leased assets in columns 12, 13, and 14 of this worksheet, respectively.
Column 11--Enter the amount reported in Part II, column 11, lines 1 and 2, relating to capitalrelated interest expense, adjusted by the amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 12--Enter the amount from column 5 plus any additional amounts reported in Part II,
column 12 adjusted by amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 13--Enter the amount from column 6 plus any additional amounts reported in Part II,
column 13 adjusted by amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 14--Enter the amount from column 7 plus any additional amounts reported in Part II,
column 14 adjusted by amounts identified on Worksheets A-6, A-8, and A-8-1.
Column 15--Enter the sum of columns 9 through 14. The amounts from column 15, lines 1 and
2, must equal the amounts on Worksheet A, column 7, lines 1 and 2.
Rev. 2
40-103
4016
4016.
FORM CMS-2552-10
08-11
WORKSHEET A-8 - ADJUSTMENTS TO EXPENSES
In accordance with 42 CFR 413.9(c)(3), if your operating costs include amounts not related to
patient care, these amounts are not reimbursable under the program. If your operating costs
include amounts flowing from the provision of luxury items or services (i.e., those items or
services substantially in excess of or more expensive than those generally considered necessary
for the provision of needed health services), such amounts are not allowable.
This worksheet provides for the adjustments in support of those listed on Worksheet A, column
6. These adjustments, required under the Medicare principles of reimbursement, are made on the
basis of cost or amount received (revenue) only if the cost (including direct cost and all
applicable overhead) cannot be determined. If the total direct and indirect cost can be
determined, enter the cost. Submit with the cost report a copy of any work papers used to
compute a cost adjustment. Once an adjustment to an expense is made on the basis of cost, you
may not determine the required adjustment to the expense on the basis of revenue in future cost
reporting periods. Enter the following symbols in column 1 to indicate the basis for adjustment:
"A" for cost or "B" for amount received. Line descriptions indicate the more common activities
which affect allowable costs or result in costs incurred for reasons other than patient care and,
thus, require adjustments.
Types of adjustments entered on this worksheet include (1) those needed to adjust expenses to
reflect actual expenses incurred; (2) those items which constitute recovery of expenses through
sales, charges, fees, etc.; (3) those items needed to adjust expenses in accordance with the
Medicare principles of reimbursement; and (4) those items which are provided for separately in
the cost apportionment process.
If an adjustment to an expense affects more than one cost center, record the adjustment to each
cost center on a separate line on Worksheet A-8.
NOTE: When adjustments affect capital, they must be appropriately identified as impacting
capital related building and fixtures or capital related movable equipment. If these
adjustments affect other capital-related costs, indicate in column 5 the capital related
cost category shown on Worksheet A-7, Part III, columns 9 through 14.
Enter additional costs as positive amounts. Enter reductions of cost as a negative number. Enter
a net total (if a reduction of cost) as a negative number.
Line Descriptions
Lines 1 - 3--Enter the investment income to be applied against interest expense. (See CMS Pub.
15-1, §202.2 for an explanation.)
Line 7--For patient telephones, make an adjustment on this line or establish a nonreimbursable
cost center. When this line is used, base the adjustment on cost. Revenue is not used. (See
CMS Pub. 15-1, §2328.)
Line 10--Enter the total provider-based physician adjustments for personal patient care services
and RCE limitations. Obtain this amount from Worksheet A-8-2, column 18, sum of all lines.
NOTE: Make the adjustment to Worksheet A, column 6 for each applicable cost center from
Worksheet A-8-2, column 18, line as appropriate.
Line 12--Obtain this amount from section A, column 6 of Worksheet A-8-1.
NOTE: Worksheet A-8-1 represents the detail of the various cost centers on Worksheet A
which must be adjusted.
40-104
Rev. 2
10-12
FORM CMS-2552-10
4016 (Cont.)
Line 21--Enter the cash received from the imposition of interest, finance, or penalty charges on
overdue receivables. Use this income to offset the allowable administration and general costs.
(See CMS Pub. 15-1, §2110.2.)
Line 22--Enter the interest expense imposed by the contractor on Medicare overpayments. Also,
enter interest expense on borrowing made to repay Medicare overpayments.
Line 23--Enter, if applicable, the amount from Worksheet A-8-3, line 65.
Line 24--Enter, if applicable, the amount from Worksheet A-8-3, line 65.
Line 25--This line pertains to the hospital-based SNF only. When the utilization review covers
only Medicare patients or Medicare and title XIX patients, allocate 100 percent of the reasonable
compensation paid to the physicians for their services on utilization review committees to the
health care programs. Apportion all other allowable costs applicable to utilization review which
cover only health care program patients among all users of the hospital-based SNF. Reclassify
such other costs on Worksheet A-6. Enter the physicians’ compensation for service on
utilization review committees which cover only health care program patients in the hospitalbased SNF. The amount entered equals the amount shown on Worksheet A, column 6, line 114.
(See CMS Pub. 15-1, §2126.2.) If the utilization review costs pertain to more than one program,
the amount entered on Worksheet E-2, column 1, line 7 must equal the amount adjusted on
Worksheet A-8.
Lines 26 and 27--When depreciation expense computed in accordance with the Medicare
principles of reimbursement differs from depreciation expenses per your books, enter the
difference on lines 26 and 27, as applicable. Use line 26 capital related buildings and fixtures
costs and line 27 for new capital related movable equipment costs. Personal use of assets
requires adjustment to depreciation expense, e.g., automotive used 50% for business and 50%
personal.
Line 28--This adjustment is required for salaries and fringe benefits paid to nonphysician
anesthetists reimbursed on a fee schedule. (See the instructions for Worksheet A, line 19.)
Line 29--Sections 1861(s)(2)(K), 1842(b)(6)(C), and 1842(b)(12) of the Act provide for
coverage of and separate payment for services performed by a physician assistant. The physician
assistant is an employee of the hospital and payment is made to the employer of the physician
assistant. Make an adjustment on Worksheet A-8 for any payments made directly to the
physician assistant for services rendered. This avoids any duplication of payments.
Line 30--Enter, if applicable, the amount from Worksheet A-8-3, line 65 for occupational
therapy services rendered.
Line 31--Enter, if applicable, the amount from Worksheet A-8-3, line 65 for speech pathology
services rendered.
Line 32--For CAHs, where applicable in accordance with ARRA of 2009, section 4102, remove
the current year depreciation expense associated with purchased assets for which the total cost
or remaining un-depreciated cost was reimbursed either in the current or prior cost reporting
period as EHR incentive payment if such depreciation was included on Worksheet A, line 2
(capital-related movable equipment) or any other line. This includes the depreciation expense
for EHR assets purchased in the current cost reporting period, as well as depreciation expense
related to the remaining net book value (i.e., un-depreciated basis) of EHR assets purchased in
prior cost reporting periods which were not fully depreciated at the beginning of the current cost
reporting period.
Also, use this line to remove that portion of the annual rent/lease expense applicable to EHR
assets leased under a virtual purchase lease which equals the depreciation expense for this asset
since the
Rev. 3
40-105
4016 (Cont.)
FORM CMS-2552-10
10-12
total cost of the asset (or the un-depreciated cost if the lease was initiated in a prior cost
reporting period), was claimed as EHR incentive payment. Also remove any portion of the total
rental charge which exceeds the actual cost of ownership of the EHR asset. (See PRM-1, section
110.B.2.) In accordance with PRM-1, section 110.B.2, the actual cost of ownership of an asset
leased under a virtual purchase lease includes not only the depreciation expense, but insurance
and interest as well. For example, if the depreciation for the asset is $50,000 per year, the
insurance is $3,000 per year, the interest is $10,000 per year, and the rental charge is $70,000
per year, the rental expense must be limited to the cost of ownership which in this example is
$63,000. Since the adjustment to limit the rent expense to the cost of ownership is $7,000, the
actual adjustment on this line will be to reduce the allowable rent expense for this EHR asset by
$57,000 (i.e., $50,000 depreciation portion and $7,000 excess rental charge over the cost of
ownership).
Lines 33 - 49--Enter any additional adjustments which are required under the Medicare
principles of reimbursement. Label the lines appropriately to indicate the nature of the required
adjustments. If the number of blank lines is not sufficient, subscript lines 33 through 49. The
grossing up of costs in accordance with provisions of CMS Pub. 15-1, §2314 is an example of an
adjustment entered on these lines and is explained below.
If you furnish ancillary services to health care program patients under arrangements with others
but simply arrange for such services for non-health care program patients and do not pay the
non-health care program portion of such services, your books reflect only the costs of the health
care program portion. Therefore, allocation of indirect costs to a cost center which includes only
the cost of the health care program portion results in excessive assignment of indirect costs to the
health care programs. Since services were also arranged for the non-health care program
patients, allocate part of the overhead costs to those groups.
In the foregoing situation, do not allocate indirect costs to the cost center unless your contractor
determines that you are able to gross up both the costs and the charges for services to non-health
care program patients so that both costs and charges for services to non-health care program
patients are recorded as if you had provided such services directly. See the instructions for
Worksheet C, Part I for grossing up of your charges.
Meals furnished by you to an outpatient receiving dialysis treatment also require an adjustment.
These costs are nonallowable for title XVIII reimbursement. Therefore, the cost of these meals
must be adjusted.
In accordance with CMS Pub. 27, §501, compensation paid to a physician for RHC services
rendered in a hospital-based RHC is cost reimbursed. Where the physician agreement
compensates for RHC services as well as non-RHC services, or services furnished in the
hospital, the related compensation must be eliminated on Worksheet A-8 and billed to the Part B
contractor. If not specified in the agreement, a time study must be used to allocate the physician
compensation.
If the hospital performs ESRD services and costs are reported on either line 74, 94, or both, these
costs should include the cost of the drugs Epoetin and Aranesp. Do not report the cost of these
drugs claimed in any other cost center. These costs will be removed later on Worksheet B-2.
If the hospital pays membership dues to an organization that performs lobbying and political
activities, the portion of the dues associated with these non-allowable activities must be removed
from costs.
Line 50--Enter the sum of lines 1 through 49. Transfer the amounts in column 2 to Worksheet A,
column 6, line as appropriate.
40-106
Rev. 3
08-11
4017.
FORM CMS-2552-10
4017
WORKSHEET A-8-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS AND HOME OFFICE COSTS
In accordance with 42 CFR 413.17, costs applicable to services, facilities, and supplies furnished
to you by organizations related to you by common ownership or control are includable in your
allowable cost at the cost to the related organization, except for the exceptions outlined in 42
CFR 413.17(d). This worksheet provides for the computation of any needed adjustments to costs
applicable to services, facilities, and supplies furnished to the hospital by organizations related to
you or costs associated with the home office. In addition, it shows certain information
concerning the related organizations with which you have transacted business as well as home
office costs. (See CMS Pub. 15-1, chapter 10, and §2150 respectively.)
Part A--Cost applicable to home office costs, services, facilities, and supplies furnished to you by
organizations related to you by common ownership or control are includable in your allowable
cost at the cost to the related organizations. However, such cost must not exceed the amount a
prudent and cost conscious buyer pays for comparable services, facilities, or supplies that are
purchased elsewhere.
Columns 1, 2 and 3--Enter in columns 1 and 3, respectively, the worksheet A line number and
specific expense category from your books and/or records associated with the acquisition of
services, facilities, and/or supplies from related organizations. Column 2 is automatically
completed based on the cost center in column 1.
Column 4--Enter the allowable cost from the books and/or records of the related organization
which includes only the actual cost incurred by the related organization for services, facilities,
and/or supplies and excludes any markup, profit or amounts that otherwise exceed the acquisition
cost of such items.
Column 5--Enter the amount included on Worksheet A for services, facilities, and/or supplies
acquired from related organizations.
Column 6--Enter the result of column 4 minus column 5.
Column 7--Enter the specific column of Worksheet A-7, Part III, columns 9 through 14 impacted
by the adjustment.
Part B--Use this part to show your relationship to organizations for which transactions were
identified in Part A. Show the requested data relative to all individuals, partnerships,
corporations, or other organizations having either a related interest to you, a common ownership
with you, or control over you as defined in CMS Pub. 15-1, chapter 10 in columns 1 through 6,
as appropriate.
Complete only those columns which are pertinent to the type of relationship which exists.
Columns 1 and 2--Enter in column 1 the appropriate symbol which describes your relationship to
the related organization. If the symbol A, D, E, F, or G is entered in column 1, enter the name of
the related individual in column 2.
Column 3--If the individual indicated in column 2 or the organization indicated in column 4 has
a financial interest in you, enter the percent of ownership as a ratio.
Column 4--Enter the name of the related corporation, partnership, or other organization.
Column 5--If you or the individual indicated in column 2 has a financial interest in the related
organizations, enter the percent of ownership in such organization as a ratio.
Column 6--Enter the type of business in which the related organization engages (e.g., medical
drugs and/or supplies, laundry and linen service).
Rev. 2
40-107
4018
FORM CMS-2552-10
4018.
WORKSHEET A-8-2 - PROVIDER-BASED PHYSICIAN ADJUSTMENTS
08-11
In accordance with 42 CFR 413.9, 42 CFR 415.55, 42 CFR 415.60, 42 CFR 415.70, and 42 CFR
415.102(d), you may claim as allowable cost only those costs which you incur for physician
services that benefit the general patient population of the provider or which represent availability
services in a hospital emergency room under specified conditions. (See 42 CFR 415.150 and 42
CFR 415.164 for an exception for teaching physicians under certain circumstances.) 42 CFR
415.70 imposes limits on the amount of physician compensation which may be recognized as a
reasonable provider cost.
Worksheet A-8-2 provides for the computation of the allowable provider-based physician cost
you incur. 42 CFR 415.60 provides that the physician compensation paid by you must be
allocated between services to individual patients (professional services), services that benefit
your patients generally (provider services), and nonreimbursable services such as research. Only
provider services are reimbursable to you through the cost report. This worksheet also provides
for the computation of the reasonable compensation equivalent (RCE) limits required by 42 CFR
415.70. The methodology used in this worksheet applies the RCE limit to the total physician
compensation attributable to provider services reimbursable on a reasonable cost basis. Enter the
total provider-based physician adjustment for personal care services and RCE limitations
applicable to the compensation of provider-based physicians directly assigned to or reclassified
to general service cost centers. RCE limits are not applicable to a medical director, chief of
medical staff, or to the compensation of a physician employed in a capacity not requiring the
services of a physician, e.g., controller. RCE limits also do not apply to critical access hospitals,
however the professional component must still be removed on this worksheet. CAHs need only
complete columns 1 through 5 and 18. Transfer for CAHs the amount from column 4 to column
18.
NOTE: 42 CFR 415.70(a)(2) provides that limits established under this section do not apply to
costs of physician compensation attributable to furnishing inpatient hospital services
paid for under the prospective payment system implemented under 42 CFR Part 412.
Limits established under this section apply to inpatient services subject to the TEFRA rate of
increase ceiling (see 42 CFR 413.40), outpatient services for all titles, and to title XVIII, Part B
inpatient services.
Since the methodology used in this worksheet applies the RCE limit in total, make the
adjustment required by 42 CFR 415.70(a)(2) on Worksheet C, Part I. Base this adjustment on
the RCE disallowance amounts entered in column 17 of Worksheet A-8-2.
Where several physicians work in the same department, see CMS Pub. 15-1, §2182.6C for a
discussion of applying the RCE limit in the aggregate for the department versus on an individual
basis to each of the physicians in the department.
NOTE: The adjustments generated from this worksheet for physician compensation are limited
to the cost centers on Worksheet A, lines 4-99, 108-112, and 115 and subscripts as
allowed.
Column Descriptions
Columns 1 and 10--Enter the line numbers from Worksheet A for each cost center that contained
compensation for physicians who are subject to RCE limits.
Columns 2 and 11--Enter the description of the cost center used on Worksheet A. When RCE
limits are applied on an individual basis to each physician in a department, list each physician on
successive lines directly under the cost center description line, or list the first physician on the
same line as the cost center description line and then each successive line below for each
additional physician in that cost center.
40-108
Rev. 2
08-11
FORM CMS-2552-10
4018 (Cont.)
List each physician using an individual identifier (not the physician’s name, NPI, UPIN or social
security number of the individual), but rather, Dr. A, Dr. B, …, Dr. AA, Dr. BB, etcetera.
However, the identity of the physician must be made available to your contractor/contractor upon
audit. When RCE limits are applied on a departmental basis, insert the word "aggregate"
(instead of the physician identifiers) on the line below the cost center description.
Columns 3 - 9 and 12 - 18--When the aggregate method is used, enter the data for each of these
columns on the aggregate line for each cost center. When the individual method is used, enter
the data for each column on the individual physician identifier lines for each cost center.
Column 3--Enter the total physician compensation paid by you for each cost center. Physician
compensation means monetary payments, fringe benefits, deferred compensation, costs of
physician membership in professional societies, continuing education, malpractice, and any other
items of value (excluding office space or billing and collection services) that you or other
organizations furnish a physician in return for the physician's services. (See 42 CFR 415.60(a).)
Include the compensation in column 3 of Worksheet A or, if necessary, through appropriate
reclassifications on Worksheet A-6 or as a cost paid by a related organization through Worksheet
A-8-1.
Column 4--Enter the amount of total remuneration included in column 3 applicable to the
physician's services to individual patients (professional component). These services are
reimbursed on a reasonable charge basis by the Part B contractor in accordance with 42 CFR
415.102(a). The written allocation agreement between you and the physician specifying how the
physician spends his or her time is the basis for this computation. (See 42 CFR 415.60(f).)
Column 5--Enter the amount of the total remuneration included in column 3, for each cost center,
applicable to general services to you (provider component). The written allocation agreement is
the basis for this computation. (See 42 CFR 415.60(f).)
NOTE: 42 CFR 415.60(b) requires that physician compensation be allocated between
physician services to patients, the provider, and nonallowable services such as
research. Physicians' nonallowable services must not be included in columns 4 or 5.
The instructions for column 18 insure that the compensation for nonallowable services
included in column 3 is correctly eliminated on Worksheet A-8.
Column 6--Enter for each line of data, as applicable, the reasonable compensation equivalent
(RCE) limit applicable to the physician's compensation included in that cost center. The amount
entered is the limit applicable to the physician specialty as published in the Federal Register
before any allowable adjustments. The final notice on the annual update to RCE limits published
in the Federal Register, Vol. 50, No. 34, February 20, 1985, on page 7126 contains Table 1,
Estimates of FTE Annual Average Net Compensation Levels for 1984. An update was published
in the Federal Register on August 1, 2003, Vol. 68, No. 148 on page 45459. Obtain the RCE
applicable to the specialty from this table. If the physician specialty is not identified in the table,
use the RCE for the total category in the table. The beginning date of the cost reporting period
determines which calendar year (CY) RCE is used. Your location governs which of the three
geographical categories are applicable: non-metropolitan areas, metropolitan areas less than one
million, or metropolitan areas greater than one million.
Column 7--Enter for each line of data the physician's hours allocated to provider services. For
example, if a physician works 2080 hours per year and 50 percent of his/her time is spent on
provider services, then enter 1040 in this column. The hours entered are the actual hours for
which the physician is compensated by you for furnishing services of a general benefit to your
patients. If the physician is paid for unused vacation, unused sick leave, etc., exclude the hours
so paid from the hours entered. Time records or other documentation that supports this allocation
must be
Rev. 2
40-109
4018 (Cont.)
FORM CMS-2552-10
08-11
available for verification by your contractor upon request. (See CMS Pub. 15-1, §2182.3E.)
Column 8--Enter the unadjusted RCE limit for each line of data. This amount is the product of
the RCE amount entered in column 6 and the ratio of the physician’s provider component hours
entered in column 7 to 2080 hours.
Column 9--Enter for each line of data five percent of the amounts entered in column 8.
Column 12--You may adjust upward, up to five percent of the computed limit (column 9), to take
into consideration the actual costs of membership for physicians in professional societies and
continuing education paid by you.
Enter for each line of data the actual amounts of these expenses paid by you.
Column 13--Enter for each line of data the result of multiplying column 5 by column 12 and
dividing that amount by column 3.
Column 14--You may also adjust upward the computed RCE limit in column 8 to reflect the
actual malpractice expense incurred by you for the services of a physician or group of physicians
to your patients.
Enter for each line of data the actual amounts of these malpractice expenses paid by you.
Column 15--Enter for each line of data the result of multiplying column 5 by column 14 and
dividing that amount by column 3.
Column 16--Enter for each line of data the sum of columns 8 and 15 plus the lesser of columns 9
or 13.
Column 17--Compute the RCE disallowance for each cost center by subtracting the RCE limit in
column 16 from your component remuneration in column 5. If the result is a negative amount,
enter zero. Transfer the amounts for each cost center to Worksheet C, Part I, column 4 for all
hospitals subject to PPS. (See 42 CFR Part 412.)
Column 18--The adjustment for each cost center entered represents the PBP elimination from
costs entered on Worksheet A-8, column 2, line 10 and on Worksheet A, column 6 to each cost
center affected. Compute the amount by deducting, for each cost center, the lesser of the
amounts recorded in column 5 (provider component remuneration) or column 16 (adjusted RCE
limit) from the total remuneration recorded in column 3.
NOTE: If you incur cost for unpaid guarantee for emergency room physician availability,
attach a separate worksheet showing the computation of the necessary reclassification.
(See CMS Pub. 15-1, §2109.)
Line Descriptions
Line 200--Enter the total of lines 1 through 11 for columns 3 through 5, 7 through 9, and 12
through 18.
40-110
Rev. 2
08-11
4019.
FORM CMS-2552-10
4019
WORKSHEET A-8-3 - REASONABLE COST DETERMINATION FOR THERAPY
SERVICES FURNISHED BY OUTSIDE SUPPLIERS
This worksheet provides for the computation of any needed adjustments to costs applicable to
therapy services furnished by outside suppliers in CAHs. Therapy services rendered by nonCAH providers are either subject to fee schedule reimbursement or the corresponding PPS
reimbursement. Consequently, only CAHs complete this worksheet. The information required
on this worksheet provides, in the aggregate, all data for therapy services furnished by all outside
suppliers in determining the reasonableness of therapy costs.
If you contract with an outside supplier for therapy services, the potential for limitation and the
amount of payment you receive depend on several factors:
•
An initial test to determine whether these services are categorized as intermittent part
time or full time services;
•
The location where the services are rendered, i.e., at your site or an alternate site.
•
Whether detailed time and mileage records are maintained by the outside supplier;
•
Add-ons for supervisory functions, aides, overtime, equipment and supplies; and
•
Contractor determinations of reasonableness of rates charged by the supplier compared
with the going rates in the area.
4019.1 Part I - General Information--This part provides for furnishing certain information
concerning therapy services furnished by outside suppliers.
Line 1--Enter the number of weeks that services were performed on site. Count only those
weeks during which a supervisor, therapist or an assistant was on site. (See Pub. 15-I, chapter
14.)
Line 2--Multiply the amount on line 1 by 15 hours per week. This calculation is used to
determine whether services are full-time or intermittent part-time.
Line 3--Enter the number of days in which the supervisor or therapist (only report the therapists
for respiratory therapy) was on site. Count only one day when both the supervisor and therapist
were at the site during the same day.
Line 4--Enter the number of days in which the therapy assistant (PT, OT, or SP only) was on
site. Do not include days when either the supervisor or therapist was also at the site during the
same day.
NOTE: Count an unduplicated day for each day the contractor has at least one employee on
site. For example, if the contractor furnishes a supervisor, therapist and assistant on
one day, count one therapist day. If the contractor provides two assistants on one day
(and no supervisors or therapists), count one assistant day.
Line 5--Enter the number of unduplicated visits made by the supervisor or therapist. Count only
one visit when both the supervisor and therapist were present during the same visit.
Line 6--Enter the number of unduplicated visits made by the therapy assistant. Do not include in
the count the visits when either the supervisor or therapist was present during the same visit.
Line 7--Enter the standard travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.)
Rev. 2
40-111
08-11
FORM CMS-2552-10
4019.2
Line 8--Enter the optional travel expense rate applicable. (See CMS Pub. 15-1, chapter 14.) Use
this rate only for services for which time records are available.
Line 9--Enter in the appropriate columns the total number of hours worked for each category.
Line 10--Enter in each column the appropriate adjusted hourly salary equivalency amount
(AHSEA). This amount is the prevailing hourly salary rate plus the fringe benefit and expense
factor described in CMS Pub 15-1, chapter 14. This amount is determined on a periodic basis for
appropriate geographical areas and is published as an exhibit at the end of CMS Pub. 15-1,
chapter 14. Use the appropriate exhibit for the period of this cost report.
Enter in column 1 the supervisory AHSEA, adjusted for administrative and supervisory
responsibilities. Determine this amount in accordance with the provisions of Pub. 15-1, §1412.5.
Enter in columns 2, 3, and 4 (for therapists, assistants, aides, and trainees respectively) the
AHSEA from either the appropriate exhibit found in CMS Pub. 15-1, chapter 14 or from the
latest publication of rates. If the going hourly rate for assistants in the area is unobtainable, use
no more than 75 percent of the therapist AHSEA. The cost of services of a therapy aide or
trainee is evaluated at the hourly rate, not to exceed the hourly rate paid to your employees of
comparable classification and/or qualification, e.g., nurses' aides. (See CMS Pub. 15-1,
§1412.2.)
Line 11--Enter the standard travel allowance equal to one half of the AHSEA. Enter in columns
1 and 2 one half of the amount in column 2, line 10. Enter in column 3 one half of the amount in
column 3, line 10. (See CMS Pub 15-1, §1402.4.)
Lines 12 and 13--Enter the number of travel hours and number of miles driven, respectively, if
time records of visits are kept. (See CMS Pub. 15-1, §§1402.5 and 1403.1.) Subscript this line
into two categories of provider site and provider offsite as necessary. For example, report line 12
- provider site and line 12.01 - provider offsite.
NOTE: There is no travel allowance for aides employed by outside suppliers.
4019.2 Part II - Salary Equivalency Computation--This part provides for the computation of
the full-time or intermittent part-time salary equivalency.
When you furnish therapy services from outside suppliers to health care program patients but
simply arrange for such services for non health care program patients and do not pay the non
health care program portion of such services, your books reflect only the cost of the health care
program portion. Where you can gross up costs and charges in accordance with provisions of
CMS Pub. 15-1, §2314, complete Part II, lines 14 through 20 and 23 in all cases and lines 21 and
22 where appropriate. See §2810 for instructions regarding grossing up costs and charges.
However, where you cannot gross up costs and charges, complete lines 14 through 20 and 23.
Line 14 - 20--To compute the total salary equivalency allowance amounts, multiply the total
hours worked (line 9) by the adjusted hourly salary equivalency amount for supervisors,
therapists, assistants, aides and trainees (for respiratory therapy only).
Line 17--Enter the sum of lines 14 and 15 for respiratory therapy or sum of lines 14 through 16
for all others.
Line 20--Enter the sum of lines 17 through 19 for respiratory therapy or sum of lines 17 and 18
for all other.
40-112
Rev. 2
12-10
FORM CMS-2552-10
4019.3
Lines 21 and 22--If the sum of hours in columns 1 and 2 for respiratory therapy or 1 through 3
for all others, line 9 is less than or equal to the product found on line 2, complete these lines.
(See the exception above where you cannot gross up costs and charges, and services are provided
to program patients only.)
Line 21--Enter the result of line 17 divided by the sum of columns 1 and 2, line 9 for respiratory
therapy or columns 1 through 3, line 9 for all others.
Line 22--Enter the result of line 2 times line 21.
Line 23--If there are no entries on lines 21 and 22, enter the amount on line 20. Otherwise, enter
the sum of the amounts on lines 18, 19, and 22 for respiratory therapy or lines 18 and 22 for all
others.
4019.3 Part III - Standard and Optional Travel Allowance and Travel Expense Computation Provider Site--This part provides for the computation of the standard and optional travel
allowance and travel expense for services rendered on site.
Lines 24 - 28--Complete these lines for the computation of the standard travel allowance and
standard travel expense for therapy services performed at your site. One standard travel
allowance is recognized for each day an outside supplier performs skilled therapy services at
your site. For example, if a contracting organization sends three therapists to you each day, only
one travel allowance is recognized per day. (See CMS Pub. 15-1, §1403.1 for a discussion of
standard travel allowance and §1412.6 for a discussion of standard travel expense.)
Line 24--Include the standard travel allowance for supervisors and therapists. This standard
travel allowance for supervisors does not take into account the additional allowance for
administrative and supervisory responsibilities. (See CMS Pub. 15-1, §1402.4.)
Line 25--Include the standard travel allowance for assistants for physical therapy, occupational
therapy, and speech pathology.
Line 26--Enter the amount from line 24 for respiratory therapy or the sum of lines 24 and 25 for
physical therapy, occupational therapy, or speech pathology.
Line 27--Enter the result of line 7 times line 3 for respiratory therapy or line 7 times the sum of
lines 3 and 4 for all others.
Lines 29 - 35--Complete these lines for computing the optional travel allowance and expense
when proper records are maintained.
Line 31--Enter the amount on line 29 for respiratory therapy or the sum of lines 29 and 30 for all
others.
Line 32--Enter the result of line 8 times the sum of columns 1 and 2, line 13 for respiratory
therapy or columns 1, 2, and 3, line 13 for all other.
Lines 33 through 35--Enter an amount in one of these lines depending on the method utilized.
4019.4 Part IV - Standard and Optional Travel Allowance and Standard Travel Expense
Computation - Services outside Provider Site--This part provides for the computation of the
standard travel allowance, the standard travel expense, the optional travel allowance, and the
optional travel expense. (See CMS Pub. 15-1, §§1402ff, 1403.1 and 1412.6.)
Rev. 1
40-113
4019.4 (Cont.)
FORM CMS-2552-10
12-10
Lines 36-39--Complete these lines for the computation of the standard travel allowance and
standard travel expense for therapy services performed in conjunction with offsite visits. Only
use these lines if you do not use the optional method of computing travel. A standard travel
allowance is recognized for each visit to a patient’s residence. If services are furnished to more
than one patient at the same location, only one standard travel allowance is permitted, regardless
of the number of patients treated.
Lines 40 - 43--Complete the optional travel allowance and optional travel expense computations
for physical therapy, occupational therapy, and speech pathology services in conjunction with
home health services only. Compute the optional travel allowance on lines 40 through 42.
Compute the optional travel expense on line 43.
Lines 44 - 46--Choose and complete only one of the options on lines 44 through 46. However,
use lines 45 and 46 only if you maintain time records of visits. (See CMS Pub. 15-1, §1402.5.)
4019.5 Part V - Overtime Computation--This part provides for the computation of an overtime
allowance when an individual employee of the outside supplier performs services for you in
excess of your standard work week. No overtime allowance is given to a therapist who receives
an additional allowance for supervisory or administrative duties. (See CMS Pub. 15-1, §1412.4.)
Line 47--Enter in the appropriate columns the total overtime hours worked. Where the total
hours in column 5 are either zero or, equal to or greater than 2080, the overtime computation is
not applicable. Make no further entries on lines 48 through 55 (If there is a short period prorate
the hours). Enter zero in each column of line 56. Enter in column 5 the sum of the hours
recorded in columns 1, 3 and 4 for respiratory therapy, and columns 1 through 3 for physical
therapy, speech pathology, and occupational therapy.
Line 48--Enter in the appropriate column the overtime rate (the AHSEA from line 10, column as
appropriate, multiplied by 1.5).
Line 50--Enter the percentage of overtime hours by class of employee. Determine this amount
by dividing each column on line 47 by the total overtime hours in column 5, line 47.
Line 51--Use this line to allocate your standard work year for one full-time employee. Enter the
numbers of hours in your standard work year for one full-time employee in column 5. Multiply
the standard workyear in column 5 by the percentage on line 50 and enter the result in the
corresponding columns.
Line 52--Enter in columns 1 through 3 for physical therapy, speech pathology, and occupational
therapy the AHSEA from Part I, line 10, columns 2 through 4, as appropriate. Enter in columns
1, 3 and 4 the AHSEA from Part I, line 10, columns 2, 4 and 5, for respiratory therapy.
Line 56--Enter in column 5 the sum of the amounts recorded in columns 1, 3, and 4 for
respiratory therapy and columns 1 through 3 for physical therapy, speech pathology, and
occupational therapy.
4019.6
Part VI - Computation of Therapy Limitation and Excess Cost Adjustment--This part
provides for the calculation of the adjustment to the therapy service costs in determining the
reasonableness of therapy cost.
Line 58--Enter the amount reported on lines 33, 34, or 35.
Line 59--Enter the amount reported on lines 44, 45, or 46.
40-114
Rev. 1
08-11
FORM CMS-2552-10
4019.6 (Cont.)
Lines 61 and 62--When the outside supplier provides the equipment and supplies used in
furnishing direct services to your patients, the actual cost of the equipment and supplies incurred
by the outside supplier (as specified in CMS Pub 15-1, §1412.1) is considered an additional
allowance in computing the limitation.
Line 64--Enter the amounts paid and/or payable to the outside suppliers for the hospital, if
applicable, for therapy services rendered during the period as reported in the cost report. This
includes any payments for supplies, equipment use, overtime, or any other expenses related to
supplying therapy services for you. Add all subscripted lines together for purposes of calculating
the amount to be entered on this line.
Line 65--Enter the excess cost over the limitation, i.e., line 64 minus line 63. If the amount is
negative, enter a zero. Transfer this amount to Worksheet A-8, line 23 for respiratory therapy;
line 24 for physical therapy; line 30 for occupational therapy; and line 31 for speech pathology.
Rev. 2
40-115
4020
FORM CMS-2552-10
4020.
08-11
WORKSHEET B, PART I - COST ALLOCATION - GENERAL SERVICE COSTS
AND WORKSHEET B-1 - COST ALLOCATION - STATISTICAL BASIS
Base cost data on an approved method of cost finding and on the accrual basis of accounting
except where government institutions operate on a cash basis of accounting. (See 42 CFR
413.24(a).) Cost data based on such basis of accounting is acceptable subject to appropriate
treatment of capital expenditures. Cost finding is the process of recasting the data derived from
the accounts ordinarily kept by you to ascertain costs of the various types of services rendered. It
is the determination of these costs by the allocation of direct costs and proration of indirect costs.
The various cost finding methods recognized are outlined in 42 CFR 413.24. Worksheets B, Part
I, and B-1 have been designed to accommodate the stepdown method of cost finding.
The provider can elect to change the order of allocation and/or allocation statistics, as
appropriate, for the current cost reporting period if a request is received by the contractor, in
writing, 90 days prior to the end of that reporting period. The contractor has 60 days to make a
decision and notify the provider of that decision or the change is automatically accepted. The
change must be shown to more accurately allocate the overhead or should demonstrate
simplification in maintaining the changed statistics. If a change in statistics is requested, the
provider must maintain both sets of statistics until an approval is made. If both sets are not
maintained and the request is denied, the provider reverts back to the previously approved
methodology. The provider must include with the request all supporting documentation and a
thorough explanation of why the alternative approach should be used. (see CMS Pub. 15-1,
§2313)
Simplified Cost Allocation Methodology
As an alternative approach to the cost finding methods identified in CMS Pub. 15-1, §2306, the
provider may request a simplified cost allocation methodology. This methodology reduces the
number of statistical bases a provider maintains. It may result in reducing Medicare
reimbursement. A comparison is recommended if the possible loss reimbursement is surpassed
by the reduced costs of maintaining voluminous statistics. The following statistical bases must
be used for purposes of allocating overhead cost centers. There can be no deviation of the
prescribed statistics and it must be utilized for all the following cost centers.
Buildings and Fixtures
Movable Equipment
Maintenance and Repairs
Operation of Plant
Housekeeping
Employee Benefits
Cafeteria*
Administrative and General
Laundry and Linen
Dietary**
Social Service
Maintenance of Personnel
Nursing Administration
Central Services and Supply
Pharmacy
Medical Records and Library
Nursing School*
Interns and Residents
Paramedical Education
Nonphysician Anesthetists
40-116
Square Footage
Square Footage
Square Footage
Square Footage
Square Footage
Salaries
Salaries
Accumulated Costs
Patient Days
Patient Days
Patient Days
Eliminated and moved to A&G for
simplified cost finding
Nursing Salaries
Costed Requisitions
Costed Requisitions
Gross Patient Revenue
Assigned Time
Assigned Time
Assigned Time
100 percent to Anesthesiology
Rev. 2
08-11
FORM CMS-2552-10
4020 (Cont.)
NOTE: The election of the alternative method discussed above cannot result in inappropriately
shifting costs.
*Contract labor is not included and is not grossed up.
**If this is a meals on wheels program, a Worksheet A-8 adjustment is required.
Once the simplified method is elected, the provider must continue to use this method for no less
than 3 years, unless a change of ownership occurs.
The 90-day and 60-day rule previously discussed in this section still applies (CMS Pub. 15-1,
§2313).
Continuation of the Standard Allocation Methodology Instructions
Worksheet B, Part I, provides for the allocation of the expenses of each general service cost
center to those cost centers which receive the services. The cost centers serviced by the general
service cost centers include all cost centers within your organization, other general service cost
centers, inpatient routine service cost centers, ancillary service cost centers, outpatient service
cost centers, other reimbursable cost centers, special purpose cost centers, and nonreimbursable
cost centers. Obtain the total direct expenses from Worksheet A, column 7.
All direct graduate medical education costs (inpatient and outpatient in approved programs) are
reimbursed based on a specific amount per resident as computed on Worksheet E-4. Costs
applicable to interns and residents must still be allocated in columns 21 and 22. These costs are,
however, eliminated from total costs in column 25, unless you qualify for an exception. See the
instructions for column 25 for a more detailed explanation.
Worksheet B-l provides for the proration of the statistical data needed to equitably allocate the
expenses of the general service cost centers on Worksheet B, Part I. To facilitate the allocation
process, the general format of Worksheets B, Part I, and B-1 is identical. Each general service
cost center has the same line number as its respective column number across the top. Also, the
column and line numbers for each general service cost center are identical on the two
worksheets. In addition, the line numbers for each routine service, ancillary outpatient service,
other reimbursable, special purpose, and nonreimbursable cost center are identical on the two
worksheets. The cost centers and line numbers are also consistent with Worksheet A. If you
have subscripted any lines on Worksheet A, subscript the same lines on these worksheets.
NOTE: General service columns 1 through 23 and subscripts thereof must be consistent on
Worksheets B, Parts I, and II; H-2, Part I; J-1, Part I; K-5, Part I; and L-1, Part I.
The statistical basis shown at the top of each column on Worksheet B-1 is the recommended
basis of allocation of the cost center indicated which must be used by all providers completing
this form (Form CMS 2552-10), even if a basis of allocation other than the recommended basis
of allocation was used in the previous iteration of the cost report (Form CMS 2552-96). If a
different basis of allocation is used, you must indicate the basis of allocation actually used at the
top of the column subject to the applicable provisions of CMS Pub 15-1, §2313. Additionally,
the following overhead cost center statistics can be substituted for the recommended statistics
printed on Worksheet B-1 subject to the applicable provisions of CMS Pub 15-1, §2313.
Cost Center
Statistical Basis
Housekeeping
Cafeteria
Maintenance of Personnel
Medical Records
Square Footage
FTEs
Eliminate and move to A&G
Gross Patient Revenue
Rev. 2
40-117
4020 (Cont.)
FORM CMS-2552-10
08-11
Most cost centers are allocated on different statistical bases. However, for those cost centers
with the same basis (e.g., square feet), the total statistical base over which the costs are allocated
differs because of the prior elimination of cost centers that have been closed.
The general service cost centers are ordered sequentially such that the cost centers that render the
most services to and receive the least services from other cost centers are listed first. When
closing the general service cost centers, first close the cost centers that render the most services
to and receive the least services from other cost centers. List the cost centers in this sequence
from left to right on the worksheets. However, your circumstances may be such that a more
accurate result is obtained by allocating to certain cost centers in a sequence different from that
followed on these worksheets.
NOTE: General service cost centers are not allocated to provider-based physician (PBP)
clinical lab service (line 61) because this cost center is treated as a purchased service
under arrangements provided only to program beneficiaries.
If the amount of any cost center on Worksheet A, column 7, has a credit balance, show this
amount as a credit balance on Worksheet B, Part I, column 0. Allocate the costs from the
applicable overhead cost centers in the normal manner to the cost center showing a credit
balance. After receiving costs from the applicable overhead cost centers, if a general service cost
center has a credit balance at the point it is allocated, do not allocate the general service cost
center. Rather, enter the credit balance in parentheses on line 201 as well as on the first line of
the column and on line 202. This enables column 24, line 202, to crossfoot to columns 0 and 4A,
line 202 if the provider has intern & resident costs or a post-stepdown adjustment in column 25.
However, column 26 will cross foot to columns 0 and 4A if the provider has no interns &
residents costs or a post-stepdown adjustment in column 25. After receiving costs from the
applicable overhead cost centers, if a revenue producing cost center has a credit balance on
Worksheet B, Part I, column 26, do not carry forward a credit balance to any worksheet.
On Worksheet B-1, enter on the first line in the column of the cost center being allocated the
total statistical base over which the expenses are allocated (e.g., in column 1, capital-related cost
- building and fixtures, enter on line 1 the total square feet of the building on which depreciation
was taken). For all cost centers to which the capital-related cost is allocated, enter that portion of
the total statistical base applicable to each. The sum of the statistical base applied to each cost
center receiving the services rendered must equal the total base entered on the first line. Use
accumulated cost for allocating administrative and general expenses.
Do not include any statistics related to services furnished under arrangements except if:
•
Both Medicare and non-Medicare costs of arranged for services are recorded in your
records; or
•
Your contractor determines that you are able to (and do) gross up the costs and charges
for services to non-Medicare patients so that both cost and charges are recorded as if you
had furnished such services directly to all patients. (See CMS Pub. 15-1, §2314.)
Enter on line 202 of Worksheet B-l the total expenses of the cost center being allocated. Obtain
this amount from Worksheet B, Part I from the same column and line number used to enter the
statistical base on Worksheet B-1. (In the case of capital-related costs - buildings and fixtures,
this amount is on Worksheet B, Part I, column 1, line 1.)
Divide the amount entered on line 202 by the total statistic entered in the same column on the
first line. Enter the resulting unit cost multiplier on line 203. Round the unit cost multiplier to
six decimal places.
40-118
Rev. 2
08-11
FORM CMS-2552-10
4020 (Cont.)
Multiply the unit cost multiplier by that portion of the total statistics applicable to each cost
center receiving the services rendered. Enter the result of each computation on Worksheet B,
Part I, in the corresponding column and line. (See §4000.1 for rounding standards.)
After applying the unit cost multiplier to all the cost centers receiving the services rendered, the
total cost (line 202) of all the cost centers receiving the allocation on Worksheet B, Part I, must
equal the amount entered on the first line. Perform the preceding procedures for each general
service cost center. Complete the column for each cost center on both Worksheets B, Part I, and
B-1 before proceeding to the column for the next cost center.
If a general service cost center has a credit balance at the point it is allocated on Worksheet B,
Part I, do not allocate the general service cost centers. However, display the statistic
departmentally, but do not calculate a unit cost multiplier for lines 203 and 205 on Worksheet B1. Use line 204 of Worksheet B-1 in conjunction with the allocation of capital-related costs on
Worksheet B, Part II. Complete line 204 for all columns after Worksheets B, Part I, and B-1 are
completed and the amount of direct and indirect capital-related cost is determined on Worksheet
B, Part II, column 2A. Use line 205 for all columns in allocating the direct and indirect capitalrelated cost on Worksheet B, Part II. Compute the unit cost multiplier (after the amount entered
on line 204 has been determined) by dividing the capital-related costs recorded on line 204 by
the total statistic entered in the same column on the first line. Round the unit cost multipliers to
six decimal places. (See instructions for Worksheet B, Part II, for the complete methodology and
exceptions.)
Do not use line 200 to allocate costs on Worksheet B, Part I.
Since intern and resident costs are segregated into two cost centers, properly allocate general
service costs applicable to each center. A listing of general service cost centers which may be
applicable and the appropriate allocation to the separate cost centers for the intern and resident
costs is presented below.
Cost Center
Capital Related Costs - Bldgs. & Fixtures
Capital Related Costs - Movable Equipment
Employee Benefits
Administrative and General
Maintenance and Repair
Operation of Plant
Housekeeping
Cafeteria
Maintenance of Personnel
Rev. 2
Salary &
Salary Related
Fringe Benefits
X
X
X
Other
X
X
X
X
X
X
X
X
X
40-119
4020 (Cont.)
FORM CMS-2552-10
08-11
After the costs of the general service cost center have been allocated on Worksheet B, Part I,
enter in column 24 the sum of the costs in columns 4A through 23 for lines 30 through 201.
Once overhead is allocated to these cost centers, they are closed and the costs are not further
allocated to the revenue producing cost centers.
Since costs applicable to direct graduate medical education costs (inpatient and outpatient in
approved programs) are reimbursed based on a specific amount per resident, exclude these costs
from the total costs in column 26. Enter on each line in column 25 the sum of the amounts
shown on each line in columns 21 and 22. If you qualify for the exception (cost reimbursed
hospital such as CAHs do not offset I&R costs), enter only the amounts from Worksheet B-2.
In addition, when an adjustment to expenses is required after cost allocation, enter the amount
applicable to each cost center in column 25 of Worksheet B, Part I. Corresponding adjustments
to Worksheet B, Part II, may be applicable for capital-related cost adjustments. Submit a
supporting worksheet showing the computation of the adjustments in addition to completing
Worksheet B-2.
NOTE: The amount reported in column 25 must equal both the sum of the amounts shown in
columns 21 and 22 and the amount on Worksheet B-2, unless you qualify for the
exception. See the instructions for column 25 for a more detailed explanation.
Other examples of adjustments to expenses which may be required after cost allocation are (1)
the allocation of available costs between the certified portion and the non-certified portion of a
distinct part provider, and (2) costs attributable to unoccupied beds in a hospital with a restrictive
admission policy. (See CMS Pub. 15-1, §§2342-2344.3.)
After the adjustments have been entered on Worksheet B, Part I, column 25, subtract the
amounts in column 25 from the amounts in column 24, and enter the resulting amounts in
column 26 for each line. The cost subtotal entered in column 24, line 202 must equal the total
costs entered in column 0, line 202.
Transfer the totals in column 26, lines 30 through 46 (inpatient routine service cost centers), lines
50 through 76 (ancillary service cost centers), lines 88 through 93 (outpatient service cost
centers), lines 94 through 101 (other reimbursable cost centers), and 105 through 117 (special
purpose cost centers) to Worksheet C, Parts I and II, column l, lines 30 through 98. For provider
based RHC/FQHCs transfer the total costs to Worksheet M-2.
40-120
Rev. 2
08-11
FORM CMS-2552-10
4020 (Cont.)
Transfer the total cost in column 26, line 100 (intern/resident services not in approved teaching
program) to Worksheet D-2, Part I, column 2, line 1.
The total outpatient rehabilitation costs in column 26, line 93 and subscripts, must agree with
Worksheet J-1, Part I, column 26, line 22, for each provider type.
Do not transfer ASC costs from column 26, line 115. Do not transfer the nonreimbursable cost
center totals (lines 190 through 193).
NOTE: Do not transfer negative numbers.
Column Descriptions
Column 1--Include only capital costs for building and fixtures. See the instructions for
Worksheet A, line 1, for a discussion capital-related costs for building and fixtures.
Column 2-- Include only capital costs for movable equipment. See the instructions for
Worksheet A, line 2, for a discussion capital-related costs for movable equipment.
Worksheet B, Part I, Column 25--Accumulate in this column the costs for interns and residents
and post step down adjustments. Except as provided in 42 CFR 413.77(e)(1), the costs of interns
and residents (direct graduate medical education costs for inpatient and outpatient in approved
programs) are paid on a per resident amount through Worksheet E-4. In order to avoid duplicate
payments, enter the sum of the amounts reported on each line in columns 21 and 22 in the
appropriate line of column 25. In addition, enter the amounts from Worksheet B-2, lines as
appropriate. The total of columns 21 and 22 and the appropriate lines on Worksheet B-2 must
equal the total of column 25.
NOTE: 42 CFR 413.77(e)(1) provides for the establishment of a base period and a per resident
amount for new teaching hospitals. If your hospital did not have an approved medical
residency training program or did not participate in Medicare during the FY 1984 base
period, but either condition changed in a cost reporting period beginning on or after
July 1, 1985, the contractor establishes a per resident amount for the hospital using the
information from the first cost reporting period during which the hospital participates
in Medicare and the residents are on duty during the first month of that period.
Effective for cost reporting periods beginning on or after October 1, 2006, if residents
are not on duty during the first month of the cost reporting period in which the hospital
first begins to train residents, the contractor establishes a per resident amount using
information from the first cost reporting period immediately following the cost
reporting period during which the hospital participates in Medicare and residents began
training at the hospital. If your hospital begins training residents after the first month
of the cost reporting period, your hospital is reimbursed for these costs based on
reasonable cost on Worksheets D, Parts III and IV. Do not include in column 25 the
intern and resident costs from columns 21 and 22.
If you responded “N” to the question on Worksheet S-2, Part I, line 56, then your
hospital is reimbursed for these costs based on reasonable cost. If you answered “Y”
to the question on Worksheet S-2, Part I, line 56, then you are paid for graduate
medical education costs using a per resident amount through Worksheet E-4. Include
in column 25 the costs from columns 21 and 22.
If you are CAH and responded “Y” to Worksheet S-2, Part I, question 107, (indicating
that you have an I&R training program) the GME elimination is not performed.
Consequently, do not include in column 25 the intern and resident costs from columns
21 and 22.
Rev. 2
40-121
4020 (Cont.)
FORM CMS-2552-10
08-11
Worksheet B-1, Column 5A--Enter the costs attributable to the difference between the total
accumulated cost reported on Worksheet B, Part I, column 4A, line 202 and the accumulated cost
reported on Worksheet B-1, column 5, line 5. Enter any amounts reported on Worksheet B, Part
I, column 4A for (1) any service provided under arrangements to program patients and which is
not grossed up and (2) negative balances. Enter a negative one (-1) in the accumulated cost
column to identify the cost center which should be excluded from receiving any A & G costs. If
some of the costs from that cost center are to receive A & G costs then enter in the reconciliation
column the amount not to receive A & G costs to assure that only those costs to receive overhead
receive the proper allocation. Including a statistical cost which does not relate to the allocation
of administrative and general expenses causes an improper distribution of overhead. In addition,
report on line 5 the administrative and general costs reported on Worksheet B, Part I, column 5,
line 5 since these costs are not included on Worksheet B-1, column 5 as an accumulated cost
statistic.
For componentized A&G cost centers, the accumulated cost center line number must match the
reconciliation column number. Include in the column number the alpha character "A", i.e., if the
accumulated cost center for A&G is line 5.03 (Other A&G), the reconciliation column
designation must be 5A.03.
Worksheet B-1, Column 5--The administrative and general expenses are allocated on the basis of
accumulated costs. Therefore, the amount entered on Worksheet B-l, column 5, line 5, is the
difference between the amounts entered on Worksheet B, Part I, column 4A and Worksheet B-1,
column 5A. A negative cost center balance in the statistics for allocating administrative and
general expenses causes an improper distribution of this overhead cost center. Exclude negative
balances from the allocation statistics.
Worksheet B-1, Column 23--Enter the appropriate statistics based on assigned time. If, however,
the use of assigned time is not appropriate for that paramedical education program (i.e., a nondirect patient care cost center), a different statistical basis may be used. For example, if you have
a paramedical education program for hospital administration, using assigned time as the
statistical basis may be inappropriate. Use accumulated costs as the statistical basis for
allocating hospital administrative paramedical education program costs.
40-122
Rev. 2
08-11
4021.
FORM CMS-2552-10
4021
WORKSHEET B, PART II - ALLOCATION OF CAPITAL-RELATED COSTS
This worksheet provides for the determination of direct and indirect capital-related costs
allocated to those cost centers which receive the services. The cost centers serviced by the
general service cost centers include all cost centers within your organization, other general
service cost centers, inpatient routine service cost centers, ancillary service cost centers,
outpatient service cost centers, other reimbursable cost centers, special purpose cost centers, and
nonreimbursable cost centers. Hospitals receiving 100 percent Federal rate for IPPS capital
payments complete Worksheet B, Part II in its entirety.
NOTE: Unless there is a change in ownership or the provider has elected the alternative
method described in §4017, the hospital must continue the same cost finding methods
(including its cost finding bases) in effect in the hospital's prior cost reporting period.
If there is a change in ownership, the new owners may request that the contractor
approve a change in order to be consistent with their established cost finding practices.
(See CMS Pub. 15-1, §2313.)
Part II is completed by all IPPS hospitals and IPPS excluded hospitals which were part of a
complex subject to IPPS. Freestanding hospitals excluded from IPPS are not required to
complete Part II.
See the instructions for Worksheet A, lines 1 and 2, for a discussion of capital-related costs.
Use these worksheets in conjunction with Worksheets B, Part I and B-1. The format and
allocation process employed are identical to that used on Worksheets B, Part I and B-1. Any
cost centers, subscripted lines, and/or columns added to Worksheet A are also added to
Worksheet B, Part II, in the same sequence.
Column 0--Where capital-related costs have been directly assigned to specific cost centers on
Worksheet A, column 7, in accordance with CMS Pub. 15-1, §2307, enter in this column those
amounts directly assigned from your records. Where you include cost incurred by a related
organization, the portion of these costs that are capital-related costs is considered directly
assigned capital-related costs of the applicable cost center. For example, if you are part of a
chain organization that includes some costs incurred by the home office of the chain organization
in your administrative and general cost center, the amount so included represents capital-related
costs included in this column.
Columns l and 2--Obtain the amounts entered in columns l and 2, lines 4 through 199, from the
corresponding columns and lines on Worksheet B, Part I.
Column 2A--Enter the sum of columns 0 through 2 for each line.
Enter on line 204 of Worksheet B-l for each column the capital-related costs allocated. Report
these costs on the first line of each column on Worksheet B, Part II. (See exceptions below.)
Complete a unit cost multiplier for each column by dividing the amount on line 204 of
Worksheet B-l by the statistic reported on the first line of the same column. Enter the unit cost
multiplier on line 205 and round to six decimal places, e.g., .0622438 is rounded to .062244.
The allocation process on Worksheet B, Part II is identical to that used on Worksheets B, Part I
and B-l.
Multiply the unit cost multipliers on line 205 by the portion of the total statistic on Worksheet B1 applicable to each cost center. Enter the result of each computation on Worksheet B, Part II,
respectively, in the corresponding column and line.
Rev. 2
40-123
4021 (Cont.)
FORM CMS-2552-10
08-11
After the unit cost multipliers have been applied to all the cost centers, the total cost on
Worksheet B, Part II, line 202 of all the cost centers receiving the allocation must equal the
amount allocated on the first line of the column. However, this is not true in circumstances
described in the second paragraph of exceptions below. Perform these procedures for each
general service cost center. Complete the column for each cost center on Worksheets B-1 and B,
Part II before proceeding to the column for the next cost center.
EXCEPTIONS:
When a general service cost center is not allocated on Worksheet B, Part I
because it has a negative balance at the point it is to be allocated, the capitalrelated cost for the same general service cost center on Worksheet B, Part II,
is not allocated. Enter the total capital-related cost on line 201, the negative
cost center line. This enables column 2A, line 202 to cross foot to column
26, line 202, if no intern and resident cost or post step-down adjustments are
identified in column 25. Otherwise column 2A, line 202 will crossfoot to
line 24.
When a general service cost center has a negative direct cost balance on
Worksheet B, Part I, column 0 and the negative balance becomes positive
through the cost allocation process, adjust the amount of capital-related cost
determined on Worksheet B, Part II for that general cost center to reflect the
amount allocated on Worksheet B, Part I. Determine the adjusted amounts
of capital-related cost allocated on Worksheet B, Part II, by dividing the
capital-related cost by the total indirect cost allocated to the specific cost
center on Worksheet B, Part I. (Do not include the negative direct cost.)
Then multiply that ratio by the net amount allocated on Worksheet B, Part I
for that specific cost center. For cross footing purposes, enter the adjusted
capital-related costs on the first line of the column and the differences
between the total capital-related cost and the adjusted capital-related cost on
line 201 of Worksheet B, Part II. This enables column 2A, line 202 to cross
foot to column 26, line 202, if no intern and resident cost or post step-down
adjustments are identified in column 25. Otherwise column 2A, line 202 will
crossfoot to line 24.
After all the capital-related costs of the general service cost centers have been allocated on
Worksheet B, Part II, enter in column 24 the sum of columns 2A through 23 for lines 30 through
201.
When an adjustment to expenses is required after cost allocation, show the amount applicable to
each cost center in column 25 of Worksheet B, Part II. Submit a supporting worksheet showing
the computation of the adjustment in addition to completing Worksheet B-2.
Adjustments to expenses which may be required after cost allocation include (1) the allocation of
available costs between the certified portion and the noncertified portion of a distinct part
provider and (2) costs attributable to unoccupied beds of a hospital with a restrictive admission
policy. (See CMS Pub. 15-1, §§2342-2344.3.)
After the adjustments have been entered on Worksheet B, Part II, column 25, subtract the
amounts in column 25 from the amounts in column 24, and enter the resulting amounts in
column 26 for each line. The total costs entered in column 26, line 202 must equal the total costs
entered in column 2A, line 202, if no intern and resident cost or post step-down adjustments are
identified in column 25, otherwise column 2A, line 202 will equal line 24.
On Worksheet B, Part II, columns 19 through 23, lines 30 through 194 are shaded because the
full amount of nonphysician anesthetists and medical education costs is obtained from
Worksheet B, Part I, columns 19 through 23. Enter these amounts on line 200 for cross footing
purposes. If column 20 is subscripted for additional education cost centers qualifying as
educational pass through costs (see the instructions for Worksheet A, lines 20 through 23), the
subscripted column(s) must be shaded similarly to column 20.
40-124
Rev. 2
08-11
FORM CMS-2552-10
4021 (Cont.)
Since capital-related cost, non-physician anesthetists, and approved education programs are not
included in the operating cost per discharge, columns 19 through 23, lines 30 through 194 are
shaded on Worksheet B, Part II, for all lines except 19 through 23, 200, 201, and 202. These are
the only lines and columns where an approved educational cost center can be shown. For
purposes of this paragraph only, the statistic for line 200 is the sum of the statistics on lines 30
through 117 and 190 through 194 on Worksheet B-1 for the same column. Enter these amounts
on line 200 for cross footing purposes. Use line 200 of Worksheet B-1, columns 19 through 23,
for this purpose in the allocation of capital-related cost on Worksheet B, Part II. Use the statistic
on line 200 together with the statistics on lines 19 through 23 of Worksheet B-1 to allocate
columns 19 through 23 of Worksheet B, Part II. If column 20 is subscripted for additional
education cost centers qualifying as educational pass through costs (see the instructions for
Worksheet A, lines 20 through 23), the subscripted column(s) must be shaded similarly to
columns 20 through 23
The total for each column includes lines 200 and 201 for cross footing purposes.
Transfer:
From Worksheet B, Part II, Column 26
To Worksheet D, Part I
Line 30 - Adults and Pediatrics
Column l, line 30 for the hospital
Lines 31-35 - Intensive Care
Type Inpatient Hospital Units
Column 1, lines 31 through 35
Line 40 - IPF Subprovider
Column l, line 40
Line 41 - IRF Subprovider
Column l, line 41
Line 42 - Subprovider
Column l, line 42
Line 43 - Nursery
Column 1, line 43 for titles V and XIX
From Worksheet B, Part II, Column 26
To Worksheet D-l, Part III
Line 44 - SNF
Line 75 for the SNF
Sum of lines 44 and 45
Line 75 for the NF
From Worksheet B, Part II, Column 26
To Worksheet D, Part II
Lines 50-76 - Ancillary Services
Column l, lines 50-76
Lines 90, 91, subscripts of 92,
and 93 - Outpatient Service Cost
Column l, lines 90, 91, subscripts
of 92, and 93
Lines 94, 95, and 98 - Other
Reimbursable Cost Centers
Column l, lines 94, 95, and 98
To Worksheet C, Part II, Column 2
Lines 50-98
Rev. 2
Lines 50-98
40-125
4022
4022.
FORM CMS-2552-10
08-11
WORKSHEET B-2 - POST STEP-DOWN ADJUSTMENTS
This worksheet provides an explanation of the post step down adjustments reported in column 25
of Worksheets B, Parts I and II, and L-1, Part I.
Column Descriptions
Column 1--Enter a brief description of the post step down adjustment.
Column 2--Make post step down adjustments on Worksheets B, Parts I and II, and L-1, Part I.
Enter the worksheet part to which the post step down adjustment applies. For lines 74 and/or 94
remove the amount for Epoetin and Aranesp reported on Worksheet S-5 lines 13, 14, 17, and 18.
Use the codes below to identify the worksheet in which the adjustment applies:
Code
Worksheet
1
2
3
B, Part I
B, Part II
L-1, Part I
Column 3--Enter the worksheet line number to which the adjustment applies.
Column 4--Enter the amount of the adjustment. Transfer these amounts to the appropriate lines
on Worksheets B, Parts I, and II, or L-1, Part I, column 25.
Line Descriptions
Line 1--Enter the amount of the EPO adjustment for the renal dialysis inpatient department from
Worksheet S-5, line 13.
Line 2--Enter the amount of the EPO adjustment for the home dialysis program from Worksheet
S-5, line 14.
Line 3--Enter the amount of the Aranesp adjustment for the renal dialysis inpatient department
from Worksheet S-5, line 17.
Line 4--Enter the amount of the Aranesp adjustment for the home dialysis program from
Worksheet S-5, line 18.
Lines 5 - 59--Enter any additional adjustments that are required under the Medicare principles of
reimbursement. Label the lines appropriately to indicate the nature of the required adjustments.
If the number of blank lines is not sufficient, use additional Worksheets B-2.
40-126
Rev. 2
10-12
4023.
FORM CMS-2552-10
4023
WORKSHEET C - COMPUTATION OF RATIO OF COST TO CHARGES AND
OUTPATIENT CAPITAL REDUCTION
4023.1 Computation of Ratio of Cost to Charges--This worksheet computes the ratio of cost to
charges for inpatient services, ancillary services, outpatient services, and other reimbursable
services. All charges entered on this worksheet must comply with Pub. 15-1, sections 2202.4 and
2203. This ratio is used on Worksheet D, Part V, for titles V and XIX and for title XVIII;
Worksheet D-3; Worksheet D-4; Worksheet H-3, Part II; and Worksheet J-2, Part II, to
determine the program's share of ancillary service costs in accordance with 42 CFR 413.53. This
worksheet is also needed to determine the adjusted total costs used on Worksheet D-1 because of
your status as IPPS, TEFRA, or other.
42 CFR 413.106(f)(3) provides that the costs of therapy services furnished under arrangements to
a hospital inpatient are exempt from the guidelines for physical therapy and respiratory therapy if
such costs are subject to the provisions of 42 CFR 413.40 (rate of increase ceiling) or 42 CFR
Part 412 (inpatient prospective payment). However, therapy services furnished under
arrangements to CAHs are subject to the provisions of 413.106.
42 CFR 415.70(a)(2) provides that RCE limits do not apply to the costs of physician
compensation attributable to furnishing inpatient hospital services (provider component) paid for
under 42 CFR Part 412ff.
To facilitate the cost finding methodology, apply the therapy limits and RCE limits to total
departmental costs. This worksheet provides the mechanism for adjusting the costs after cost
finding to comply with 42 CFR 413.106(f)(3) and 42 CFR 415.70(a)(2). This is done by
computing a series of ratios in columns 9 through 11. In column 9, a ratio referred to as the “cost
or other ratio” is computed based on the ratio of total reasonable cost to total charges. This ratio
is used by you or your components not subject to IPPS or TEFRA (e.g., hospital-based SNFs and
CAHs). Also use this ratio for Part B services still subject to cost reimbursement. In column 10,
compute a TEFRA inpatient ratio. This ratio reflects the add-back of RT/PT limitations to total
cost since TEFRA inpatient costs are not subject to these limits. (TEFRA inpatient services are
subject to RCE limits.) In column 11, compute an IPPS inpatient ratio. This ratio reflects the
add-back of RT/PT and RCE limitations to total cost since inpatient hospital services covered by
IPPS are not subject to any of these limitations.
Column Descriptions
The following provider components may be subject to 42 CFR 413.40 or 42 CFR 412.1(a)ff:
•
•
•
•
Hospital Part A inpatient services for title XVIII,
Hospital subprovider Part A inpatient services for title XVIII,
Hospital inpatient services for titles V and XIX, and
Hospital subprovider services for titles V and XIX.
All components or portions of components not subject to IPPS, IPF PPS, IRF PPS, LTC PPS, or
TEFRA, e.g., CAH services, are classified as “Cost or Other.”
The following matrix summarizes the columns completed for Cost or Other, TEFRA Inpatient,
and IPPS:
__________Columns______________
Type of Service
Inpatient
Inpatient routine service cost centers
(lines 30-46)
Rev. 3
Cost or
Other
TEFRA
Inpatient
IPPS, IPF-PPS,
IRF-PPS
1-3
1-3
1-5
40-127
4023.1 (Cont.)
FORM CMS-2552-10
10-12
Inpatient ancillary
(lines 50-93)
1, 8, 9
1-3, 8-10
1-9, 11
Other Reimbursable
(lines 94-98)
1, 8, 9
1-3, 8-10
1-9, 11
Other Reimbursable
(lines 99-101)
1, 8
1-3, 8
1-8
Special Purpose
(lines 105-117)
1, 8
1-3, 8
1-8
Column 1--Enter on each line the amount from the corresponding line of Worksheet B, Part I,
column 26. Transfer the amount on line 92 from Worksheet D-1, Part IV, line 89, if you do not
have a distinct observation bed area. If you have a distinct observation bed area, subscript line
92 into line 92.01, and transfer the appropriate amount from Worksheet B, Part I, column 26. In
a complex comprised of an acute care hospital with an excluded unit(s) (excluded from IPPS),
only the acute care hospital may report observation bed costs. Any services provided by the
RHC/FQHC outside the benefits package for those clinics are reported by the hospital in its
appropriate ancillary cost center, but not in the RHC/FQHC cost center lines 88 and 89. Do not
bring forward any cost center with a credit balance from Worksheet B, Part I, column 26.
Column 2--Enter the amount of therapy limits applied to the cost center on lines 65 to 68.
Obtain these amounts from Worksheet A-8, lines 23, 24, 30 and 31 respectively.
NOTE: Complete this column only when the hospital or subprovider is subject to PPS or
TEFRA rate of increasing ceiling (see 42 CFR, Part 412, subpart N and P and 42 CFR
413.40, respectively). If the hospital and all subproviders have correctly indicated that
their payment system is in the “other” category on Worksheet S-2, do not complete
columns 2 through 5, 10, and 11.
Column 3--Enter on each cost center line the sum of columns 1 and 2.
Column 4--Only complete this section if you or your subproviders are subject to IPPS, IPF PPS,
IRF PPS, or LTC PPS. Enter on each line the amount of the RCE disallowance. Obtain these
amounts from the sum of the amounts for the corresponding line on Worksheet A-8-2, column
17.
Column 5--Complete this section only if you or your subproviders are subject to a PPS. Enter on
each cost center line the sum of the amounts entered in columns 3 and 4.
Columns 6 and 7--Enter on each cost center line the total inpatient and outpatient gross patient
charges including charges for charity care patients and, where applicable, standard customary
charges for items reimbursed on a fee schedule (e.g., DME, oxygen, prosthetics, and orthotics).
Also include the total inpatient and outpatient gross charges for cost centers which have a credit
balance on Worksheet B, Part I, Column 26 and, therefore, do not contain “cost” in Column 1 of
Worksheet C, Part I.
Total charges on Worksheet C, Part I, for each department are for provider services only.
Therefore, Medicare charges on Worksheets D, Parts II and IV, D-2, D-3, and D-4 must also
include provider services only. When reporting charges for a complex, e.g., hospital,
subprovider, SNF, charges for like services must be uniform. (See CMS Pub. 15-1, §2203.)
40-128
Rev. 3
10-12
FORM CMS-2552-10
4023.1 (Cont.)
When certain services are furnished under arrangements and an adjustment is made on
Worksheet A-8 to gross up costs, gross up the related charges entered on Worksheet C, Part I, in
accordance with CMS Pub. 15-1, §2314. If no adjustment is made on Worksheet A-8, show only
the charges you actually billed on Worksheet C, Part I.
NOTE: Any cost center that includes CRNA charges must exclude these charges unless the
hospital qualifies for the rural exception as outlined in §4013. All cost centers for
which CRNA costs are excluded on Worksheet A-8 must also exclude the charges
associated with these costs.
NOTE: Any charges for ancillary services provided to clinic, RHC and FQHC patients must be
reclassified to the appropriate ancillary cost center, e.g., radiology-diagnostic,
laboratory. A similar adjustment must be made to program charges.
Report on line 92 all charges for observation bed services provided in the inpatient
routine care area of the hospital. The charges relate to all payer classes and include
those observation bed charges for patients released as outpatients and those patients
admitted as inpatients. If you have a distinct observation bed unit, report your gross
charges on line 92.01 (which was subscripted on Worksheet A).
Column 8--Enter the total of columns 6 and 7.
Column 9 through 11--Cost to charge ratios are not calculated for lines 99 through 117. The
corresponding locations on Worksheet C, Part I are shaded.
Column 9, lines 50 through 98--Always complete this column. Divide the cost for each cost
center in column 1 by the total charges for the cost center in column 8 to determine the ratio of
total cost to total charges (referred to as the "Cost or Other" ratio) for that cost center. Enter the
resultant departmental ratios in this column. Round ratios to 6 decimal places.
Column 10, lines 50 through 98--Complete this section only when the hospital or its subprovider
is subject to the TEFRA rate of increase ceiling. (See 42 CFR 413.40.) Divide the amount
reported in column 3 (which represents the total cost adjusted for the add-back of amounts
excluded on Worksheet A-8 for the RT/PT limits) for each cost center by the total charges for the
cost center in column 8.
This computation determines the RT/PT adjusted ratio of cost to charges (referred to as the
TEFRA inpatient ratio) for each cost center. Enter the resultant departmental ratio. Round ratios
to 6 decimal places.
Column 11, lines 50 through 98--Complete this section only when the hospital is subject to IPPS
or LTC PPS or when its subprovider is subject to its respective PPS reimbursement
methodology. (See 42 CFR 412.1(a) through 412.125, 42 CFR, Part 412, subparts O, N, and P,
respectively). Divide the amount reported in column 5 (which represents the total cost adjusted
for the add-back of amounts excluded on Worksheet A-8 for the RT/PT and the RCE limits) for
each cost center by the total charges for the cost center in column 8.
This computation determines the RCE/RT/PT adjusted ratio of cost to charges (referred to as the
PPS inpatient ratio) for each cost center. Enter the resultant departmental ratio. Round ratios to
6 decimal places.
Line Descriptions
Lines 30 - 117--These cost centers have the same line numbers as the respective cost centers on
Worksheets A, B, and B-1. This design facilitates referencing throughout the cost report.
Rev. 3
40-129
4023.1 (Cont.)
FORM CMS-2552-10
10-12
Therefore, if you have subscripted any lines on those worksheets, you must subscript the same
lines on this worksheet.
NOTE: The worksheet line numbers start at line 30 because of the line referencing feature.
Line 200--For each of the columns 1 through 5 (total costs), respectively, enter the sum of lines
30 through 199 for all unshaded lines in accordance with Worksheet C, Part I.
For each of the columns 6, 7, and 8 (total charges), respectively, enter the sum of lines 30
through 60 and 62 through 199 for all unshaded lines in accordance with Worksheet C, Part I.
Since the charges on line 61 are also included on line 60 (laboratory), the charges on line 61
must be excluded to avoid overstating total charges.
Line 201--Enter the amounts from line 92 for columns 1, 3, and 5. Calculate the observation bed
cost on line 92 using the routine cost per diem from Worksheet D-1 because it is part of routine
costs and as such has been included in the amounts reported on line 30 for the hospital.
Therefore, in order to arrive at the total allowable costs, subtract this cost to avoid reporting these
costs twice.
Line 201, columns 6, 7, and 8, are shaded.
Line 202--For columns 1, 3, and 5, subtract line 201 from line 200, and enter the result.
Transfer Referencing
Costs--The costs of the inpatient routine service cost centers are transferred:
From Worksheet C
(Columns 1, 3, or 5)
To
Line 30
Lines 31 - 35
Line 40, 41, 42 and subscripts
Line 43 (titles V and XIX only)
Line 44 (title XVIII only)
Line 45 and subscripts (titles V and
XIX only)
Wkst. D-1, Part I, Line 21
Wkst. D-1, Part II, Lines 43 - 47
Separate Wkst. D-1, Part I, Line 21
Wkst. D-1, Part II, Line 42
Separate Wkst. D-1, Part I, Line 21
Separate Wkst. D-1, Part I, Line 21
Charges--Transfer the total charges for each of lines 50 through 98, column 8, to Worksheet D,
Part IV, column 7, lines as appropriate.
Ratios
Cost or Other Ratios--The "Cost or Other" ratio is transferred from column 9:
For
To
Hospital, subprovider, SNF, NF, swing
bed-SNF, and swing bed-NF:
1.
Inpatient ancillary services for
titles V, XVIII, Part A, and XIX
Ancillary services furnished by the
hospital-based HHA
40-130
Wkst. D-3, column 1,
for each cost center
Wkst. H-3, Part II,
column 1, line as appropriate
Rev. 3
08-11
FORM CMS-2552-10
4023.2
For
To
Hospital-based
CMHC (titles V, XVIII, and XIX)
shared ancillary services
Wkst. J-2, Part II,
column 3, line as appropriate
TEFRA Inpatient Ratio--Transfer the TEFRA inpatient ratio on lines 50 through 94 and 96
through 98 from column 10 for hospital or subprovider components for titles V, XVIII, Part A,
and XIX inpatient services subject to the TEFRA rate of increase ceiling (see 42 CFR 413.40) to
Worksheet D-3, column 1 for each cost center.
PPS Inpatient Ratio--Transfer the PPS inpatient ratio on lines 50 through 94 and 96 through 98
from column 11 for hospital or subprovider components for titles V, XVIII, Part A, and XIX
inpatient services subject to IPPS (see 42 CFR 412.1(a) through 412.125) to Worksheet D-3,
column 1 for each cost center. The transfer of the PPS inpatient ratio also applies when the
facility is an IPF subject to IPF PPS, a LTCH subject to LTCH PPS, or an IRF subject to IRF
PPS (see 42 CFR, Part 412, subpart N, O, and P, respectively).
4023.2 Part II - Calculation of Outpatient Services Cost to Charge Ratios Net of Reductions
for Medicaid Only.--This worksheet is not applicable for title XVIII. It is only applicable for
select state Medicaid programs. This worksheet computes the outpatient cost to charge ratios
reflecting the following:
•
The percentage of capital reduction as identified on Worksheet S-2, Part I, line 95, the
applicable column.
•
The reduction in reasonable costs of hospital outpatient services (other than the capitalrelated costs of such services (also known as operating reduction)) is based upon the
percentage entered on Worksheet S-2, Part I, line 97, the applicable column.
Column Descriptions
Column 1--Enter the amounts for each cost center from Worksheet B, Part I, column 26, as
appropriate. Transfer the amount on line 92 from Worksheet D-1, Part IV, line 89 for the
hospital and if you use inpatient routine beds as observation beds. If you have a distinct
observation bed area, add subscripted line 92.01 and transfer the appropriate amount from
Worksheet B, Part I, column 26. Do not bring forward costs in any cost center with a credit
balance from Worksheet B, Part I, column 26.
Column 2--Enter the sum of the amounts for each cost center from Worksheet B, Part II, as
appropriate. Do not bring forward costs in any cost center with a credit balance on Worksheet B,
Part I, Worksheet B, Part II. For line 92, enter the amounts from Worksheet D-1, Part IV,
column 5, line 90. Combine the hospital and subprovider amounts if applicable.
Column 3--For each line, subtract column 2 from column 1, and enter the result.
Column 4--Multiply column 2 by the appropriate capital reduction percentage, and enter the
result.
Column 5--Multiply column 3 by the outpatient reasonable cost reduction percentage, and enter
the result.
Column 6--Subtract columns 4 and 5 from column 1, and enter the result.
Column 7--Enter the total charges from Worksheet C, Part I, column 8.
Column 8--Divide column 6 by column 7, and enter the result.
Rev. 2
40-131
4024
4024.
FORM CMS-2552-10
08-11
WORKSHEET D - COST APPORTIONMENT
Worksheet D consists of the following five parts:
Part I
Part II
Part III
Part IV
-
Part V
-
Apportionment of Inpatient Routine Service Capital Costs
Apportionment of Inpatient Ancillary Service Capital Costs
Apportionment of Inpatient Routine Service Other Pass Through Costs
Apportionment of Inpatient/Outpatient Ancillary Service Other Pass
Through Costs
Apportionment of Medical and Other Health Services Costs
At the top of each part, indicate by checking the appropriate boxes the health care program,
provider component, and the payment system, as applicable, for which the part is prepared.
NOTE: Only hospital components subject to PPS or TEFRA complete Worksheet D, Parts I
through IV. CAHs do not complete Parts I through IV. Hospital based SNF and NF
providers are added to the D, Part III and will also complete a separate Worksheet D,
Part IV.
Line Descriptions for Parts I Through V
Lines 30 through 43 (for Parts I and III) and lines 44 and 45 (for Part III) and 50 through 98 (for
Parts II, IV, and V)--These cost centers have the same line numbers as the respective cost centers
on Worksheets A, B, B-1, and C. This design facilitates referencing throughout the cost report.
Therefore, any lines subscripted on those worksheets, must subscripted on this worksheet.
4024.1 Part I - Apportionment of Inpatient Routine Service Capital Costs--This part computes
the amount of capital-related costs applicable to hospital inpatient routine service costs.
Complete only one Worksheet D, Part I, for each title. Report hospital and subprovider
information on the same worksheet, lines as appropriate. Complete this part for all payment
methods.
Column 1--Enter on each line the capital-related cost for each cost center, as appropriate. Obtain
this amount from Worksheet B, Part II, column 26.
Column 2--Compute the amount of the swing bed adjustment. If you have a swing bed
agreement or have elected the swing bed optional method of reimbursement, determine the
amount for the cost center in which the swing beds are located by multiplying the amounts in
column 1 by the ratio of the amount entered on Worksheet D-1, line 26, to the amount entered on
Worksheet D-1, Part I, line 21.
Column 3--For each line, subtract the amount, if any, in column 2 from the amount in column 1,
and enter the result.
Column 4--Enter on each line the total patient days, excluding swing bed days, for that cost
center. For line 30, enter the total days reported on Worksheet S-3, Part I, column 8, the sum of
lines 1 and 28. For lines 31 through 43, enter the days from Worksheet S-3, Part I, column 8,
lines 8 through 12, 13, and 16-18 (as applicable), respectively.
Column 5-- Divide the capital costs of each cost center in column 3 by the total patient days in
column 4 for each line to determine the capital per diem cost. Enter the resultant per diem cost
in column 5.
Column 6--Enter the program inpatient days for the applicable cost centers. For line 30, enter
the days reported on Worksheet S-3, Part I, columns 5, 6, or 7, as appropriate, line 1. For lines
31 through 43, enter the days from Worksheet S-3, Part I, columns 5, 6, or 7 as appropriate, lines
8 through 12, 13, and 16-18 (as applicable), respectively.
40-132
Rev. 2
10-12
FORM CMS-2552-10
4024.2
NOTE: When you place overflow general care patients temporarily in an intensive care type
inpatient hospital unit because all beds available for general care patients are occupied,
count the days as intensive care type inpatient hospital days for purposes of computing
the intensive care type inpatient hospital unit per diem. However, count the program
days as general routine days in computing program reimbursement. (See CMS Pub.
15-1, §2217.) Add any program days for general care patients of the component who
temporarily occupied beds in an intensive care or other special care unit to line 30, and
decrease the appropriate intensive care or other special care unit by those days.
Column 7--Multiply the per diem in column 5 by the inpatient program days in column 6 to
determine the program’s share of capital costs applicable to inpatient routine services, as
applicable.
4024.2 Part II - Apportionment of Inpatient Ancillary Service Capital Costs--This worksheet is
provided to compute the amount of capital costs applicable to hospital inpatient ancillary
services for titles V, XVIII, Part A, and XIX. Complete a separate copy of this worksheet for
each subprovider for titles V, XVIII, Part A, and XIX, as applicable. In this case, enter the
subprovider component number in addition to showing the provider number.
Make no entries on this worksheet for any costs centers with a negative balance on Worksheet B,
Part I, column 26.
Column 1--Enter on each line the capital-related costs for each cost center, as appropriate.
Obtain this amount from Worksheet B, Part II, column 26. For the hospital component or
subprovider, if applicable, enter on line 92 the amount from Worksheet D-1, Part IV, column 1,
line 90.
Column 2--Enter on each line the total charges applicable to each cost center as shown on
Worksheet C, Part I, column 8.
Column 3--Divide the capital cost of each cost center in column 1 by the charges in column 2 for
each line to determine the cost to charge ratio. Round the ratios to six decimal places, e.g., round
0321514 to .032151. Enter the resultant departmental ratio in column 3.
Column 4--Enter on each line the appropriate title V, XVIII, Part A, or XIX inpatient charges
from Worksheet D-3, column 2. For title XVIII, enter on line 92 the observation bed charges
applicable to title XVIII patients subsequently admitted after being treated in the observation
area. Enter on line 96 the Medicare charges for medical equipment rented by an inpatient. The
charges are reimbursed under the DRG. However, you are entitled to the capital-related cost
pass through applicable to this medical equipment.
NOTE: Program charges for PPS providers are reported in the cost reporting period in which
the discharge is reported. TEFRA providers report charges in the cost reporting period
in which they occur.
Do not include in Medicare charges any charges identified as MSP/LCC.
Column 5--Multiply the capital ratio in column 3 by the program charges in column 4 to
determine the program’s share of capital costs applicable to titles V, XVIII, Part A, or XIX
inpatient ancillary services, as appropriate.
Rev. 3
40-133
4024.3
FORM CMS-2552-10
10-12
4024.3 Part III - Apportionment of Inpatient Routine Service Other Pass Through Costs--This
part computes the amount of pass through costs other than capital applicable to hospital inpatient
routine service costs. Determine capital-related inpatient routine service costs on Worksheet D,
Part I. Complete only one Worksheet D, Part III for each title. Report hospital, subprovider,
hospital-based SNF and NF/ICF-MR (if applicable) information on the same worksheet, lines as
appropriate. SNFs are now required to report medical education costs as a pass through cost.
Column 1--Transfer from Worksheet B, Part I, column 20, for each applicable line, (plus or
minus post step down adjustments reported on Worksheet B-2, if applicable), the applicable
medical education costs for nursing school when Worksheet S-2, Part I, line 60 is yes. Do not
transfer the costs if the response is no.
Column 2--Transfer from Worksheet B, Part I, column 23, for each applicable line, (plus or
minus post step down adjustments reported on Worksheet B-2, if applicable), the applicable
medical education costs for paramedical education (allied health) when Worksheet S-2, Part I,
line 60 is yes. Do not transfer the costs if the response is no.
Column 3--Transfer from Worksheet B, Part I, the sum of columns 21 and 22, for each
applicable line, plus or minus post step down adjustments (reported on Worksheet B-2), the
applicable medical education costs for interns and residents when Worksheet S-2, Part I, line 57,
column 1 is yes and column 2 is no. Otherwise do not transfer the costs.
NOTE: If you qualify for the exception in 42 CFR 413.77(e)(1), because this is the first cost
reporting period in which you are training residents in approved programs and the
residents were not on duty during the first month of this cost reporting period, then all
direct graduate medical education costs are reimbursed as a pass through based on
reasonable cost.
Column 4--Compute the amount of the swing bed adjustment. If you have a swing bed
agreement, determine the amount for the cost center in which the swing beds are located by
multiplying the sum of the amounts in columns 1 through 3 by the ratio of the amount entered on
Worksheet D-1, Part I, line 26 to the amount entered on Worksheet D-1, Part I, line 21.
Column 5--Enter the sum of columns 1 through 3 (including subscripts) minus column 4.
Column 6--Enter on each line the total patient days, excluding swing bed days, for that cost
center. Transfer these amounts from the appropriate Worksheet D, Part I, column 4. For SNFs
enter total patient days from Worksheet S-3, Part I, column 8, line 19.
Column 7--Enter the per diem cost for each line by dividing the cost of each cost center in
column 5 by the total patient days in column 6.
Column 8--Enter the program inpatient days for the applicable cost centers. Transfer these
amounts from the appropriate Worksheet D, Part I, column 6. For SNF (line 44) enter the
program days from Worksheet S-3, Part I, column 6, line 19.
Column 9--Multiply the per diem cost in column 7 by the inpatient program days in column 8 to
determine the program's share of pass through costs applicable to inpatient routine services, as
applicable. Transfer the sum of the amounts on lines 30 through 35 and 43 to Worksheet D-1,
Part I, line 50 for the hospital. If you are a title XVIII hospital paid under IPPS, also transfer this
sum to Worksheet E, Part A, line 57. Transfer the amounts on lines 40 through 42 to the
appropriate
40-134
Rev. 3
10-12
FORM CMS-2552-10
4024.4
Worksheet D-1, line 50 for the subprovider. Also transfer the amount on line 40 to Worksheet E3, Part II, line 28 and the amount on line 41 to Worksheet E-3, Part III, line 29. For hospitalbased SNF, NF or ICF/MR that follow Medicare principles, transfer the amount in column 9, line
44 to Worksheet E-3, Part VI, line 2 or for NF or ICF/MR to Worksheet E-3, Part VII, line 26, as
applicable.
4024.4 Part IV - Apportionment of Inpatient/Outpatient Ancillary Service Other Pass Through
Costs--The TEFRA rate of increase limitation applies to inpatient operating costs. In order to
determine inpatient operating costs, it is necessary to exclude capital-related and medical
education costs as these costs are reimbursed separately. Hospitals and subprovider components
subject to IPPS must also direct medical education costs as these costs are reimbursed separately.
Determine capital-related inpatient ancillary costs on Worksheet D, Part II. SNFs are required to
report medical education costs as a pass through cost. Prepare a separate Worksheet D, Part IV
for the SNF and NF or ICF/MR (if applicable). Hospital payment for outpatient services are
made prospectively with the exception of certain pass through costs identified on this worksheet.
This worksheet is provided to compute the amount of pass through costs other than capital
applicable to hospital inpatient and outpatient ancillary services for titles V, XVIII, Part A, and
XIX. Complete a separate copy of this worksheet for each subprovider for titles V, XVIII, Part
A, and XIX, as applicable. In this case, enter the subprovider component number in addition to
showing the provider number.
Make no entries on this worksheet for any costs centers with a negative balance on Worksheet B,
Part I, column 26.
Column 1--Do not use this column as CRNA services are billed and paid through claims
processing and are included on Worksheet D, Part V. Enter on each line (after any adjustments
made after cost finding) the nonphysician anesthetist cost for hospitals and components
qualifying for the exception to the CRNA fee schedule. (See §4013, line 19 description for more
information.) Obtain this amount from Worksheet B, Part I, column 19 plus or minus any
adjustments reported on Worksheet B, Part I, column 25 for nonphysician anesthetist.
Column 2--Transfer from Worksheet B, Part I, column 20, for each applicable line, (plus or
minus post step down adjustments made on Worksheet B, Part I, column 25, if applicable), the
applicable medical education costs for nursing school when Worksheet S-2, Part I, line 60 is yes.
Do not transfer the costs if the response is no. For the hospital only, enter on line 92,
observation beds, the amount from Worksheet D-1, Part IV, column 5, line 91.
Column 3--Transfer from Worksheet B, Part I, column 23, for each applicable line, (plus or
minus post step down adjustments made on Worksheet B, Part I, column 25, if applicable), the
applicable medical education costs for paramedical education (allied health) when Worksheet S2, Part I, line 60 is yes. Do not transfer the costs if the response is no. For the hospital
component only, enter on line 92 the observation bed amount from Worksheet D-1, Part IV,
column 5, line 92.
Column 4--Transfer from Worksheet B, Part I, the sum of columns 21 and 22, for each
applicable line, (plus or minus post step down adjustments made on Worksheet B, Part I, column
25), the applicable medical education costs for interns and residents when Worksheet S-2, Part I,
line 57, column 1 is yes and column 2 is no, otherwise do not transfer the costs. For the hospital
only, enter on line 92, observation beds, the amount from Worksheet D-1, Part IV, column 5, line
93.
Rev. 3
40-135
4024.5
FORM CMS-2552-10
10-12
NOTE: If you qualify for the exception in 42 CFR 413.77(e)(1) because this is the first cost
reporting period in which you are training residents in approved programs and the
residents were not on duty during the first month of this cost reporting period, then all
direct graduate medical education costs for interns and residents in approved programs
are reimbursed as a pass through based on reasonable cost.
Column 5--This column represents total inpatient other pass-through costs. Enter on each
appropriate line the sum of the amounts entered on the corresponding lines in columns 1 through
4 and applicable subscripts.
Column 6--This column represents outpatient other pass-through costs. Enter on each
appropriate line the sum of the amounts entered on the corresponding lines in columns 2, 3 and 4
and applicable subscripts.
Column 7--Enter on each line the charges applicable to each cost center as shown on Worksheet
C, Part I, column 8.
Column 8--Divide the cost of each cost center in column 5 by the charges in column 7 for each
line to determine the cost/charge ratio. Round the ratios to six decimal places, e.g., round
.0321514 to .032151. Enter the resultant departmental ratio in column 8.
Column 9--This column computes the outpatient ratio of cost to charges. Divide the cost of each
cost center in column 6 by the charges in column 7 for each line to determine the cost/charge
ratio. Round the ratios to six decimal places, e.g., round .0321514 to .032151. Enter the
resultant departmental ratio in column 9.
Column 10--Enter on each line titles V, XVIII, Part A, or XIX inpatient charges from Worksheet
D-3. Do not include in Medicare charges any charges identified as MSP/LCC.
Column 11--Multiply the ratio in column 8 by the charges in column 10 to determine the
program's share of pass through costs applicable to titles V, XVIII, Part A, or XIX inpatient
ancillary services, as appropriate.
For hospitals, CAHs and subproviders transfer column 11, line 200 to Worksheet D-1, Part II,
column 1, line 51. If you are an IPPS hospital or subprovider, also transfer this amount to
Worksheet E, Part A, line 58. For SNFs for title XVIII transfer the amount on line 200 to
Worksheet E-3, Part VI, line 3 or titles V and XIX, SNFs, NFs and ICF/MRs to Worksheet E-3,
Part VII, line 26, as applicable.
Column 12--Enter on each line titles XVIII, Part B, V or XIX (if applicable) outpatient charges
from Worksheet D, Part V, column 2 and applicable subscripts. Do not include in Medicare
charges any charges identified as MSP/LCC.
Column 13--Multiply the ratio in column 9 by the charges in column 12 to determine the
program's share of pass through costs applicable to titles XVIII, Part B, V or XIX (if applicable)
outpatient ancillary services, as appropriate.
For hospitals, IPPS hospitals, CAHs and subproviders transfer column 13, line 200 to Worksheet
E, Part B, line 9.
4024.5 Part V - Apportionment of Medical and Other Health Services Costs--This worksheet
provides for the apportionment of costs applicable to hospital outpatient services reimbursable
under titles V, XVIII, and XIX. Title XVIII is reimbursed in accordance with 42 CFR 413.53.
For services rendered on and after August 1, 2000, outpatient services are subject to outpatient
PPS.
40-136
Rev. 3
10-12
FORM CMS-2552-10
4024.5 (Cont.)
Enter in the appropriate cost center the program charges from the PS&R or from provider
records.
Providers exempt from outpatient PPS (i.e., CAHs), complete columns 3, 4, 6 and 7. All other
providers subscript columns 2 and 5 as necessary. Include charges for vaccine, i.e.,
pneumococcal, flu, hepatitis, and osteoporosis as indicated on line 73 below.
Exclude charges for which costs were excluded on Worksheet A-8. For example, CRNA costs
reimbursed on a fee schedule are excluded from total cost on Worksheet A-8. For titles V and
XIX, enter the appropriate outpatient service charges.
NOTE: Do not enter CORF, OPT, OSP, OOT, or CMHC charges on Worksheet D, Part V.
Report only charges for CMHCs on Worksheet J-2.
For title XVIII, complete a separate Worksheet D, Part V, for each provider component as
applicable. Enter the applicable component number in addition to the hospital provider number.
Make no entries in columns 5 through 7 of this worksheet for any cost centers with a negative
balance on Worksheet B, Part I, column 26. However, complete columns 1 through 4 for such
cost centers.
In accordance with ACA, section 3121 as amended by the Medicare and Medicaid Extenders Act
(MMEA) of 2010, section 108, the Temporary Payroll Tax Cut Continuation Act of 2011,
section 308, and the Middle Class Tax Relief and Job Creation Act of 2012, section 3002, hold
harmless payments are extended for rural hospitals with 100 or fewer beds through December
31, 2012; SCHs and EACHs regardless of bed size through February 29, 2012; and SCHs and
EACHs with 100 or fewer beds through December 31, 2012. As such, rural hospitals and SCHs
or EACHs that qualify and whose cost reporting period overlaps the effective date, (Worksheet
S-2, Part I, line 120, column 1 or 2 is yes), must subscript column 2 and enter the applicable
charges that correspond to the respective portion of the cost reporting period.
In accordance with ACA 2010, section 3138, cancer hospitals must utilize a predetermined
payment to cost ratio (PCR) to calculate the corresponding transitional outpatient payment
effective for services rendered beginning January 1, 2012. The PCR may be revised each
calendar year. Where the cost reporting period overlaps a PCR revision date, subscript column
2 and the corresponding column 5 to represent the portion of the cost reporting period that
corresponds to each unique PCR. See section 4030.2 for further instruction/information.
Column 1--Enter on each line in column 1 the ratio from the corresponding line on Worksheet C,
column 9.
Columns 2 through 4--General Instructions--Do not include in Medicare charges any charges
identified as MSP/LCC.
Column 2--PPS Reimbursed Services--Enter the charges for services rendered which are subject
to the prospective payment system. These charges should not include services paid under the fee
schedule such as physical therapy, speech pathology or occupational therapy. Create separate
subscripted column (e.g. 2.01, 2.02) when a cost reporting period overlaps the effective dates for
the various transitional corridor payments and/or when a provider experiences a geographic
reclassification from urban to rural. However, no subscripting is required when a provider
geographically reclassifies from rural to urban. The subscripting of this column will directly
correspond to the subscripts of Worksheet E, Part B, lines 2 through 8.
Do not include in any column services excluded from OPPS because they are paid under another
fee schedule, e.g., rehabilitation services and clinical diagnostic lab.
Column 3--Cost Reimbursed Services Subject to Deductibles and Coinsurance--Enter the
charges for services rendered which are subject to cost reimbursement. This includes services
rendered by CAHs.
Rev. 3
40-137
4024.5 (Cont.)
FORM CMS-2552-10
10-12
Include the charges for drugs and supplies related to ESRD dialysis (excluding EPO and
Aranesp, and any drugs or supplies paid under the composite rate), and corneal tissue on line 73.
Column 4--Cost Reimbursed Services Not Subject to Deductibles and Coinsurance--Vaccine
Cost Apportionment--This column provides for the apportionment of costs which are not subject
to deductible and coinsurance i.e., Pneumococcal, Influenza, Hepatitis B and Osteoporosis.
Enter such charges for services which are not subject to deductible and coinsurance.
Column 5--Multiply the charges in column 2 and subscripts, if necessary, by the ratios in column
1, and enter the result. Line 200 equals the sum of lines 50 through 98.
Column 6--Multiply the charges in column 3 by the ratios in column 1, and enter the result. Line
200 equals the sum of lines 50 through 98.
Column 7--Multiply the charges in column 4 by the ratios in column 1, and enter the result. Line
200 equals the sum of lines 50 through 98.
Line Descriptions
Line 60--Generally, for title XVIII, Medicare outpatient covered clinical laboratory services are
paid on a fee basis, and should not be included on this line. Outpatient CAH clinical laboratory
services will be paid on a reasonable cost basis not subject to deductibles and coinsurance. In
addition, hospital outpatient laboratory testing by a hospital laboratory with fewer than 50 beds
in a qualified rural area will also be paid on a reasonable cost basis not subject to deductibles and
coinsurance, for cost reporting periods beginning on or after July 1, 2010, but before July 1, 2012
(Patient Protection and Affordable Care Act of 2010, section 3122, amended by the MMEA,
§109). For title V and XIX purposes, follow applicable State program instructions.
For CAHs, outpatient clinical laboratory diagnostic tests are paid at 101 percent of reasonable
costs, and the beneficiary is not required to be physically present in the CAH at the time the
specimen is collected. As such, enter the corresponding charges on this line. See MIPPA 2008,
section 148 and CR 6395, transmittal 1729, dated May 8, 2009.
Line 61--Enter the program charges for provider clinical laboratory tests for which the provider
reimburses the pathologist. See §4013 for a more complete description on the use of this cost
center. For title XVIII, do not include charges for outpatient clinical diagnostic laboratory
services. For titles V and XIX purposes, follow applicable State program instructions.
NOTE: Since the charges on line 61 are also included on line 60, laboratory, reduce the total
charges to prevent double counting. Make this adjustment on line 201.
Line 71--Enter in columns 2 and 3 the charges for medical supplies charged to patients which are
not paid on a fee schedule. Do not report the charges for prosthetics and orthotics.
Line 72--Enter in columns 2 and 3 the charges for implantable devices charged to patients which
are not paid on a fee schedule. Do not report the charges for prosthetics and orthotics.
Line 73--Enter the program charges for drugs charged to patients. Enter in column 2 charges for
vaccines and drugs reimbursed at 100 percent under OPPS. Include in column 3 charges for
drugs paid at 80 percent of cost subject to deductibles and coinsurance, such as osteoporosis
drugs and drugs paid under OPPS such as hepatitis vaccines. Include in column 4 vaccine
charges for vaccines reimbursed at 100 percent of cost such as pneumococcal and influenza
vaccines not subject to deductibles and coinsurance.
Line 74--The only renal dialysis services entered on this line are for inpatients that are not
reimbursed under the composite rate regulations. (See 42 CFR 413.170.) Therefore, include
only inpatient Part B charges on this line in column 3. Enter the related costs in column 6.
40-138
Rev. 3
08-11
FORM CMS-2552-10
4024.5 (Cont.)
Line 75--Enter in column 3 the outpatient ASC facility charges and Part B charges for the
hospital nondistinct part ambulatory surgery center. These charges represent the ASC facility
charge only (i.e., in lieu of operating or recovery room charges), and do not include charges for
the ancillary services provided to the patient.
Lines 88 - 93--Use these lines for outpatient service cost centers.
NOTE: For lines 88, 89 and 90, any ancillary service billed as clinic, RHC, or FQHC services
must be reclassified to the appropriate ancillary cost center, e.g., radiology-diagnostic,
PBP clinical lab services - program only. A similar adjustment must be made to
program charges.
Line 92--Enter in column 2 the title XVIII Part B charges for observation beds. These are the
charges for patients who were treated in the nondistinct observation beds and released. These
patients were not admitted as inpatients.
Line 94--The only home program dialysis services which are cost reimbursed are those rendered
to beneficiaries who have elected the option to deal directly with Medicare. Home program
dialysis services reimbursed under the composite rate regulation (see 42 CFR 413.170) are not
included on this line. This line includes costs applicable to equipment-related expenses only.
Line 95--For PPS hospital providers ambulance services are reimbursed under the ambulance fee
schedule. As such, do not report charges for ambulance services rendered (column 2 for non
PPS hospitals).
However, for CAHs eligible for cost reimbursement for ambulance services (billed as exempt
from the ambulance fee schedule), charges for ambulance services on line 95 are transferred
from your records or PS&R report type 85C. Enter charges in column 3 and multiply column 1
times column 3. Enter the result in column 6.
Lines 96 and 97--For title XVIII, DME is paid on a fee schedule through the contractor and,
therefore, is not paid through the cost report.
Line 200--Enter the sum of lines 50 through 98.
Line 201--Enter in columns 3 and 4 program charges for provider clinical laboratory tests where
the physician bills the provider for program patients only. Obtain this amount from line 61.
Line 202--Enter in columns 3, 4, 6 and 7 and subscripts, the amount on line 200 plus or minus
the amounts on line 201, if applicable.
Transfer Referencing: For title XVIII, transfer the sum of the amounts in columns 3 and 4 and
applicable subscripts, line 202 to Worksheet E, Part B, line 12 (ancillary services charges).
Make no transfers of swing bed charges to Worksheet E-2 since no LCC comparison is made.
For titles V and XIX (other than IPPS), transfer the sum of the amounts in columns 2, 3 and /or 4
plus subscripts as applicable, line 202 plus the amount from Worksheet D-3, column 2, line 202
to the appropriate Worksheet E-3, Part VII, line 9.
For titles V and XIX (under IPPS), transfer the amount in columns 2, 3 and /or 4 plus subscripts
as applicable, line 202 to the appropriate Worksheet E-3, Part VII, line 9.
Rev. 2
40-139
4024.5 (Cont.)
FORM CMS-2552-10
08-11
NOTE: If the amount on line 202 includes charges for professional patient care services of
provider-based physicians, eliminate the amount of the professional component
charges from the total charges, and transfer the net amount as indicated. Submit a
schedule showing these computations with the cost report.
Transfer References
From Wkst. D, Part V
Title XVIII,
Part B
Swing Bed
To
Titles V or XIX or
Title XVIII,
Part B
Column 6, line 202 and column 7,
line 73 and subscripts
N/A
Wkst. E, Part B,
col. 1 ( & subscripts),
line 1
Columns 5, line 202
N/A
Wkst. E, Part B,
col. 1 ( & subscripts),
line 2
Sum of columns 2, 3 and 4 as
applicable (SNF only), line 202
N/A
Wkst. E, Part B,
line 12 or Wkst. E-3,
Part VII, col. 1, line
9 for titles V or XIX
Sum of column 6 and 7 (SNF only)
line 202
Wkst E-2
col. 2, line 3
Wkst. E, Part B,
line 1 or Wkst. E-3,
Part VII, col. 1, line 2
for titles V or XIX
40-140
Rev. 2
08-11
4025.
FORM CMS-2552-10
4025
WORKSHEET D-1 - COMPUTATION OF INPATIENT OPERATING COST
This worksheet provides for the computation of hospital inpatient operating cost in accordance
with 42 CFR 413.53 (determination of cost of services to beneficiaries), 42 CFR 413.40 (ceiling
on rate of hospital cost increases), and 42 CFR 412.1 through 412.125 (prospective payment).
All providers must complete this worksheet.
Complete a separate copy of this worksheet for the hospital (including CAH), each subprovider,
hospital-based SNF, and hospital-based other nursing facility. Also, complete a separate copy of
this worksheet for each health care program under which inpatient operating costs are computed.
When this worksheet is completed for a component, show both the hospital and component
numbers.
At the top of each page, indicate by checking the appropriate line the health care program,
provider component, and the payment system for which the page is prepared.
Worksheet D-1 consists of the following four parts:
Part I
Part II
Part III
Part IV
-
All Provider Components
Hospital and Subproviders Only
Skilled Nursing Facility, Other Nursing Facility, and ICF/MR Only
Computation of Observation Bed Pass Through Cost
NOTE: If you have made a swing bed election for your certified SNF, treat the SNF costs and
patient days as though they were hospital swing bed-SNF type costs and patient days
on Parts I and II of this worksheet. Do not complete Part III for the SNF. (See CMS
Pub. 15-1, §2230.9B.)
Definitions
The following definitions apply to days used on this worksheet.
Inpatient Day--The number of days of care charged to a beneficiary for inpatient hospital
services is always documented in units of full days. A day begins at midnight and ends 24 hours
later. Use the midnight to midnight method in reporting the days of care for beneficiaries even if
the hospital uses a different definition for statistical or other purposes.
A part of a day, including the day of admission, counts as a full day. However, do not count the
day of discharge or death, or a day on which a patient begins a leave of absence, as a day. If
both admission and discharge or death occur on the same day, consider the day a day of
admission and count it as one inpatient day.
Include a maternity patient in the labor/delivery room ancillary area at midnight in the census of
the inpatient routine (general or intensive) care area only if the patient has occupied an inpatient
routine bed at some time since admission. Count no days of inpatient routine care for a
maternity inpatient who is discharged (or dies) without ever occupying an inpatient routine bed.
However, once a maternity patient has occupied an inpatient routine bed, at each subsequent
census include the patient in the census of the inpatient routine care area to which she is
assigned, even if the patient is located in an ancillary area (labor/delivery room or another
ancillary area) at midnight. In some cases, a maternity patient may occupy an inpatient bed only
on the day of discharge if the day of discharge differs from the day of admission. For purposes
of apportioning the cost of inpatient routine care, count this single day of routine care as the day
of admission (to routine care) and discharge. This day is considered as one day of inpatient
routine care. (See CMS Pub. 15-1, §2205.2.)
Rev. 2
40-141
4025 (Cont.)
FORM CMS-2552-10
08-11
When an inpatient is occupying any other ancillary area (e.g., surgery or radiology) at the census
taking hour prior to occupying an inpatient bed, do not record the patient’s occupancy in the
ancillary area as an inpatient day in the ancillary area. However, include the patient in the
inpatient census of the routine care area.
When the patient occupies a bed in more than one patient care area in one day, count the
inpatient day only in the patient care area in which the patient was located at the census taking
hour.
Newborn Inpatient Day--Newborn inpatient days are the days that an infant occupies a newborn
bed in the nursery. Include an infant remaining in the hospital after the mother is discharged
who does not occupy a newborn bed in the nursery, an infant delivered outside the hospital and
later admitted to the hospital but not occupying a newborn bed in the nursery, or an infant
admitted or transferred out of the nursery for an illness in inpatient days. Also, include an infant
born in and remaining in the hospital and occupying a newborn bed in the nursery after the
mother is discharged in newborn inpatient days.
Private Room Inpatient Day--Private room inpatient days are the days that an inpatient occupies
a private room. If you have only private rooms, report your days statistic as general inpatient
days. Inpatient private room days are used for computing any private room differential
adjustment on Worksheet D-1, Part I if you have a mixture of different type rooms to
accommodate patients. Do not count swing bed-SNF or swing bed-NF type services rendered in
a private room as private room days.
Inpatient Swing Bed Days--Inpatient swing bed days are the days applicable to swing bed-SNF
or swing bed-NF type services. See 413.53(a)(2)
Intensive Care Type Inpatient Days--Intensive care type inpatient days are those days applicable
to services rendered in intensive care type inpatient hospital units. These units must meet the
requirements specified in CMS Pub. 15-1, §2202.7.II.A.
NOTE: When you place overflow general care patients temporarily in an intensive care type
inpatient hospital unit because all beds available for general care patients are occupied,
count the days as intensive care type inpatient hospital days for purposes of computing
the intensive care type inpatient hospital unit per diem. However, count the program
days as general routine days in computing program reimbursement. (See CMS Pub.
15-1, §2217.)
Observation Beds--Observation beds, for purposes of this worksheet, are those beds in general
routine areas of the hospital which are not organized as a distinct, separately staffed observation
area and which are used to house patients for observation. These beds need not be used full time
for observation patients. These beds are not to be confused with a subintensive care unit (i.e.,
definitive observation unit, a stepdown from intensive care reported as an inpatient cost center
following surgical intensive care (line 34)). If you have a distinct observation bed unit (an
outpatient cost center), report the costs of this unit on the subscripted line 92.01 on Worksheet A.
4025.1 Part I - All Provider Components--This part provides for the computation of the total
general inpatient routine service cost net of swing bed cost and private room cost differential for
each separate provider component. When this worksheet is completed for a component, show
both the hospital and component numbers.
Line Descriptions
Lines 1 through 16--Inpatient days reported, unless specifically stated, exclude days applicable to
newborn and intensive care type patient stays. Report separately the required statistics for the
hospital, each subprovider, hospital-based SNF, hospital-based other nursing facility and
ICF/MR. Obtain the information from your records and/or Worksheet S-3, Part I, columns and
lines as indicated.
40-142
Rev. 2
10-12
FORM CMS-2552-10
4025.1 (Cont.)
Line 1--Enter the total general routine inpatient days, including private room days, swing bed
days, observation bed days, and hospice days, as applicable. Do not include routine care days
rendered in an intensive care type inpatient hospital unit. Enter the total days from Worksheet S3, Part I, column 8 for the component and lines as indicated: hospitals from lines 7 and 28;
subproviders from lines 16 through 18, as applicable, and 28, if applicable; SNFs from line 19;
and NFs from line 20. If you answered yes to line 92 of Worksheet S-2, the NF days come from
line 19 for the SNF level of care and line 20 for the NF level of care, and you will need to
prepare a separate Worksheet D-1 for each level of care for title XIX.
Line 2--Enter the total general routine inpatient days. Include private room days and exclude
swing bed and newborn days. Hospitals enter the sum of the days entered on Worksheet S-3,
Part I, column 8, lines 1 and 28. Subproviders, SNFs, and NFs enter the days from line 1 of this
worksheet.
Line 3--Enter the total private room days excluding swing bed private room days and observation
bed days. If you have only private room days, do not complete this line.
Line 4--Enter the result of line 2, minus line 3, minus total observation bed days from
Worksheet S-3, Part I, column 8, line 27. The result will be semi-private room days exclusive of
swing bed semi-private room days and observation bed days. If you have only private room
days, such days will be included in this line.
NOTE: For purposes of this computation, the program does not distinguish between semiprivate and ward accommodations. (See CMS Pub. 15-1, §2207.3.)
Line 5--Enter the total swing bed-SNF type inpatient days, including private room days, through
December 31 of your cost reporting period. If you are on a calendar year end, report all swing
bed-SNF type inpatient days.
Line 6--Enter the total swing bed-SNF type inpatient days, including private room days, after
December 31 of your cost reporting period. If you are on a calendar year end, enter zero. The
sum of lines 5 and 6 equals Worksheet S-3 Part I, line 5, column 8.
Line 7--Enter the total swing bed-NF type inpatient days, including private room days, through
December 31 of your cost reporting period. If you are on a calendar year end, report all swing
bed-NF type inpatient days. This line includes title V, title XIX, and all other payers.
Line 8--Enter the total swing bed-NF type inpatient days, including private room days, after
December 31 of your cost reporting period. If you are on a calendar year end, enter zero. This
line includes title V, title XIX, and all other payers. The sum of lines 7 and 8 equals Worksheet
S-3, Part I, line 6, column 8.
NOTE: Obtain the amounts entered on lines 5 and 7 from your records.
Line 9--Enter the total program general routine inpatient days as follows:
Type of Provider
Hospital
Subprovider
applicable
SNF
NF
Rev. 3
From
Wkst. S-3, Part I, cols. 5, 6, or 7, line 1
Wkst. S-3, Part I, cols. 5, 6, or 7, line 16, 17, or 18 as
Wkst. S-3, Part I, cols. 5, 6, or 7, line 19
Wkst. S-3, Part I, cols. 5, 6, or 7, for SNF only level of care;
line 19. If line 92 of Wkst S-2, Part I is a “Y”, two D-1s must
be completed for title XIX using line 19 for SNF level of care
and line 20 for the NF level of care; or line 20 only for NF
level of care.
40-143
4025.1 (Cont.)
FORM CMS-2552-10
10-12
Include private room days and exclude swing bed and newborn days for each provider
component. Add any program days for general care patients of the component who temporarily
occupied beds in an intensive care or other special care unit. (See CMS Pub. 15-1, §2217.)
NOTE: If Worksheet S-2, line 92 columns 1 or 2, as applicable is “Y” for yes, then Worksheet
D-1 for title XIX (for the SNF and NF component) must be completed. The results are
to be combined and transferred to title XIX SNF, Worksheet E-3, Part VII, line 1.
Line 10--Enter the title XVIII swing bed-SNF type inpatient days, including private room days,
through December 31 of your cost reporting period. If you are on a calendar year end, report all
program swing bed-SNF type inpatient days. Combine titles V and XIX for all SNF lines if your
State recognizes only SNF level of care.
Line 11--Enter the title XVIII swing bed-SNF type inpatient days, including private room days,
after December 31 of your cost reporting period. If you are on a calendar year end, enter zero.
Line 12--Enter the total titles V or XIX swing bed-NF type inpatient days, including private
room days, through December 31 of your cost reporting period. If you are on a calendar year
end, report all program swing bed-NF type inpatient days.
Line 13--Enter the total titles V or XIX swing bed-NF type inpatient days, including private
room days, after December 31 of your reporting period. If you are on a calendar year end, enter
zero.
NOTE: If you are participating in both titles XVIII and XIX, complete, at a minimum, a
separate Worksheet D-1, Part I, for title XIX, lines 9, 12, and 13. If these data are not
supplied, the cost report is considered incomplete and is rejected.
Line 14--Enter the total medically necessary private room days applicable to the program,
excluding swing bed days, for each provider component.
Line 15--Enter, for titles V or XIX only, the total nursery inpatient days from Worksheet S-3,
Part I, column 8, line 13.
Line 16--Enter, for titles V or XIX only, the total nursery inpatient days applicable to the
program from Worksheet S-3, Part I, columns 5 and 7, respectively, line 13.
Lines 17 - 27--These lines provide for the carve out of reasonable cost of extended care services
furnished by a swing bed hospital. Under the carve out method, the total costs attributable to
SNF type and NF type routine services furnished to all classes of patients are subtracted from
total general inpatient routine service costs before computing the average cost per diem for
general routine hospital care. The rates on lines 17 through 20 are supplied by your contractor.
Line 17--Enter the Medicare swing-bed SNF rate applicable to the calendar year in which
inpatient days on line 5 occurred. If the swing-bed SNF rate for the prior calendar year is higher,
enter that rate instead. (See CMS Pub. 15-1, §2230ff.) Critical access hospitals do not complete
this line.
40-144
Rev. 3
10-12
FORM CMS-2552-10
4025.1 (Cont.)
Line 18--Enter the Medicare swing-bed SNF rate applicable to the calendar year in which
inpatient days on line 6 occurred. If the swing-bed SNF rate for the prior calendar year is higher,
enter that rate instead. (See CMS Pub. 15-1, §2230ff.) Critical access hospitals do not complete
this line.
Line 19--Enter the average Statewide rate per patient day paid under the State Medicaid plan for
routine services furnished by nursing facilities (other than NFs for the mentally retarded) in that
State. This rate is approximated by taking the average rate from the prior calendar year (i.e. the
calendar year preceding the year relating to inpatient days reported on line 7), updated to
approximate the current year rate. Obtain the proper rate from your contractor.
Line 20--Enter the average Statewide rate per patient day paid under the State Medicaid plan for
routine services furnished by nursing facilities (other than NFs for the mentally retarded) in that
State. This rate is approximated by taking the average rate from the prior calendar year (i.e. the
calendar year preceding the year relating to inpatient days reported on line 8), updated to
approximate the current year rate. Obtain the proper rate from your contractor.
Line 21--Enter the total general inpatient routine service costs for the applicable provider
component.
For titles V, XVIII, and XIX, enter the amounts from Worksheet C, Part I, line 30 for adults and
pediatrics or lines 40, 41, or 42, as applicable for the subprovider, as appropriate:
COST or OTHER
TEFRA
PPS
Inpatient - Column 1 (includes CAHs)
Inpatient - Column 3 (includes cancer and children’s hospitals)
Inpatient - Column 5 (includes acute, IPFs, IRFs, & LTCHs)
SNF/NF Inpatient Routine--For title XVIII, transfer this amount from Worksheet C, Part I,
column 5, line 44 (SNF). For titles V and XIX, transfer this amount from Worksheet B, Part I,
column 26, line 45 (NF) or 45.01 ICF/MR.
Line 22--Enter the product of the days on line 5 multiplied by the amount on line 17.
Line 23--Enter the product of the days on line 6 multiplied by the amount on line 18.
Line 24--Enter the product of the days on line 7 multiplied by the amount on line 19.
Line 25--Enter the product of the days on line 8 multiplied by the amount on line 20.
Line 26--Enter the sum of the amounts on lines 22 through 25. This amount represents the total
reasonable cost for swing bed-SNF type and NF type inpatient services.
For critical access hospitals, subtract the sum of lines 24 and 25 from the amount reported on line
21. Divide that result by the patient days equal to lines 2, 5, and 6 above to arrive at a per diem
(Retain this amount for the calculation required on lines 38, 64 and 65). Multiply the per diem
by the total days reported on lines 5 and 6. Add that result to the amounts reported on lines 24
and 25.
Line 27--Subtract the amount on line 26 from the amount on line 21. This amount represents the
general inpatient routine service cost net of swing bed-SNF type and NF type inpatient costs.
Lines 28 - 36--All providers must complete lines 28 through 36. PPS providers complete these
lines for data purposes only. However, if line 4 equals line 2 above you are not to complete
these lines.
Line 28--Enter the total charges for general inpatient routine services, excluding charges for
swing bed-SNF type and NF type inpatient services and observation bed days (from your
records).
Rev. 3
40-145
4025.1 (Cont.)
FORM CMS-2552-10
10-12
Line 29--Enter the total charges for private room accommodations, excluding charges for private
room accommodations for swing bed-SNF type and NF type inpatient services and observation
bed days (from your records).
Line 30--Enter the total charges for semi-private room and ward accommodations, excluding
semi-private room accommodation charges for swing bed-SNF type and NF type services (from
your records).
Line 31--Enter the general inpatient routine cost to charge ratio (rounded to six decimal places)
by dividing the total inpatient general routine service costs (line 27) by the total inpatient general
routine service charges (line 28).
Line 32--Enter the average per diem charge (rounded to two decimal places) for private room
accommodations by dividing the amount on line 29 by the days on line 3.
Line 33--Enter the average per diem charge (rounded to two decimal places) for semi-private
accommodations by dividing the amount on line 30 by the days on line 4.
Line 34--Subtract the average per diem charge for all semi-private accommodations (line 33)
from the average per diem charge for all private room accommodations (line 32) to determine the
average per diem private room charge differential. If a negative amount results from this
computation, enter zero on line 34.
Line 35--Multiply the average per diem private room charge differential (line 34) by the inpatient
general routine cost to charge ratio (line 31) to determine the average per diem private room cost
differential (rounded to two decimal places).
Line 36--Multiply the average per diem private room cost differential (line 35) by the private
room accommodation days (excluding private room accommodation days applicable to swing
bed-SNF type and NF type services) (line 3) to determine the total private room accommodation
cost differential adjustment.
Line 37--Subtract the private room cost differential adjustment (line 36) from the general
inpatient routine service cost net of swing bed-SNF type and NF type costs (line 27) to determine
the adjusted general inpatient routine service cost net of swing bed-SNF type service costs, NF
type service costs, and the private room accommodation cost differential adjustment. If line 4
equals line 2, enter the amount from line 27 above.
4025.2 Part II - Hospital and Subproviders Only--This part provides for the apportionment of
inpatient operating costs to titles V, XVIII, and XIX and the calculation of program excludable
cost for all hospitals and subproviders. For hospitals reimbursed under TEFRA, it provides for
the application of a ceiling on the rate of cost increase for the hospital and subproviders. When
the worksheet is completed for a component, show both the hospital and component numbers.
CAHs are also required to complete this worksheet.
Line Descriptions
Line 38--For non-IPPS providers, (includes CAHs), divide the adjusted general inpatient routine
service cost (line 37) by the total general inpatient routine service days including private room
(excluding swing bed and newborn) days (line 2) to determine the general inpatient routine
service average cost per diem (rounded to two decimal places).
For PPS providers (includes IRFs, IPFs, and LTCHs under 100 percent PPS), divide the sum of
lines 36 and 37 by the inpatient days reported on line 2.
40-146
Rev. 3
08-11
FORM CMS-2552-10
4025.2 (Cont.)
For CAHs the per diem, unless there is an adjustment for private room differential, should be
equal to the per diem calculated in the formula on line 26. If this is a CAH and there is a private
room differential, process as a non-PPS provider.
Line 39--Multiply the total program inpatient days including private room (excluding swing bed
and newborn) days (line 9) by the adjusted general inpatient routine service average cost per
diem (line 38) to determine the general inpatient service cost applicable to the program.
Line 40--Multiply the medically necessary private room (excluding swing bed) days applicable
to the program (line 14) by the average per diem private room cost differential (line 35) to
determine the reimbursable medically necessary private room cost applicable to the program.
PPS providers including IRF, IPF and LTCH, reimbursed at 100 percent Federal rate enter zero.
Line 41--Add lines 39 and 40 to determine the total general inpatient routine service cost
applicable to the program.
Line 42--This line is for titles V and XIX only and provides for the apportionment of your
inpatient routine service cost of the nursery, as appropriate.
Column 1--Enter the total inpatient cost applicable to the nursery from Worksheet C, Part I, line
43.
TEFRA, COST, or OTHER Inpatient
PPS Inpatient, or IPF, IRF, and LTCH PPS
Column 3
Column 5
Column 2--Enter the total inpatient days applicable to the nursery from line 15.
Column 3--Divide the total inpatient cost in column 1 by the total inpatient days in column 2
(rounded to two decimal places).
Column 4--Enter the program nursery days from line 16.
Column 5--Multiply the average per diem cost in column 3 by the program nursery days in
column 4.
Lines 43 through 47--These lines provide for the apportionment of the hospital inpatient routine
service cost of intensive care type inpatient hospital units (excluding nursery) to the program.
Column 1--Enter on the appropriate line the total inpatient routine cost applicable to each of the
indicated intensive care type inpatient hospital units from Worksheet C, Part I, lines 31 through
35, as appropriate.
TEFRA, COST, or OTHER Inpatient
PPS Inpatient, or IPF, IRF and LTCH PPS
Column 3
Column 5
Column 2--Enter on the appropriate line the total inpatient days applicable to each of the
indicated intensive care type inpatient units. Transfer these inpatient days from Worksheet S-3,
Part I, column 8, lines 8 through 12, as appropriate.
Column 3--For each line, divide the total inpatient cost in column 1 by the total inpatient days in
column 2 (rounded to two decimal places).
Column 4--Enter on the appropriate line the program days applicable to each of the indicated
intensive care type inpatient hospital units. Transfer these inpatient days from Worksheet S-3,
Part I, columns 5, 6, or 7, as appropriate, lines 8 through 12.
Rev. 2
40-147
4025.2 (Cont.)
FORM CMS-2552-10
08-11
NOTE: When you place overflow general care patients temporarily in an intensive care type
inpatient hospital unit because all beds available for general care patients are occupied,
count the days as intensive care type unit days for the purpose of computing the
intensive care type unit per diem. The days are included in column 2. However, count
the program days as general routine days in computing program reimbursement. Enter
the program days on line 9 and not in column 4, lines 43 through 47, as applicable.
(See CMS Pub. 15-1, §2217.)
Column 5--Multiply the average cost per diem in column 3 by the program days in column 4.
Line 48--Enter the total program inpatient ancillary service cost from the appropriate Worksheet
D-3, column 3, line 200.
Line 49--Enter the sum of the amounts on lines 41 through 48. When this worksheet is
completed for components, neither subject to prospective payment, nor subject to the target rate
of increase ceiling (i.e., "Other" box is checked), transfer this amount to Worksheet E-3, Part V,
line 1 or Part VII, line 1, as appropriate. Do not complete lines 50-63.
For all inclusive rate providers (Method E) apply the percentage to the sum of the
aforementioned lines (lines 41 through 48) based on the provider type designated on Worksheet
S-2, column 4, line 3 (see CMS Pub. 15-1, section 2208).
Lines 50-53--These lines compute total program inpatient operating cost less program capitalrelated, nonphysician anesthetists, and approved medical education costs. Complete these lines
for all provider components.
Line 50--Enter on the appropriate worksheet the total pass through costs including capital-related
costs applicable to program inpatient routine services. Transfer capital-related inpatient routine
cost from Worksheet D, Part I, column 7, sum of lines 30 through 35 and line 43 for the hospital,
and line 40, 41, or 42, as applicable, for the subprovider. Add that amount to the other pass
through costs from Worksheet D, Part III, column 9, sum of lines 30 through 35 and line 43 for
the hospital, and line 40, 41, or 42, as applicable, for the subprovider.
Line 51--Enter the total pass through costs including capital-related costs applicable to program
inpatient ancillary services. Transfer capital-related inpatient ancillary costs from Worksheet D,
Part II, column 5, line 200. Add that amount to the other pass through costs from Worksheet D,
Part IV, column 11, line 200.
Line 52--Enter the sum of lines 50 and 51.
Line 53--Enter total program inpatient operating cost (line 49) less program capital-related,
nonphysician anesthetists (if appropriate), and approved medical education costs (line 52).
Lines 54 through 63--Except for those hospitals specified below, all hospitals (and distinct part
hospital units) excluded from prospective payment are reimbursed under cost reimbursement
principles and are subject to the ceiling on the rate of hospital cost increases (TEFRA). (See 42
CFR 413.40.) CAHs do not complete these lines as reimbursement is based on reasonable cost.
The following hospitals are reimbursed under special provisions and, therefore, are not generally
subject to TEFRA or prospective payment:
•
Hospitals reimbursed under approved State cost control systems (see 42 CFR 403.300
through 403.322);
•
Nonparticipating hospitals furnishing emergency services to Medicare beneficiaries.
40-148
Rev. 2
12-10
FORM CMS-2552-10
4025.2 (Cont.)
For your components subject to the prospective payment system or not otherwise subject to the
rate of increase ceiling as specified above, make no entries on lines 54 through 63.
NOTE: A new non-PPS hospital or subprovider (Lines 85 and/or 86 of Worksheet S-2 with a
“Y” response) is cost reimbursed for all cost reporting periods through the end of its
first 12 month cost reporting period. The 12 month cost reporting period also becomes
the TEFRA base period unless an exemption under 42 CFR 413.40 (f) is granted. If
such an exemption is granted, cost reimbursement continues through the end of the
exemption period. The last 12 month period of the exemption is the TEFRA base
period. New providers will be paid the lower of their inpatient operating costs per case
or 110 percent of the national median of the target amounts for similar provider types.
Line 54--Enter the number of program discharges including deaths (excluding newborn and
DOAs) for the component from Worksheet S-3, Part I, columns 12 through 14 (as appropriate),
lines 14 and 16 through 18 (as appropriate). A patient discharge, including death, is a formal
release of a patient.
Line 55--Enter the target amount per discharge as obtained from your contractor. The target
amount establishes a limitation on allowable rates of increase for hospital inpatient operating
cost. The rate of increase ceiling limits the amount by which your inpatient operating cost may
increase from one cost reporting period to the next. (See 42 CFR 413.40.)
Line 56--Multiply the number of discharges on line 54 by the target amount per discharge on line
55 to determine the rate of increase ceiling.
Line 57--Subtract line 53 from line 56 to determine the difference between adjusted inpatient
operating cost and the target amount.
Line 58 through 62--This line provides incentive payments when your cost per discharge for the
cost reporting period subject to the ceiling is less than the applicable target amount per discharge.
In addition bonus payments are provided for hospitals who have received PPS exempt payments
for three or more previous cost reporting periods and whose operating costs are less than the
target amount, expected costs (lesser of actual costs or the target amount for the previous year),
or trended costs (lesser of actual operating costs or the target amount in 1996; or for hospitals
where its third full cost reporting period was after 1996 the inpatient operating cost per discharge
), updated and compounded by the market basket. It also provides for an adjustment when the
cost per discharge exceeds the applicable target amount per discharge. If line 57 is zero, enter
zero on lines 58 through 62. New providers skip lines 58 through 62 and go to line 63.
Line 58--If line 57 is a positive amount (actual inpatient operating cost is less than the target
amount), enter on line 58 the lesser of 15 percent of line 57 or 2 percent of line 56. If line 57 is
negative, do not complete line 58 (leave blank), however, complete line 62 for calculation of any
adjustments to the operating costs.
Line 59--Enter the inpatient operating cost per discharge updated and compounded by the market
basket for each year through the current reporting year.
Line 60--Enter from the prior year cost report, the lesser of the hospital’s inpatient operating cost
per discharge (line 53/line 54) or line 55, updated by the market basket.
Rev. 1
40-149
4025.3
FORM CMS-2552-10
12-10
Line 61--If (line 53/line 54) is less than the lower of lines 55, 59 or 60, enter the lesser of 50
percent of the amount by which operating costs (line 53) are less than expected costs (line 54
times line 60), or 1 percent of the target amount (line 56); otherwise enter zero. (42 CFR
413.40(d)(4)(i))
Line 62--If line 57 is a negative amount (actual inpatient operating cost is greater than the target
amount) and line 53 is greater than 110 percent of line 56, enter on this line the lesser of (1) or
(2): (1) 50 percent of the result of (line 53 minus 110 percent of line 56) or (2) 10 percent of line
56; otherwise enter zero. (42 CFR 413.40(d)(3))
Line 63--Allowable Cost Plus incentive Payment--If line 57 is a positive amount, enter the sum
of lines 52, 53, 58 and 61 (if applicable). If line 57 is a negative amount enter the sum of lines
52, 56, and 62. If line 57 is zero, enter the sum of lines 52 and 56. New providers enter the
lesser of lines 53 or 56 plus line 52.
Line 64--Enter the amount of Medicare swing bed-SNF type inpatient routine cost through
December 31 of the cost reporting period. Determine this amount by multiplying the program
swing bed-SNF type inpatient days on line 10 by the rate used on line 17. For CAHs multiply
line 10 times the per diem calculated on line 38.
Line 65--Enter the amount of Medicare swing bed-SNF type inpatient routine cost for the period
after December 31 of the cost reporting period. Determine this amount by multiplying the
program swing bed-SNF type inpatient days on line 11 by the rate used on line 18. For CAHs
multiply line 11 times the per diem calculated on line 38.
Line 66--Enter the sum of lines 64 and 65. For CAHs only transfer this amount to Worksheet E2, column 1, line 1.
Line 67--Enter the amount of titles V or XIX swing bed-NF type inpatient routine cost through
December 31 of the cost reporting period. Determine this amount by multiplying the program
swing bed-NF type inpatient days on line 12 by the rate used on line 19.
Line 68--Enter the amount of titles V or XIX swing bed-NF type inpatient routine cost for the
period after December 31 of the cost reporting period. Determine this amount by multiplying the
program swing bed-NF type inpatient days on line 13 by the rate used on line 20.
Line 69--Enter the sum of lines 67 and 68. Transfer this amount to the appropriate Worksheet E2, column 1, line 2. If your state recognizes only one level of care obtain the amount from line
66.
4025.3 Part III - Skilled Nursing Facility, Other Nursing Facility, and Intermediate Care
Facility/Mental Retardation Only--This part provides for the apportionment of inpatient
operating costs to titles V, XVIII, and XIX. Hospital-based SNFs complete lines 70 through 74
and 83 through 86 for data purposes only as SNFs are reimbursed under SNF PPS for title XVIII.
Complete lines 70-89 for titles V and XIX. When this worksheet is completed for a component,
show both the hospital and component numbers. Any reference to the nursing facility will also
apply to the intermediate care facility/mental retardation unit.
Line Descriptions
Line 70--Enter the hospital-based SNF or other nursing facility routine service cost from Part I,
line 37.
Line 71--Calculate the adjusted general inpatient routine service cost per diem by dividing the
amount on line 70 by inpatient days, including private room days, shown on Part I, line 2.
Line 72--Calculate the routine service cost by multiplying the program inpatient days, including
the private room days in Part I, line 9, by the per diem amount on line 71.
40-150
Rev. 1
10-12
FORM CMS-2552-10
4025.3 (Cont.)
Line 73--Calculate the medically necessary private room cost applicable to the program by
multiplying the days shown in Part I, line 14 by the per diem in Part I, line 35.
Line 74--Add lines 72 and 73 to determine the total reasonable program general inpatient routine
service cost.
Lines 75 - 82--Apportionment of Inpatient Operating Costs for Other Nursing Facilities (NF)-These lines are used for titles V and/or XIX only. For title XVIII Medicare, skip lines 75
through 82 and continue with line 83.
Line 75--Enter the capital-related cost allocated to the general inpatient routine service cost
center. For titles V and XIX, transfer this amount from Worksheet B, Part II, column 26, line 45
(NF).
Line 76--Calculate the per diem capital-related cost by dividing the amount on line 75 by the
days in Part I, line 2.
Line 77--Calculate the program capital-related cost by multiplying line 76 by the days in Part I,
line 9.
Line 78--Calculate the inpatient routine service cost by subtracting line 77 from line 74.
Line 79--Enter the aggregate charges to beneficiaries for excess costs obtained from your
records.
Line 80--Enter the total program routine service cost for comparison to the cost limitation.
Obtain this amount by subtracting line 79 from line 78.
Line 81--Enter the inpatient routine service cost per diem limitation. This amount is provided by
your state contractor.
Line 82--Enter the inpatient routine service cost limitation. Obtain this amount by multiplying
the number of inpatient days shown on Part I, line 9 by the cost per diem limitation on line 81.
Line 83--For titles V and XIX, enter the amount of reimbursable inpatient routine service cost
determined by adding line 77 to the lesser of line 80 or line 82. If you are a provider not subject
to the inpatient routine service cost limit, enter the sum of lines 77 and 80. For title XVIII, enter
the amount from line 74.
Line 84-- Enter the program ancillary service amount from Worksheet D-3, column 3, line 200.
Line 85--Enter (only when Worksheet D-1 is used for a hospital-based SNF and NF) the
applicable program's share of the reasonable compensation paid to physicians for services on
utilization review committees to an SNF and/or NF. Include the amount eliminated from total
costs on Worksheet A-8, line 25. If the utilization review costs are for more than one program,
the sum of all the Worksheet D-1 amounts reported on this line must equal the amount adjusted
on Worksheet A-8, line 25.
Line 86--Calculate the total program inpatient operating cost by adding the amounts on lines 83
through 85. Transfer this amount to the appropriate Worksheet E-3, Part VII, line 1 except for
SNFs subject to SNF PPS. For NF and ICF/MR, transfer this amount to Worksheet E-3, Part
VII, line 1 for titles V and XIX.
Rev. 3
40-151
4025.4
FORM CMS-2552-10
10-12
4025.4 Part IV - Computation of Observation Bed Pass Through Cost--This part provides for
the computation of the total observation bed costs and the portion of costs subject to
reimbursement as a pass through cost for observation beds that are only in the general acute care
routine area of the hospital. For title XIX, insert the amount calculated for title XVIII for the
hospital, if applicable. To avoid duplication of reporting observation bed costs, do not transfer
the title XIX amount to Worksheet C.
Line 87--Transfer the total observation bed days from Worksheet S-3, Part I, column 8, line 28.
NOTE: Observation days are only recognized and reported in the inpatient routine area of the
hospital.
Line 88--Calculate the result of general inpatient routine cost on line 27 divided by line 2.
Line 89--Multiply the number of days on line 87 by the cost per diem on line 88 and enter the
result. Transfer this amount to Worksheet C, Parts I and II, column 1, line 92.
Lines 90 - 93--These lines compute the observation bed costs used to apportion the routine pass
through costs and capital-related costs associated with observation beds for PPS and TEFRA
providers. Lines 90 through 93 correspond to specific medical education programs reported on
Worksheet D, Part III, columns 1, 2, and 3, respectively.
Column 1--For line 90, transfer the amount from Worksheet D, Part I, column 1, line 30 for the
hospital. For line 91 through 93, enter the cost from Worksheet D, Part III, columns 1, 2 and 3,
line 30.
Column 2--Enter on each line the general inpatient routine cost from line 27. Enter the same
amount on each line.
Column 3--Divide column 1 by column 2 for each line, and enter the result. If there are no costs
in column 1, enter 0 in column 3.
Column 4--Enter the total observation cost from line 89. Enter the same amount on each line.
Column 5--Multiply the ratio in column 3 by the amount in column 4. Use this cost to apportion
routine pass through costs associated with observation beds on Worksheet D, Parts II and IV.
Transfer the amount in column 5:
From
Wkst. D-1, Part IV
Col. 5, line 90
Col. 5, line 91
Col. 5, line 92
Col. 5, line 93
40-152
To
Wkst. D, Part II
Col. 1, line 92
To
Wkst D, Part IV
Col. 2, line 92
Col. 3, line 92
Col. 4, line 92
Rev. 3
12-10
4026.
FORM CMS-2552-10
4026.1
WORKSHEET D-2 - APPORTIONMENT OF COST OF SERVICES RENDERED
BY INTERNS AND RESIDENTS
4026.1 Part I - Not in Approved Teaching Program.--Use this part only if you have interns and
residents who are not in an approved teaching program. (See CMS Pub. 15-1, chapter 4.) If you
have more than one hospital-based outpatient rehabilitation provider, subscript line 17 to
accommodate reporting data for each.
Column 1--Enter the percentage of time that interns and residents are assigned to each of the
indicated patient care areas on lines 1 through 19 and 21 through 26 (from your records).
Column 2--Enter on line 1 the total cost of services rendered in all patient care areas from
Worksheet B, Part I, column 26, line 100. Multiply the amount in column 1 by the total cost in
column 2, line 1. Enter the resulting amounts on the appropriate lines in column 2.
Inpatient
Column 3--Enter the total inpatient days applicable to the various patient care areas of the
complex.
Description
Enter in Col. 3
Inpatient Days From
Worksheet D-1
Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive
Care Unit
Other Intensive Care
Type Unit
Nursery
IPF - Inpatient Routine
IPF - Inpatient Routine
Subprovider
SNF
NF
line 2
line 3
line 4
line 5
Part I, col. 1, line 1
Part II, col. 2, line 43
Part II, col. 2, line 44
Part II, col. 2, line 45
line 6
Part II, col. 2, line 46
line 7
line 8
line 10
line 11
line 12
line 13
line 14
Part II, col. 2, line 47
S-3, Part I, col. 8, line 13
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Column 4--Divide the allocated expenses in column 2 by the inpatient days in column 3 to arrive
at the average per diem cost for each cost center.
For swing bed-SNF or swing bed-NF facilities, transfer the per diem amount in column 4, line 2,
to Worksheet E-2, column 1 (for titles V and XIX) or column 2 (for title XVIII), line 4.
Rev. 1
40-153
4026.1 (Cont.)
FORM CMS-2552-10
12-10
Columns 5, 6, and 7--Enter in the appropriate column the health care program inpatient days for
each patient care area.
Titles V and XIX
Description
Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care
Unit
Surgical Intensive
Care Type Unit
Other Intensive
Care Type Unit
Nursery
IPF - Inpatient Routine
IRF - Inpatient Routine
Subprovider
SNF
NF
Enter in column 5 for
title V or column 7
for title XIX
From Worksheet D-1
line 2
line 3
line 4
line 5
Part I, col. 1, line 9
Part II, col. 4, line 43
Part II, col. 4, line 44
Part II, col. 4, line 45
line 6
Part II, col. 4, line 46
line 7
Part II, col. 4, line 47
line 8
line 10
line 11
line 12
line 13
line 14
Part II, col. 4, line 42
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Part I, col. 1, line 1
Title XVIII--Enter in column 6, lines 2 through 13, as appropriate, the total number of days in
which beneficiaries were inpatients of the provider and had Medicare Part B coverage. Such
days are determined without regard to whether Part A benefits were available. Submit a
reconciliation with the cost report demonstrating the computation of Medicare Part B inpatient
days. The following reconciliation format is recommended:
Cost
Center
Part A
Inpatient plus
Days
Part B
Only Days
minus
Part A Coverage
But No Part B =
Days Coverage
Medicare
Part B
Days
Part A Inpatient Days--Enter the Medicare Part A inpatient days from Worksheet D-1.
Cost Center
From Worksheet D-1
Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Type Unit
Surgical Intensive Care Type Unit
Other Intensive Care Type Unit
IPF - Inpatient Routine
IRF - Inpatient Routine
Subprovider
Skilled Nursing Facility
Part I, column 1, line 9
Part II, column 4, line 43
Part II, column 4, line 44
Part II, column 4, line 45
Part II, column 4, line 46
Part II, column 4, line 47
Part I, column 1, line 9
Part I, column 1, line 9
Part I, column 1, line 9
Part I, column 1, line 9
Part B Only Days--Enter the total number of days from your records in which inpatients were
covered under Medicare Part B but did not have Part A benefits available.
No Part B Days--Enter the total number of days from your records in which inpatients were
covered under Medicare Part A but did not have Part B benefits available.
40-154
Rev. 1
10-12
FORM CMS-2552-10
4026.1 (Cont.)
Columns 8, 9, and 10--Multiply the average cost per day in column 4 by the health care program
days in columns 5, 6, and 7, respectively. Enter the resulting amounts in columns 8, 9, and 10, as
appropriate, for each cost center.
Outpatient
Column 3--Enter the total charges applicable to each outpatient service area. Obtain the total
charges from Worksheet C, column 8, lines 88 through 93.
Column 4--Compute the total outpatient cost to charge ratio by dividing costs in column 2 by
charges in column 3 for each cost center.
Columns 5, 6, and 7--Enter in these columns program charges for outpatient services. Do not
include in Medicare charges any charges identified as MSP/LCC.
Titles V and XIX:
Sum of
_
Description
Enter in col. 5 for
title V or col. 7
for title XIX
Worksheet D-3,
col. 2
Worksheet D, Part V,
sum of cols. 2 - 4
(& applicable subscripts)
RHC
FQHC
Clinic
Emergency
Observation Beds
Other Outpatient
line 21
line 22
line 23
line 24
line 25
line 26
line 88
line 89
line 90
line 91
line 92
line 93
line 88
line 89
line 90
line 91
line 92
line 93
Title XVIII:
From
Description
Charges
RHC
FQHC
Clinic
Emergency
Observation Beds
Other Outpatient
Enter in col.
6 for Title
XVIII
Worksheet
D-3, col. 2
Worksheet D, Part V
cols. 2 - 4
(& applicable subscripts)
line 21
line 22
line 23
line 24
line 25
line 26
line 88
line 89
line 90
line 91
line 92
line 93
plus
plus
plus
plus
plus
plus
line 88 minus
line 89 minus
line 90 minus
line 91 minus
line 92 minus
line 93 minus
Less Part A
Only
From
Provider
Records
NOTE: Submit a reconciliation worksheet with the cost report showing the computations used
for the charges for column 6.
If you have subproviders, the amounts entered in these columns are the sum of the hospital and
subprovider Worksheets D-3 and D, Part V.
Columns 8, 9, and 10, lines 21-26--Compute program outpatient costs for titles V and XIX and
title XVIII, Part B cost by multiplying the cost to charge ratio in column 4 by the program
outpatient charges in columns 5, 6, and 7. Enter the resulting amounts in columns 8, 9, and 10,
as appropriate, for each cost center.
Rev. 3
40-155
4026.2
FORM CMS-2552-10
10-12
Transfer program expenses.
From Title V (Column 8)/Title XIX (Column 10)
Hospital: Sum of lines 9 and 27
TO
Worksheet E-3, Part VII, line 19
Subprovider: lines 10-12, as applicable
TO
Worksheet E-3, Part VII, line 19
Other Nursing Facility: line 14
TO
Worksheet E-3, Part VII, line 19
From Title XVIII (Column 9) (only if Part II is not utilized)
Hospital: Sum of lines 9 and 27
TO
Worksheet E, Part B, line 22
Subprovider: line 10-12, as applicable
TO
Worksheet E, Part B, line 22
Skilled Nursing Facility: line 13
TO
Worksheet E, Part B, line 22
4026.2 Part II - In An Approved Teaching Program (Title XVIII, Part B Inpatient Routine
Costs Only)--This part provides for reimbursement for inpatient routine services rendered by
interns and residents in approved teaching programs to Medicare beneficiaries who have Part B
coverage and are not entitled to benefits under Part A. (See CMS Pub. 15-1, chapter 4, and
§2120.) Do not complete this section unless you qualify for the new teaching hospital exception
for graduate medical education payments in 42 CFR 413.77(e)(1).
Column 1--Enter the amounts allocated in the cost finding process to the indicated cost centers.
Obtain these amounts from Worksheet B, Part I, sum of the amounts in columns 21 and 22, as
adjusted for any post stepdown adjustments applicable to interns and residents in approved
teaching programs.
Column 2--Enter the adjustment for interns and residents costs applicable to swing bed services
but allocated to hospital routine cost. Compute these amounts as follows:
Swing
Inpatient =
Bed
Amount
Interns and
Residents Costs
Allocated to
Adults &
Pediatrics
For line
30 (SNF)
Wkst. D-2,
col. 1, line 29
Wkst. D-1,
sum of lines 5
and 6
Wkst. D-1,
line 1
For line
31 (NF)
Wkst. D-2,
col. 1, line 29
Wkst. D-1,
sum of lines 7
and 8
Wkst. D-1,
line 1
times
Total
Swing
Bed
Days
divided
by
Total
Days
The amount subtracted from line 29 must equal the sum of the amounts computed for lines 30
and 31.
40-156
Rev. 3
10-12
FORM CMS-2552-10
4026.3
If you have swing beds in your IPF subprovider, complete line 38 to adjust for swing bed costs.
Compute the swing bed amounts as explained above except that the interns and residents costs
allocated to adults and pediatrics (line 38) comes from Worksheet D-2, column 1, line 38. The
amount subtracted from line 38 must equal the sum of subscripts of line 38, as applicable. If you
have swing beds in your IRF subprovider, complete line 39 to adjust for swing bed costs.
Compute the swing bed amounts as explained above except that the interns and residents costs
allocated to adults and pediatrics (line 39) comes from Worksheet D-2, column 1, line 39. The
amount subtracted from line 39 must equal the sum of subscripts of line 39, as applicable.
Column 3--Enter on lines 29 and 38 through 40, as applicable, the amounts in column 1 minus
the amount in column 2. Enter on line 30 the amount from column 2. Enter on lines 32 through
36 and 41 the amounts from column 1.
Column 4--Enter the total inpatient days applicable to the various patient care areas of the
complex. (See instructions for Part I, column 3. For line 30, this is from Worksheet D-1, sum of
lines 5 and 6.)
Column 5--Divide the allocated expense in column 3 by the inpatient days in column 4 to arrive
at the average per diem cost for each cost center.
Column 6--Enter on lines 29, 30, 32 through 36, and 38 through 41, as applicable, the total
number of days in which inpatients were covered under Medicare Part B but did not have Part A
benefits available.
Column 7--Multiply the average per diem cost in column 5 by the number of inpatient days in
column 6 to arrive at the expense applicable to title XVIII for each cost center. Transfer the
amount on line 30, or lines 38 through 40 if you are a subprovider with a swing bed, to
Worksheet E-2, column 2, line 6.
For columns 1, 3, and 7, enter on line 37 the sum of the amounts on line 29 plus the sum of the
amounts on lines 32 through 36.
Transfer the expenses on lines 37 through 41 to the appropriate lines on Part III, column 4,
whenever you complete both Parts I and II.
However, when only Part II is completed, transfer the amount entered in column 7, lines 37
through 41 to Worksheet E, Part B, line 22, as appropriate.
4026.3 Part III - Summary for Title XVIII (To be completed only if both Parts I and II are
used)--Do not complete this section unless you qualify for the exception for graduate medical
education payments in 42 CFR 413.77(e)(1). This part is applicable to Medicare only and is
provided to summarize the amounts apportioned to the program in Parts I and II. This part is
completed only if both Parts I and II are used.
Transfer title XVIII expenses.
Description
From Column 6
Hospital
Subprovider
SNF
Line 45
Line 46-48
Line 49
Rev. 3
TO
TO
TO
Worksheet E, Part B, line 22
Worksheet E, Part B, line 22
Worksheet E, Part B, line 22
40-157
4027
FORM CMS-2552-10
4027.
WORKSHEET
APPORTIONMENT
D-3 - INPATIENT
ANCILLARY
10-12
SERVICE
COST
This worksheet provides for the apportionment of cost applicable to hospital inpatient services
reimbursable under titles V, XVIII and XIX as indicated in 42 CFR 413.53. All hospital filing a
full cost report, including CAHs (Worksheet S-2, line 105 is marked “Y”) must complete this
worksheet. Complete a separate copy of this worksheet for each sub-provider, distinct part SNF
and NF, swing-bed SNF and NF, or any other component. Identify the health care program,
provider component, and the payment system by checking the appropriate boxes at the top of the
worksheet.
The cost centers on this worksheet have the same line numbers as the respective cost centers on
Worksheets A, B, B-1, and C. This design facilitates referencing throughout the cost report.
Column 1--Enter the ratio of cost to charges developed for each cost center from Worksheet C,
lines 50 through 94 and 96 through 98. The ratios in columns 10 and 11 of Worksheet C are
used only for hospital or subprovider components for titles V, XVIII, and XIX inpatient services
subject to the TEFRA rate of increase ceiling (see 42 CFR 413.40) or PPS (see 42 CFR 412,
Subpart N, O, or P), respectively. Use the ratios in column 9 in all other cases.
Column 2--Enter from the PS&R or your records the inpatient program charges applicable to
the provider component services only (not professional component) in the appropriate cost
centers as detailed below. Also include charges for cost centers with a negative balance on
Worksheet B Part I, column 26. Do not include program charges for swing bed services and
Medicare charges identified as MSP/LCC.
Lines 30 - 35--Enter the program charges from the PS&R or your records (hospital only).
Lines 40 - 42--Enter in column 2 the inpatient program charges for the subproviders’ component
only. For subprovider components do not complete lines 30-35 and 43. For a Hospital complex
do not complete lines 40-42.
Line 43--Enter the charges for your nursery department for which you were reimbursed.
Complete this for Medicaid services only.
Line 61--Enter the program charges for your clinical laboratory tests for which you reimburse the
pathologist. See the instructions for Worksheet A (see §4013) for a more complete discussion on
the use of this cost center.
NOTE: Since the charges on line 61 are also included on line 60, laboratory, you
must reduce total charges to prevent double counting. Make this adjustment on line
201.
40-158
Rev. 3
10-12
FORM CMS-2552-10
4027 (Cont.)
Line 73--Enter only the program charges for drugs charged to patients that are not paid a
predetermined amount.
Lines 88 - 90 and 93--Do not enter on these lines program charges related to any inpatient
ancillary services (e.g., radiology- diagnostic, laboratory) provided in a clinic, RHC, or FQHC
and billed as inpatient services. Instead, reclassify such program charges to the related
ancillary cost centers.
Lines 92 and 92.01--Enter on these lines, as applicable, the program charges for observation
bed services if the patient was subsequently admitted as an inpatient. However, these program
charges can only be reported on the main hospital’s (e.g., acute care hospital, freestanding
psychiatric hospital, freestanding rehabilitation hospital) Worksheet D-3. (That is, program
charges for observation bed services provided to patients subsequently admitted as inpatients to
an acute hospital’s excluded psychiatric or rehabilitation unit must be reported on Worksheet D3 of the acute hospital.)
Lines 96 and 97--Do not enter program charges for oxygen rented or sold as the fee schedule
applies for these services.
Line 200--Enter the total of the amounts in columns 2 and 3, lines 50 through 94 and 96 through
98.
Line 201--Enter in column 2 program charges for your clinical laboratory tests when the
physician bills you for program patients only. Obtain this amount from line 61.
Line 202--Enter in column 2 the amount on line 200 less the amount on line 201.
Transfer the amount in column 2, line 202, as follows.
For title XVIII, Part A (other reimbursement), transfer the amount to Worksheet E-3, Part V, line
8. Do not transfer this amount if you are reimbursed under PPS or TEFRA. No transfers of
swing bed charges are made to Worksheet E-2 since no LCC comparison is made. For titles V
and XIX (if not a PPS provider), transfer the amount plus the amount from Worksheet D, Part V,
sum of columns 3 and 4, line 202, to Worksheet E-3, Part VII, column 1, line 9.
Rev. 3
40-159
4027 (Cont.)
FORM CMS-2552-10
10-12
Column 3--Multiply the indicated program charges in column 2 by the ratio in column 1 to
determine the program inpatient expenses.
Transfer column 3, line 200, as follows:
Type of Provider
TO
Hospital
Subprovider
SNF
NF
Swing Bed-SNF
Swing Bed-NF
Wkst. D-1, Part II, col. 1, line 48
Wkst. D-1, Part II, col. 1, line 48
Wkst. D-1, Part III, col. 1, line 84
Wkst. D-1, Part III, col. 1, line 84
Wkst. E-2, col. 1, line 3
Wkst. E-2, col. 1, line 3
40-160
Rev. 3
12-10
4028.
FORM CMS-2552-10
4028.1
WORKSHEET D-4 - COMPUTATION OF ORGAN ACQUISITION COSTS AND
CHARGES FOR HOSPITALS WHICH ARE CERTIFIED TRANSPLANT
CENTERS
Only certified transplant centers (CTCs) are reimbursed directly by the Medicare program for
organ acquisition cost. This worksheet provides for the computation and accumulation of organ
acquisition costs and charges for CTCs. Check the appropriate box (heart, liver, lung, pancreas,
intestine, kidney, islet, or other organs - specify) to determine which organ acquisition cost is
being computed. Use a separate worksheet for each type of organ.
Hospitals that are not CTCs are not reimbursed by the Medicare program for organ acquisition
costs and do not complete this worksheet. Such hospitals have to obtain revenue by the sale of
any organs excised to an organ procurement organization (OPO) or CTC.
Worksheet D-4 consists of the following four parts:
Part I
Services)
Part II
Part III
Part IV
-
Computation of Organ Acquisition Cost (Inpatient Routine and Ancillary
- Computation of Organ Acquisition Cost (Other than Inpatient Routine and
Ancillary Service Costs)
- Summary of Costs and Charges
- Statistics
4028.1 Part I - Computation of Organ Acquisition Costs (Inpatient Routine and Ancillary
Services)-Lines 1 through 7--These lines provide for the computation of inpatient routine service costs
applicable to organ acquisition and for the accumulation of inpatient routine service charges for
organ acquisition.
Column 1--Enter on lines 1 through 6, as appropriate, the inpatient routine charges applicable to
organ acquisition. Enter on line 7 the sum of the amounts reported on lines 1 through 6.
Column 2--Enter on lines 1 through 6, as appropriate, the average per diem cost from Worksheet
D-1:
Description
To
Worksheet D-4,
Part I, Col. 2
From Worksheet
D-1, Part II
Adults & Pediatrics
Intensive Care
Coronary Care
Burn Intensive Care Type Unit
Surgical Intensive Care Type Unit
Other Intensive Care Type Unit
line 1
line 2
line 3
line 4
line 5
line 6
col. 1, line 38
col. 3, line 43
col. 3, line 44
col. 3, line 45
col. 3, line 46
col. 3, line 47
Column 3--Enter from your records on lines 1 through 6, as appropriate, total organ acquisition
days (Medicare and non-Medicare). An organ acquisition day is an inpatient day of care
rendered to an organ donor patient who is hospitalized for the surgical removal of an organ for
transplant or a day of care rendered to a cadaver in an inpatient routine service area for the
purpose of surgical removal of its organs for transplant. Enter on line 7 the sum of the days on
lines 1 through 6.
Column 4--Enter on lines 1 through 6, as appropriate, the amount in column 2 multiplied by the
amount in column 3. Enter on line 7 the sum of lines 1 through 6.
Rev. 1
40-161
4028.2
FORM CMS-2552-10
12-10
Lines 8 - 40--These lines provide for the computation of ancillary service cost applicable to
organ acquisition. These lines also provide for the accumulation of inpatient and outpatient
organ acquisition ancillary charges.
Column 1--Enter on lines 8 through 40 the "cost or other" cost to charges ratio from Worksheet
C, column 9.
Column 2--Enter from your records inpatient and outpatient organ acquisition ancillary charges.
Enter on line 41 the sum of lines 8 through 40.
Column 3--Enter on lines 8 through 40 the organ acquisition costs. Compute this amount by
multiplying the ratio in column 1 by the amount in column 2 for each cost center. Enter on line
41 the sum of lines 8 through 40.
4028.2 Part II - Computation of Organ Acquisition Costs (Other Than Inpatient Routine and
Ancillary Service Costs)-Lines 42 - 47--Use these lines to apportion the cost of inpatient services attributable to organ
acquisitions rendered in each of the inpatient routine areas by interns and residents not in an
approved teaching program.
Column 1--Enter on the appropriate lines the average per diem cost of interns and residents not
in an approved teaching program in each of the inpatient routine areas. Obtain these amounts
from Worksheet D-2, Part I, column 4, lines as indicated.
Column 2--Enter the number of organ acquisition days in each of the inpatient routine areas from
Part I, column 3, lines 1 through 6, as appropriate.
Column 3--Multiply the per diem amount in column 1 by the number of days in column 2 for
each cost center.
Line 48--For columns 2 and 3, enter the sum of lines 42 through 47.
Lines 49 - 54--These lines provide for the computation of the cost of outpatient services
attributable to organ acquisitions rendered in each of the outpatient service areas by interns and
residents not in an approved teaching program.
Column 1--Enter on the appropriate lines the organ acquisition charges in each of the outpatient
service areas. Obtain these amounts from Part I, column 2, lines 35 through 40, as appropriate.
Column 2--Enter the ratio of the outpatient costs of interns and residents not in an approved
teaching program to the hospital outpatient service charges in each of the outpatient service
areas. Obtain these ratios from Worksheet D-2, Part I, column 4, lines as indicated.
Column 3--Multiply the charges in column 1 by the ratios in column 2 for each cost center.
Enter the sum of lines 49 through 54 on line 55.
40-162
Rev. 1
10-12
4028.3
FORM CMS-2552-10
4028.3
Part III - Summary of Costs and Charges--
Line 56--Enter in column 1 the sum of the costs in Part I, column 4, line 7 and column 3, line 41.
Enter in column 3 the sum of the charges in Part I, column 1, line 7 and column 2, line 41.
Line 57--Enter in column 1 the cost of inpatient services of interns and residents not in an
approved teaching program from Part II, column 3, line 48. Enter in column 3 your charges for
the services for which the cost is entered in column 1. If you do not charge separately for the
services of interns and residents, enter zero in column 3.
Line 58--Enter in column 1 the cost of outpatient services of interns and residents not in an
approved teaching program from Part II, column 3, line 55. Enter in column 3 the provider
charges for the services for which the cost is entered in column 1. If you do not charge
separately for the services of interns and residents, enter zero in column 3.
Line 59--Enter in column 1 the direct organ acquisition costs and allocated general service costs
from Worksheet B, Part I, column 26, lines 105, 106, 107, 108, 109, 110, or 111, whichever is
applicable.
These direct costs include, but are not limited to, the cost of services purchased under
arrangements or billed directly to you for:
• Fees for physician services (preadmission donor and recipient tissue typing),
• Costs for organs acquired from other providers or organ procurement organizations,
• Transportation costs of organs,
• Organ recipient registration fees,
• Surgeon’s fees for excising cadaveric organs, and
• Tissue typing services furnished by independent laboratories.
NOTE: Transportation costs to ship organs outside of the United States are not an
allowable cost.
If you have a schedule of charges which represents the various direct organ acquisition costs
included in column 1, enter in column 3 the total of the charges which are applicable to the costs
in column 1. However, if you have no such schedule of charges, enter the amount from column
1 in column 3.
Line 60--If you have elected to be reimbursed for the services of teaching physicians on the basis
of cost, enter in columns 1 and 3 the amount from Worksheet(s) D-5, Part II, column 3, lines 24
through 31, as applicable.
Line 61--Enter in columns 1 and 3 the sum of lines 56 through 60. This amount must be equal to
or greater than the amount reported on line 66 (revenues for organs sold).
Line 62--Enter the number of total usable organs (this includes all organs applicable to this
worksheet except those that could not be transplanted). For islets since the number of islets cells
injected into a recipient will vary depending on the patient, enter the number of patients who
received islets injections. Each patient is allowed a maximum of two islet injections per
inpatient stay.
Rev. 3
40-163
4028.3 (Cont.)
FORM CMS-2552-10
10-12
Line 63-Enter total usable organs (line 62) less the sum of organs sent to military hospitals
(without a reciprocal sharing agreement with the Organ Procurement Organization (OPO) in
effect prior to March 3, 1988 and approved by the contractor), to veterans’ hospitals, organs sent
outside the United States, and organs transplanted into non-Medicare beneficiaries. Include
organs that had partial payments by a primary insurance payer in addition to Medicare. Do not
include organs that were totally paid by primary insurance other than Medicare, as they are nonMedicare. Do not include organs procured from a non-certified OPO.
Line 64--Enter line 63 divided by line 62.
Line 65--Enter in column 1 the amount in column 2, line 64 multiplied by the amount in column
1, line 61. Enter in column 3 the amount in column 2, line 64 multiplied by the amount in
column 3, line 61.
Line 66--Enter in columns 1 and 3 the total revenue applicable to:
o
Organs (included on line 63) furnished to other providers and organs sent to procurement
organizations and others;
o
Organs sent to OPOs, military hospitals with a reciprocal sharing agreement with the OPO
in effect prior to March 3, 1988, and approved by the contractor, and organs sent to transplant
centers; and
o
Organs that were partially reimbursed by another primary insurer other than Medicare and
were included on line 63
NOTE: When the primary payer makes a single payment for the transplant and
acquisition, it is necessary to prorate the amount received between the transplant and
the acquisition based on the charges submitted to the payer. Report the primary payer
amounts applicable to organ transplants on Worksheet E, Part A, line 60. Report the
primary payer amounts applicable to organ acquisition on this line.
Line 67--Enter the amount entered on line 65 minus the amount on line 66.
Line 68--Enter in all columns the total amount of organ acquisition charges billed to Medicare
under Part B. This occurs when organs are transplanted into Medicare beneficiaries who, on the
day of transplantation, are not entitled to Part A benefits. This computation reflects an
adjustment between Medicare Part A and Part B costs and charges so that the amount added
under Part B is the same amount subtracted under Part A.
Line 69--For columns 1 and 3 subtract line 68 from line 67. For columns 2 and 4 transfer that
amount from line 68.
40-164
Rev. 3
12-10
4028.4
FORM CMS-2552-10
4028.4
Part IV - Statistics.--
Lines 70 - 84--The data entered are data applicable to living donors (column 1) and cadaveric
donors (column 2). Use column 1 (living related) for kidney, partial liver, and partial lung
transplants. If you complete this worksheet for hearts, pancreases, intestines, whole livers, whole
lungs, or islets do not complete column 1.
Line 74--Enter the sum of lines 70 through 73.
Lines 75 - 82--Enter in columns 1 and 2 the appropriate number of organs sold (or transplanted).
Enter in column 3 the revenue applicable to organs furnished to other providers, organ
procurement organizations and others, and for organs transplanted into non-Medicare patients.
Such revenues must be determined under the accrual method of accounting. If organs are
transplanted into non-Medicare patients who are not liable for payment on a charge basis, and as
such there is no revenue applicable to the related organ acquisitions, the amount entered on these
lines must also include an amount representing the acquisition cost of the organs transplanted
into such patients. Determine this amount by multiplying the average cost of organ acquisition
by the number of organs transplanted into non-Medicare patients not liable for payment on a
charge basis.
Compute the average cost of organ acquisition by dividing the total cost of organ acquisition
(including the inpatient routine service costs and the inpatient ancillary service costs applicable
to organ acquisitions) by the total number of organs transplanted into all patients and furnished
to others. If the average cost cannot be determined in the manner described, then use the
appropriate standard organ acquisition charge in lieu of the average cost.
Line 83--Enter in columns 1 and 2 the applicable number of unusable organs.
Line 84--Enter the sum of lines 75 through 83. These totals equal the totals on line 74, columns
1 and 2.
Rev. 1
40-165
4029
4029.
FORM CMS-2552-10
12-10
WORKSHEET D-5 - APPORTIONMENT OF COST FOR THE SERVICES OF
TEACHING PHYSICIANS
This worksheet provides for the computation of the RCE limit by medical specialty and for the
apportionment of reimbursable adjusted cost to titles V, XVIII, and XIX for the direct medical
and surgical services, including the supervision of interns and residents, rendered by physicians
to patients in a teaching hospital which makes the election described in CMS Pub. 15-1, §2148.
NOTE: CAHs do not complete this worksheet.
If such election is made, direct medical and surgical services to program patients, including
supervision of interns and residents, rendered in a teaching hospital by physicians on the hospital
staff are reimbursable as provider services on a reasonable cost basis. In addition, certain
medical school costs may be reimbursed. Payments for services donated by volunteer physicians
to program patients are made to a fund designated by the organized medical staff the teaching
hospital or medical school.
Limits on the amount of physician compensation which may be recognized as a reasonable
provider cost are imposed in accordance with 42 CFR 415.70.
Worksheet D-5 consists of two parts:
Part I
Part II
-
Reasonable Compensation Equivalent Computation
Apportionment of Cost for the Services of Teaching Physicians
4029.1 Part I - Reasonable Compensation Equivalent Computation--This part provides for the
computation of the RCE limit by medical specialty of the physician on the hospital staff or
physician on the medical school faculty. Complete separate parts for the hospital staff
physicians and for physicians on the medical staff faculty. This part must be completed by
applicable hospitals.
42 CFR 415.70(a)(2) provides that limits established under this section do not apply to costs of
physician compensation attributable to furnishing inpatient hospital services paid for under the
prospective payment system. (See 42 CFR Part 412.)
Limits established under this section apply to inpatient services subject to the TEFRA rate of
increase ceiling (see 42 CFR 413.40), outpatient services for all titles, and to title XVIII, Part B
inpatient services.
42 CFR 415.162 provides for the reimbursement of direct medical and surgical services to
patients, including supervision of interns and residents, rendered in a teaching hospital by
physicians on the faculty of a medical school where the hospital exercises the election as
provided in 42 CFR 415.160.
Where several physicians work in the same specialty, see CMS Pub. 15-1, §2182.6C for a
discussion of applying the RCE limit in the aggregate for the specialty versus on an individual
basis to each of the physicians in the specialty.
When RCE limits are applied on an individual basis to each physician in a medical specialty,
prepare a supporting worksheet identical in columnar format to Worksheet D-5, Part I, for each
medical specialty. Enter on the first line under columns 1 and 9 the line number applicable to the
medical specialty (as displayed on Worksheet D-5, Part I). Enter the name of the medical
specialty on the first line in columns 2 and 10. Following the first line, use a separate line to
compute the adjusted cost of physician’s direct medical and surgical services (column 16) for
each physician.
40-166
Rev. 1
08-11
FORM CMS-2552-10
4029.1 (Cont.)
Enter the total amount from column 16 of the supporting worksheet in column 16 of the line on
Worksheet D-5, Part I, corresponding to the medical specialty for which the supporting
worksheet is prepared. If the individual physician method is used, list each physician using an
individual identifier that is not necessarily the name or social security number of the physician
(e.g., Dr. A, Dr. B). However, the identity of the physician must be made available to your
contractor.
NOTE: The method used on Worksheet D-5 (i.e., aggregate or individual physician) must be
the same as the method used on Worksheet A-8-2.
Column Descriptions
Column 3--Enter for each medical specialty the amount of the total cost included in Worksheet
A-8-2, column 3. When the individual physician method is used, enter in column 3 of the
supporting worksheet the amount included on Worksheet A-8-2, column 3, for that physician.
Column 4--Enter for each medical specialty the amount of the cost included in Worksheet A-8-2,
column 4, for the direct medical and surgical services, including the supervision of interns and
residents by physicians on the hospital staff or by physicians on the faculty of a medical school,
as appropriate.
If the individual physician method is used, enter in column 4 of the supporting worksheet the
amount included on Worksheet A-8-2, column 4, for the indicated physician.
Column 5--Enter for each line of data the reasonable compensation equivalent (RCE) limit
applicable to the physician’s compensation. The amount entered is the limit applicable to the
physician specialty as published in CMS Pub. 15-1, §2182.6 before any allowable adjustments.
Obtain the RCE applicable to the specialty from the table listed in the FR, Vol. 68, No. 148, page
45488, dated Friday, August 1, 2003. If the physician specialty is not identified in the table, use
the RCE for the total category in the table. The beginning date of the cost reporting period
determines which calendar year (CY) RCE is used. Your location governs which of the three
geographical categories are applicable: non-metropolitan areas, metropolitan areas less than one
million, or metropolitan areas greater than one million.
Column 6--Enter the physician’s hours allocated to professional services (i.e., professional
component hours) in all components (e.g., hospitals, subproviders) of the health care complex. If
the physician is paid for unused vacation, unused sick leave, etc., exclude the hours so paid from
the hours entered in this column. Time records or other documentation that supports this
allocation must be available for verification by your contractor upon request. (See CMS Pub.
15-1, §2182.3E.)
Column 7--Enter the unadjusted RCE limit for each line of data. This amount is the product of
the RCE amount entered in column 5 and the ratio of the physician’s professional component
hours entered in column 6 to 2080 hours.
Column 8--Enter for each line of data five percent of the amounts entered in column 7.
Column 11--You may adjust upward, up to five percent of the computed limit (column 8), the
computed RCE limit in column 7 to take into consideration the actual costs of membership for
physicians in professional societies and continuing education paid by the provider or medical
school.
Enter for each line of data the actual amounts of these expenses paid by the provider or medical
school.
Column 12--Enter for each line of data the result of multiplying column 4 by column 11 and
dividing by column 3.
Rev. 2
40-167
4029.2
FORM CMS-2552-10
08-11
Column 13--You may also adjust upward the computed RCE limit in column 7 to reflect the
actual malpractice expense incurred by the provider or by the medical school, as appropriate, for
the services of a physician or group of physicians to provider patients. In making this adjustment,
your contractor determines the ratio of that portion of compensated physician time spent in
furnishing services in the provider (both to the provider and to provider patients) to the
physician’s total working time and adjusts the total malpractice expense proportionately.
Enter for each line of data the actual amounts of these malpractice expenses paid by the provider
(or medical school, if applicable).
Column 14--Enter for each line of data the result of multiplying column 4 by column 13 and
dividing by column 3.
Column 15--Enter for each line of data the sum of columns 7 and 14 plus the lesser of columns 8
or 12.
Column 16--Enter for each line of data the adjusted cost of direct medical and surgical services,
including the supervision of interns and residents (i.e., the lesser of column 4 or column 15).
Line Descriptions
Line 11--Total the amounts in columns 3 through 8 and 11 through 16.
4029.2 Part II - Apportionment of Cost for Services of Teaching Physicians--This part
provides for the computation and apportionment of reimbursable cost to titles V, XVIII, and XIX
for the adjusted direct medical and surgical services, including the supervision of interns and
residents, rendered by physicians to patients in a teaching hospital which makes the election
described in CMS Pub. 15-1, §2148. Complete this part for the hospital and each subprovider.
Line Descriptions
Line 1--Enter in the appropriate column the adjusted cost of direct medical and surgical services,
including the supervision of interns and residents, rendered to all patients by physicians on the
hospital staff (column 1) and by physicians on the medical school faculty (column 2), as
determined in accordance with CMS Pub. 15-1, §2148. Transfer these amounts from Part I,
column 16, line 11. Enter the same amount on each component’s copy of Part II.
Line 2--Enter in column 1 the sum of the inpatient days and the outpatient visit days for all
patients in the health care complex. Compute these days in the manner described in CMS Pub.
15-1, §2218.C. Enter in column 2 the same number of days as entered in column 1. Make the
same entries on each copy of Part II.
Line 3--Enter the result obtained by dividing the cost of services on line 1 by the sum of the days
on line 2 for each category of physicians.
Lines 4 through 17--Enter in column 1, on the appropriate line, the reimbursable days and
outpatient visit days for titles V, XVIII, and XIX for the applicable component of the health care
complex. Lines 10 through 17 contain the total of the title XVIII organ acquisition days and
outpatient visit days. Enter in column 2 the same number of days as entered in column 1.
Compute these days from your records in the manner described in CMS Pub. 15-1, §2218.C.
Lines 18 through 31--Enter on the appropriate line the result of multiplying the days entered on
lines 4 through 17 by the average cost per diem from line 3. Enter the total of columns 1 and 2
in column 3 for each line. The total becomes a part of the reimbursement settlement through the
transfers denoted on this worksheet.
40-168
Rev. 2
10-12
4030.
FORM CMS-2552-10
4030.1
WORKSHEET E - CALCULATION OF REIMBURSEMENT SETTLEMENT
Worksheet E, Parts A and B, calculate title XVIII settlement for inpatient hospital services under
inpatient PPS (IPPS) and title XVIII (Part B) settlement for medical and other health services.
Worksheet E-3 computes title XVIII, Part A settlement for non-IPPS hospitals, settlements under
titles V and XIX, and settlements for title XVIII SNFs reimbursed under a prospective payment
system. Worksheet E-4 computes total direct graduate medical education costs.
Worksheet E consists of the following two parts:
Part A - Inpatient Hospital Services Under PPS
Part B - Medical and Other Health Services
Application of Lesser of Reasonable Cost or Customary Charges--Worksheet E, Part B allows
for the computation of the lesser of reasonable costs or customary charges (LCC), where
applicable, for services covered under Part B. Make a separate computation on each of these
worksheets. In addition, make separate computations to determine whether the services on any
or all of these worksheets are exempt from LCC. For example, the provider may meet the
nominality test for the services on Worksheet E, Part B and, therefore, be exempt from LCC only
for these services.
For those provider Part B services exempt from LCC for this reason, reimbursement for the
affected services is based on 80 percent of reasonable cost net of the Part B deductible amounts.
4030.1
Part A - Inpatient Hospital Services Under IPPS--
For SCH/MDH status change and/or geographical reclassification (see 42 CFR 412.102/103)
subscript column 1 for lines 1-3, 22, 28, 29, 33, 34, 41, 45 47, and 48. If you responded “1” and
“2” or “2” and “1”, respectively to Worksheet S-2, Part I, questions 26 and 27, which indicated
your facility experienced a change in geographic classification status during the year, subscript
column 1 and report the payments before the reclassification in column 1 and on or after the
reclassification in column 1.01.
Enter on lines 1 through 3 in column 1 the applicable payment data for the period applicable to
SCH status. Enter on lines 1 through 3 in column 1.01 the payment data for the period in which
the provider did not retain SCH status. The data for lines 1 through 3 must be obtained from the
provider's records or the PS&R.
Line Descriptions
Line 1--The amount entered on this line is computed as the sum of the Federal operating portion
(DRG payment) paid for PPS discharges during the cost reporting period and the DRG payments
made for PPS transfers during the cost reporting period.
Line 2--Enter the amount of outlier payments made for PPS discharges during the period. See 42
CFR 412, Subpart F for a discussion of these items.
Line 2.01--For inpatient PPS services rendered during the cost reporting period, enter the
operating outlier reconciliation amount for operating expenses from line 92.
Line 3--Hospitals receive payments for indirect medical education for managed care patients
based on the DRG payment that would have been made if the service had not been a managed
care service. The PS&R will capture in conjunction with the PPS PRICER the simulated
payments. Enter the total managed care "simulated payments" from the PS&R.
Line 4--Enter the result of dividing the number of bed days available (Worksheet S-3, Part I,
column 3, line 14) by the number of days in the cost reporting period (365 or 366 in case of leap
year). Do not include statistics associated with an excluded unit (subprovider).
Rev. 3
40-169
4030.1 (Cont.)
FORM CMS-2552-10
10-12
NOTE: Reduce the bed days available by swing bed days (Worksheet S-3, Part I, column 8,
sum of lines 5 and 6), and the number of observation days (Worksheet S-3, Part I,
column 8, line 28).
Indirect Medical Educational Adjustment Calculation for Hospitals--Calculate the IME
adjustment only if you answered “yes” to line 56 on Worksheet S-2 and complete lines 5 to 29 as
applicable. (See 42 CFR 412.105.) Hospitals that incur indirect costs for graduate medical
education programs are eligible for an additional payment as defined in 42 CFR 412.105(d).
This section calculates the additional payment by applying the applicable multiplier of the
adjustment factor for such hospitals.
Calculation of the IME adjusted FTE Resident cap in accordance with 42 CFR 412.105(f):
Line 5--Enter the FTE count for allopathic and osteopathic programs for the most recent cost
reporting period ending on or before December 31, 1996. (42 CFR 412.105(f)(1)(iv).) Adjust
this count for the 30 percent increase for qualified rural hospitals and also adjust for any
increases due to primary care residents that were on approved leaves of absence. (42 CFR
412.105(f)(1)(iv) and (xi) respectively.) Temporarily reduce the FTE count of a hospital that
closed a program(s), if the regulations at 42 CFR 412.105(f)(1)(ix) are applicable. (Effective
10/1/2001, see 42 CFR 413.79(h)(3)(ii)).
Line 6--Enter the FTE count for allopathic and osteopathic programs which meet the criteria for
an adjustment to the cap for new programs in accordance with 42 CFR 413.79(e). For hospitals
qualifying for a cap adjustment under 42 CFR 413.79(e)(1), the cap is effective beginning with
the fourth program year of the first new program accredited or begun on or after January 1, 1995.
For hospitals qualifying for a cap adjustment under 42 CFR 413.79(e)(2), the cap for each new
program accredited is effective in the fourth program year of each of those new programs (see 66
FR, August 1, 2001, page 39881). The cap adjustment reported on this line should not include
any resident FTEs that were already included in the cap on line 5. Also enter here the allopathic
or osteopathic FTE count for residents in all years of a rural track program that meet the criteria
for an add-on to the cap under 42 CFR 412.105(f)(1)(x). (If the rural track program is a new
program under 42 CFR 413.79 and qualifies for a cap adjustment under 42 CFR 413.79(e)(1) or
(3), do not report FTE residents in the rural track program on this line until the fourth program
year. Report these FTEs on line 16.
Line 7--Enter the section 422 reduction amount to the IME cap as specified under 42 CFR
§412.105(f)(1)(iv)(B)(1).
Line 7.01--Enter the section 5503 reduction amount to the IME cap as specified under 42 CFR
§412.105(f)(1)(iv)(B)(2). If this cost report straddles July 1, 2011, calculate the prorated section
5503 reduction amount off the cost report and enter the result on this line. (Prorate the cap
reduction amount by multiplying it by the ratio of the number of days from July 1, 2011 to the
end of the cost reporting period to the total number of days in the cost reporting period.)
Otherwise enter the full cap reduction amount.
Line 8--Enter the 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.
Line 8.01--Enter, as applicable, all of or a portion of the amount of the FTE cap slots the
hospital was awarded under section 5503 of the ACA. The amount of the section 5503 award
that is reported on this line is the amount of the section 5503 award that is being “used” in this
cost reporting period. In the 5-year evaluation period following implementation of section 5503
(that is, July 1, 2011 through June 30, 2016), at least 75 percent of the slots are to be “used” for
additional primary care and/or general surgery residents, while 25 percent of the amount that is
reported may be (but need not be) “used” for other purposes. During the 5-year evaluation
period, failure to meet the requirements at 42 CFR section 413.79(n)(2) of the regulations means
loss of a hospital’s section
40-170
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
5503 slots. Therefore, do not automatically report the full amount of the section 5503 award;
only enter the amount of the section 5503 award that equates to at least 75 percent of the FTEs
being “used” for additional primary care and/or general surgery FTEs, and no more than 25
percent being used for other FTEs. If, during the 5-year evaluation period, your hospital has not
added any primary care or general surgery residents in accordance with receipt of the section
5503 award, leave this line blank and do not report any of the section 5503 award on this line in
this cost reporting period. If this cost report straddles July 1, 2011, calculate the applicable
prorated section 5503 amount of increase to the cap “off the cost report” and enter the result on
this line. (The prorated cap increase amount is to be calculated by multiplying the number of
FTE cap slots that would be reported for the entire cost reporting period in accordance with the
preceding instructions by the ratio of the number of days from July 1, 2011 to the end of the cost
reporting period to the total number of days in the cost reporting period).
Line 8.02--Enter the amount of increase if the hospital was awarded FTE cap slots from a closed
teaching hospital under section 5506 of ACA. Further subscript this line (lines 8.03 through
8.20) as necessary if the hospital receives FTE cap slot awards on more than one occasion under
section 5506. Refer to the letter from CMS awarding this hospital the slots under section 5506 to
determine the effective date of the cap increase. If the section 5506 award is phased in over
more than one effective date, only report the portions of the section 5506 award as they become
effective. If the effective date of the cap increase is not the same as your fiscal year begin date,
then prorate the cap increase accordingly. (Prorate the cap increase amount by multiplying it by
the ratio of the number of days from the effective date of the cap increase to the end of the cost
reporting period to the total number of days in the cost reporting period).
Line 9--Adjusted IME FTE Resident Cap--Enter the result of line 5 plus line 6 minus line 7
minus line 7.01 plus or minus line 8 plus line 8.01 plus line 8.02 plus applicable subscripts.
However, if the resulting IME cap is less than zero (0), enter zero (0) on this line.
Calculation of the allowable current year FTEs:
Line 10--Enter the FTE count for allopathic and osteopathic programs in the current year from
your records. Do not include residents in the initial years of the new program, which means that
the program has not yet completed one cycle of the program (i.e., “period of years,” or the
minimum accredited length of the program). (42 CFR 412.105(f)(1)(iv) and/or (f)(1)(v).) Contact
your contractor for instructions on how to complete this line if you have a new program for
which the period of years is less than or more than three years. Exclude FTE residents displaced
by hospital or program closure that are in excess of the cap for which a temporary cap
adjustment is needed (42 CFR 412.105(f)(1)(v)).
Line 11--Enter the FTE count for residents in dental and podiatric programs.
Line 12--Enter the result of the lesser of line 9, or line 10 added to line 11.
Line 13--Enter the total allowable FTE count for the prior year, either from Form 2552-96 line
3.14 or from Form 2552-10 line 12, as applicable. Do not include residents in the initial years of
the program that are exempt from the rolling average under 42 CFR 412.105(f)(1)(v). However,
if the period of years during which the FTE residents in any of your new training programs were
exempted from the rolling average has expired (see 42 CFR 412.105(f)(1)(v)), enter on this line
the allowable FTE count from line 12 plus the count of previously new FTE residents in that
specific program that were added to line 16 of the prior year’s cost report (line 3.17 if the prior
year cost report was the 2552-96). If you were not training any residents in approved teaching
programs in the prior year, make no entry.
Line 14--Enter the total allowable FTE count for the penultimate year, either from Form 2552-96
line 3.14, or Form 2552-10 line 12, as applicable. If you were not training any residents in
approved
Rev. 3
40-171
4030.1 (Cont.)
FORM CMS-2552-10
10-12
programs in the penultimate year, make no entry. Do not include residents in the initial years of
the program that are exempt from the rolling average under 42 CFR 412.105(f)(1)(v). However,
if the period of years during which the FTE residents in any of your new training programs were
exempted
from the rolling average has expired (see 42 CFR 412.105(f)(1)(v)), enter on this line the
allowable FTE count from line 12 plus the count of previously new FTE residents in that specific
program that were added to line 16 of the penultimate year’s cost report. (Line 3.17 if the prior
year cost report was the 2552-96).
Line 15--Enter in the sum of lines 12 through 14 divided by three.
Line 16--Enter the number of FTE residents in the initial years of the program that meet the
rolling average exception. (See 42 CFR 412.105(f)(1)(v))
Line 17--Enter the additional FTEs for residents that were displaced by program or hospital
closure, which you would not be able to count without a temporary cap adjustment (See 42 CFR
412.105(f)(1)(v)).
Line 18-Enter the sum of lines 15, 16 and 17.
Line 19--Enter the current year resident to bed ratio. Line 18 divided by line 4.
Line 20--In general, enter from the prior year cost report the intern and resident to bed ratio by
dividing line 12 by line 4 (divide line 3.14 by line 3 if the prior year cost report was the 255296). However, if the provider is participating in training residents in a new medical residency
training program(s) under 42 CFR 413.79(e), add to the numerator of the prior year intern and
resident to bed ratio the number of FTE residents in the current cost reporting period that are in
the initial period of years of a new program (i.e., the period of years is the minimum accredited
length of the program). If the provider is participating in a Medicare GME affiliation agreement
under 42 CFR 413.79(f), and the provider increased its current year FTE cap and current year
FTE count due to this affiliation agreement, identify the lower of: a) the difference between the
current year numerator and the prior year numerator, and b) the number by which the FTE cap
increased per the affiliation agreement, and add the lower of these two numbers to the prior
year’s numerator (see FR Vol. 66, No. 148 dated August 1, 2001, page 39880). Effective for
cost reporting periods beginning on or after 10/1/02, if the hospital is training FTE residents in
the current year that were displaced by the closure of another hospital or program, also adjust the
numerator of the prior year ratio for the number of current year FTE residents that were
displaced by hospital or program closure (42 CFR 412.105(a)(1)(iii)). The amount added to the
prior year’s numerator is the displaced resident FTE amount that you would not be able to count
without a temporary cap adjustment. This is the same amount of displaced resident FTEs entered
on line 17.
Line 21--Enter the lesser of lines 19 or 20.
Line 22--Calculate the IME payment adjustment as follows: Multiply the appropriate multiplier
of the adjustment factor (currently 1.35) times {((1 + line 21) to the .405 power) - 1} times {the
sum of line 1 + line 3}.
IME Adjustment Calculation for the Add-on--Computation of IME payments for additional
allopathic and osteopathic resident cap slots received under 42 CFR §412.105(f)(1)(iv)(C)-Complete lines 23 through 28 only where the amount on line 23 is greater than zero (0).
Line 23--Section 422 IME FTE Cap--Enter the number of allopathic and osteopathic IME FTE
residents cap slots the hospital received under 42 CFR §412.105(f)(1)(iv)(C), section 422 of the
MMA.
Line 24--IME FTE Resident Count Over the Cap--Subtract line 9 from line 10 and enter the
result here. If the result is zero or negative, the hospital does not need to use the 422 IME cap.
Therefore, do not complete lines 23 through 28.
40-172
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
Line 25--Section 422 Allowable IME FTE Resident Count--If the count on line 24 is greater than
zero, enter the lower of line 23 or line 24.
Line 26--Resident to Bed Ratio for Section 422--Divide line 25 by line 4.
Line 27--IME Adjustment Factor for Section 422 IME Residents--Enter the result of the
following: .66 times [({1 + line 26} to the .405 power) - 1].
Line 28--IME Add On Adjustment--Enter the sum of lines 1 and 3, multiplied by the factor on
line 27.
Line 29--Total IME Payment--Enter the sum of lines 22 and 28.
Disproportionate Share Adjustment--Section 1886(d)(5)(F) of the Act, as implemented by 42
CFR 412.106, requires additional Medicare payments to hospitals with a disproportionate share
of low income patients. Calculate the amount of the Medicare disproportionate share adjustment
on lines 30 through 34. Complete this portion only if you are an IPPS hospital and answered yes
to line 22, column 1 of Worksheet S-2, Part I.
Line 30--Enter the percentage of SSI recipient patient days to Medicare Part A patient days.
(Obtain the percentage from your contractor.)
Line 31--Enter the percentage resulting from the calculation of Medicaid patient days
(Worksheet S-2, Part I, columns 1 through 6, line 24) to total days reported on Worksheet S-3,
Part I, column 8, line 14, plus column 8, line 32, minus the sum of lines 5 and 6, plus employee
discount days reported on Worksheet S-3, Part I, column 8, line 30.
Line 32--Add lines 30 and 31 to equal the hospital’s DSH patient percentage.
Line 33--Compare the percentage on line 32 with the criteria described in 42 CFR 412.106(c)
and (d). Enter the payment adjustment factor calculated in accordance with 42 CFR 412.106(d).
Hospitals qualifying for DSH in accordance with 42 CFR 412.106(c)(2) (Pickle Amendment
hospitals), if Worksheet S-2, Part I, line 22, column 2 is “Y” for yes, enter 35.00 percent on line
33.
In addition, for MDH providers the rural 12 percent DSH payment cap is no longer applicable.
Line 34--Multiply line 33 by line 1.
Lines 35 - 39--Reserved for future use.
Additional Payment for High Percentage of ESRD Beneficiary Discharges--Calculate the
additional payment amount allowable for a high percentage of ESRD beneficiary discharges
pursuant to 42 CFR 412.104. When the average weekly cost per dialysis treatment changes
within a cost reporting period, create an additional column (column 1.01) for lines 41 and 45.
Line 40--Enter total Medicare discharges reported on Worksheet S-3, Part I, excluding
discharges for MS-DRGs 652, 682, 683, 684, and 685 (see FR 161, Vol. 73, dated August 19,
2008, pages and 48520 and 48447).
Line 41--Enter total Medicare discharges for ESRD beneficiaries who received dialysis treatment
during an inpatient stay (see Vol. 69, FR 154, dated August 11, 2004, page 49087) excluding
MS-DRGs 652, 682, 683, 684, and 685 (see FR 161, Vol. 73, dated August 19, 2008, pages
48520 and 48447).
Line 42--Divide line 41, sum of columns 1 and 1.01 by line 40. If the result is less than 10
percent, you do not qualify for the ESRD adjustment.
Rev. 3
40-173
4030.1 (Cont.)
FORM CMS-2552-10
10-12
Line 43--Enter the total Medicare ESRD inpatient days excluding MS-DRGs 652, 682, 683, 684,
and 685, as applicable.
Line 44--Enter the average length of stay expressed as a ratio to 7 days. Divide line 43 by line
41, sum of columns 1 and 1.01, and divide that result by 7 days.
Line 45--Enter the average weekly cost per dialysis treatment of $405.45 ($135.15 times the
average weekly number of treatments (3)). See CR 6679, Transmittal 113, dated October 30,
2009. This amount is subject to change on an annual basis. Consult the appropriate CMS
change request for future rates.
Line 46--Enter the ESRD payment adjustment (line 44, column 1 times line 45, column 1 times
line 41, column 1 plus, if applicable, line 44, column 1 times line 45, column 1.01 times line 41,
column 1.01).
Line 47--Enter the sum of lines 1, 2, 2.01, 29, 34, and 46.
Line 48--Sole community hospitals are paid the highest of the Federal payment rate, the hospitalspecific rate (HSR) determined based on a Federal fiscal year 1982 base period (see 42 CFR
412.73), or the hospital-specific rate determined based on a Federal fiscal year 1987 base period.
(See 42 CFR 412.75.) Medicare dependent hospitals are paid the highest of the Federal payment
rate, or the Federal rate plus 75 percent of the amount of the excess over the Federal rate of the
highest rate for the 1982, 1987, 2002, or 2006 base period hospital specific rate. For SCHs and
Medicare dependent/small rural hospitals, enter the applicable hospital-specific payments.
For sole community hospitals only, the hospital-specific payment amount entered on this line is
supplied by your contractor. Calculate it by multiplying the sum of the DRG weights for the
period (per the PS&R) by the final per discharge hospital-specific rate for the period. For new
hospital providers established after 1987, do not complete this line. Use the hospital specific rate
based on the higher of the cost reporting periods beginning in FY 1982, 1987, or 1996.
Additionally, for sole community hospitals only (effective for cost reporting periods beginning
on or after January 1, 2009), use the hospital specific rate based on the higher of the cost
reporting periods beginning in FY 1982, 1987, 1996, or 2006. (See 42 CFR 412.78.)
For MDH discharges occurring on or after October 1, 2006, and before October 1, 2012, an
MDH can use a FY 2002 hospital specific rate.
Line 49--For SCHs, enter the greater of line 47 or 48. For MDH discharges occurring on or after
October 1, 2006, and before October 1, 2012, if line 47 is greater than line 48, enter the amount
on line 47. Where line 48 is greater than line 47, enter the amount on line 47, plus 75 percent of
the amount that line 48 exceeds line 47. Hospitals not qualifying as SCH or MDH providers will
enter the amount from line 47.
For hospitals subscripting column 1 of line 47 due to a change in geographic location, this
computation will be computed separately for each column, and the sum of the calculations will
be entered in column 1 of this line.
Line 50--Enter the payment for inpatient program capital costs from Worksheet L, Part I, line 12;
or Part II, line 5, as applicable.
Line 51--Enter the special exceptions payment for inpatient program capital, if applicable
pursuant to 42 CFR 412.348(g) by entering the result of Worksheet L, Part III, line 13 less
Worksheet L, Part III, line 17. If this amount is negative, enter zero on this line.
Line 52--Enter the amount from Worksheet E-4, line 49. Complete this line only for the hospital
component.
40-174
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
Obtain the payment amounts for lines 53 and 54 from your contractor.
Line 53--Enter the amount of Nursing and Allied Health Managed Care payments if applicable.
Line 54--Enter the special add-on payment for new technologies (PM A-02-124, change request
2301, dated December 13, 2002).
Line 55--Enter the net organ acquisition cost from Worksheet(s) D-4, Part III, column 1, line 69.
Line 56--Enter the cost of teaching physicians from Worksheet D-5, Part II, column 3, line 20.
Line 57--Enter on the appropriate Worksheet E, Part A, the routine service other pass through
costs from Worksheet D, Part III, column 9, lines 30 through 35 for the hospital and lines 40
through 42 as applicable for the subproviders.
Line 58--Enter the ancillary service other pass through costs from Worksheet D, Part IV, column
11, line 200.
Line 59--Enter the sum of lines 49 through 58.
Line 60--Enter the amounts paid or payable by workmens' compensation and other primary
payers when program liability is secondary to that of the primary payer. There are six situations
under which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, treat the services as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted by you in these situations.) Include
the patient days and charges in total patient days and charges but do not include them in program
patient days and charges. In this situation, enter no primary payer payment on line 60. In
addition, exclude amounts paid by other primary payers for outpatient dialysis services
reimbursed under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to the primary payer payment or deductible and coinsurance)
less applicable deductible and coinsurance. Credit primary payer payment toward the
beneficiary's deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 60 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance. Do not enter primary payer payments credited toward the beneficiary's deductible
and coinsurance on line 60.
Rev. 3
40-175
10-12
FORM CMS-2552-10
4030.1 (Cont.)
Enter the primary payer amounts applicable to organ transplants. However, do not enter the
primary payer amounts applicable to organ acquisitions. Report these amounts on Worksheet D4, Part III, line 66.
If you are subject to PPS, include the covered days and charges in the program days and charges,
and include the total days and charges in the total days and charges for inpatient and pass
through cost apportionment. Furthermore, include the DRG amounts applicable to the patient
stay on line 1. Enter the primary payer payment on line 60 to the extent that the primary payer
payment is not credited toward the beneficiary's deductible and coinsurance. Do not enter
primary payer payments credited toward the beneficiary's deductibles.
Line 61--Enter the result of line 59 minus line 60.
Line 62--Enter from the PS&R or your records the deductibles billed to program patients.
Line 63--Enter from the PS&R or your records the coinsurance billed to program patients.
Line 64--Enter the program allowable bad debts, reduced by the bad debt recoveries.
recoveries exceed the current year’s bad debts, line 64 and 65 will be negative.
If
Line 65--Enter the result of line 64 (including negative amounts) times 70 percent.
Line 66--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. These amounts must also be reported on line 64.
Line 67--Enter the sum of lines 61 and 65 minus the sum of lines 62 and 63.
Line 68--Enter the partial or full credits received from manufacturers for replaced devices
applicable to MS-DRGs listed in Change Request 5860, transmittal 1509, dated May 9, 2008.
Line 69--Enter the time value of money for operating expenses, the capital outlier reconciliation
amount and time value of money for capital related expenses by entering the sum of lines 93, 95
and 96.
For SCHs, if the hospital specific payment amount on line 48, is greater than the federal specific
payment amount on line 47, do not complete this line.
Line 70--Enter any other adjustments. For example, enter an adjustment resulting from changing
the recording of vacation pay from cash basis to accrual basis. (See Pub. 15-1, §2146.4.)
Specify the adjustment in the space provided.
Enter on line 70.95 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Transmittal 1 indicated the use of line 70.96 for the additional payment in accordance with the
Health Care and Education Reconciliation Act (HCERA) of 2010, section 1109 which
established an additional payment effective for cost reporting periods which end during Federal
fiscal years 2011 and 2012 (one payment for each year) for qualifying providers under section
1886(d) of the Act and also indicated the use of Worksheet E-1, Part I, for the corresponding
interim payment. Such instructions are hereby rescinded and eliminated, as section 1109
payments will be funded by a separate appropriation unrelated to Part A of the Medicare trust
fund and are accordingly excluded from the Medicare cost report.
40-176
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
Effective for discharges occurring during Federal fiscal years 2011 and 2012 (October 1, 2010,
through September 30, 2011, and October 1, 2011, through September 30, 2012, respectively),
temporary improved/changed payments are mandated by §§3125 and 10314 ACA of 2010, as
addressed in 42 CFR 412.101 for discharges occurring during Federal fiscal years 2011 and
2012. For cost reporting periods which overlap October 1 for years 2010, 2011, and 2012, enter
on lines 70.96 (Low Volume Adjustment for FFY 2011) (and if necessary, line 70.97 (Low
Volume Adjustment for FFY 2012)) the Medicare inpatient payment adjustment for low volume
hospitals as applicable in accordance with Exhibit 4 (low volume adjustment calculation schedule
and corresponding instructions). The low volume adjustment payment must also be recorded on
Worksheet E-1 as an interim payment.
Line 71--Enter the amount due you (i.e., the sum of the amounts on line 67 plus or minus lines
69 and 70 minus line 68).
Line 72--Enter the total interim payments (received or receivable) from Worksheet E-1, column
2, line 4. For contractor final settlements, enter the amount reported on Worksheet E-1, column
2, line 5.99 on line 73. Include in interim payment the amount received as the estimated nursing
and allied health managed care payments.
Line 74--Enter line 71 minus the sum of lines 72 and 73. Transfer to Worksheet S, Part III.
Line 75--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations for
this line.
Lines 76 through 89 were intentionally skipped to accommodate future revisions to this
worksheet.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E, PART A. LINES 90
THROUGH 96 ARE FOR CONTRACTOR USE ONLY.
Line 90--Enter the original operating outlier amount from line 2 sum of all columns of this
Worksheet E, Part A prior to the inclusion of lines 92, 93, 95, and 96 of Worksheet E, Part A.
Line 91--Enter the original capital outlier amount from Worksheet L, part I, line 2.
Line 92--Enter the operating outlier reconciliation adjustment amount in accordance with CMS
Pub. 100-4, Chapter 3, §20.1.2.5 - §20.1.2.7.
Line 93--Enter the capital outlier reconciliation adjustment amount in accordance with CMS
Pub. 100-4, Chapter 3, §20.1.2.5 - §20.1.2.7.
Line 94--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 100-4,
Chapter 3, §20.1.2.5 - §20.1.2.7.)
Line 95--Enter the operating time value of money for operating related expenses.
Line 96--Enter the capital time value of money for capital related expenses.
NOTE: If a cost report is reopened more than one time, subscript lines 90 through 96,
respectively, one time for each time the cost report is reopened.
Rev. 3
40-176.1
4030.1 (Cont.)
FORM CMS-2552-10
10-12
Instructions For Completing Exhibit 4-Low Volume Adjustment Calculation Schedule:
Sections 3125 and 10314 of ACA 2010 amended the low-volume hospital adjustment in section
1886(d)(12) of the Social Security Act by revising, for FYs 2011 and 2012, the definition of a
low-volume hospital and the methodology for calculating the low-volume payment adjustment.
CMS implemented these changes to the low-volume payment adjustment in the regulations at
section 412.101 in the FY 2011 IPPS final rule (75 FR 50238 through 50275).
Under the ACA, sections 3125 and 10314 provide for a temporary change in the low-volume
adjustment for qualifying hospitals for FYs 2011 and 2012 as follows:
•
•
Those hospitals with 200 or fewer Medicare discharges will receive an adjustment of
an additional 25 percent for each discharge; and
Those with more than 200 and fewer than 1,600 Medicare discharges will receive an
adjustment of an additional percentage for each discharge. This adjustment is
calculated using the formula [(4/14) - (Medicare discharges/5600)].
To qualify as a low-volume hospital, the hospital must meet both of the following criteria:
•
•
Be more than 15 road miles from the nearest subsection (d) hospital; and
Have fewer than 1,600 Medicare discharges based on the latest available Medicare
Provider Analysis and Review (MedPAR) data.
CMS provided a table listing the IPPS hospitals with fewer than 1,600 Medicare discharges and
their low-volume percentage add-on if applicable, for FYs 2011 and 2012. However, this list is
not a list of all hospitals that qualify for the low-volume adjustment since it does not reflect
whether or not the hospital meets the mileage criteria. Hospitals were required to request lowvolume status in writing to their FI/MAC and provide documentation that they met the mileage
criteria. In order to receive the applicable low-volume add-on payment, FIs/MACs will verify
that the hospital meets both the discharge and mileage criteria.
The low-volume payment adjustment for eligible hospitals is based on their total per discharge
payments made under section 1886 of the Act, including capital IPPS payments, DSH payments,
IME payments, and outlier payments. For SCHs and MDHs, the low-volume payment
adjustment for eligible hospitals is based on either the Federal rate or the hospital-specific
payment (HSP) rate, whichever results in a greater operating IPPS payment. The low-volume
payment amount calculated by the IPPS Pricer is an interim payment amount and is subject to
adjustment during year end cost report settlement if any of the payment amounts upon which the
low-volume payment amount is based are also recalculated at cost report settlement (for
example, payments for DSH and IME or Federal rate versus HSP rate payments for SCHs and
MDHs).
Note: Because a hospital’s eligibility for the low-volume payment adjustment and/or a
hospital’s applicable low-volume adjustment percentage can change during its cost reporting
period (for example, a hospital with a cost report that spans the start of the Federal Fiscal Year
(FFY)), it is necessary to determine the low-volume payment amount using the applicable
low-volume adjustment percentage for the FFY and payment amounts listed above for a
hospital’s discharges that occur during the FFY for each FFY included by the hospitals’ cost
reporting period.
40-176.2
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
After the cost report is calculated for settlement the low-volume payment adjustment must be
calculated. The low-volume payment amount must be calculated by FFY. Therefore, if the cost
report overlaps a FFY the information computed on Worksheet E, Part A must be recomputed by
FFY accordingly. The amounts may not be prorated but must be calculated using the
appropriate information. The following payment amounts are multiplied by the low-volume
payment adjustment percentage by FFY:
−
−
−
−
−
−
−
−
−
−
Operating Federal IPPS payments;
Operating HSR payments;
Operating Outlier payments including any Operating Outlier Reconciliation amounts;
Operating IME payments;
Operating IME payments for Medicare Advantage patients;
Operating DSH payments;
ESRD Adjustment payments;
Total Capital IPPS payment
New Technology payments; and
Capital Outlier Reconciliation amounts (if applicable, see instructions)
Complete Exhibit 4 to compute the low-volume adjustment applicable to this cost reporting
period. The following Exhibit 4 is designed to simulate the Medicare cost report and must be
completed after the cost report is calculated for settlement.
Column 0--Line references are comparable to the actual line references on Worksheet E, Part A
and Worksheet L, Part I.
Column 1--Enter from Worksheet E, Part A and Worksheet L, Part I, the amounts reported on
the corresponding lines of the Medicare cost report.
Column 2--Enter amounts related to discharges occurring in the cost reporting period either
pre-entitlement (discharges occurring in the cost reporting period prior to October 1, 2010) or
post-entitlement (discharges occurring in the cost reporting period after September 30, 2012).
Discharges occurring in these periods are not eligible for the low-volume adjustment.
In addition, if there are discharges occurring during either FFY 2011 or 2012 and the provider
was not eligible for the low-volume adjustment for the entire eligibility period, report the
information relative to those discharges in this column, for example, where a provider has a cost
reporting period ending June 30, 2011. The low-volume adjustment for discharges occurring in
this cost reporting period is effective for discharges on or after October, 1, 2010; however, the
provider did not request the low-volume adjustment until November 15, 2010 and the lowvolume adjustment was implemented within 30 days of the request. The period of time from
October 1, 2010 until the MAC notified the provider of eligibility, which should be no later than
December 15, 2010, is considered a period of ineligibility.
Column 3--Enter amounts related to discharges occurring on or after October 1, 2010 through
September 30, 2011 in column 3. Do not include information for discharges occurring during
the period of ineligibility.
Column 4--Enter amounts related to discharges occurring during the period of October 1, 2011
through September 30, 2012 in column 4. Do not include information for discharges occurring
during the period of ineligibility.
Column 5--Subtotal columns 2 through 4. Column 5 must agree with column 1 and any resulting
rounding difference should be applied to the highest value in columns 2-4.
Rev. 3
40-176.3
4030.1 (Cont.)
FORM CMS-2552-10
10-12
Line Descriptions
Line 1--The amount entered on this line is computed as the sum of the Federal operating portion
(DRG payment) paid for PPS discharges during the cost reporting period and the DRG
payments made for PPS transfers during the cost reporting period. The PS&R information must
be split and reported in columns 2 through 4 and must concur with the PS&R paid through date
used to calculate the cost report for settlement.
Line 2--Enter the amount of outlier payments made for PPS discharges occurring during the cost
reporting period. The PS&R information must be split and reported in columns 2 through 4 and
must concur with the PS&R paid through date used to calculate the cost report for settlement.
Line 3 (Corresponds to Worksheet E, Part A, Line 2.01)--For inpatient PPS services rendered
during the cost reporting period, enter the operating outlier reconciliation amount for operating
expenses from line Worksheet E, Part A, line 92 for each respective period. The lump sum utility
produces a claim by claim output. If the provider has two different low-volume hospital
adjustment percentages during its cost reporting period, the MAC must report the operating and
capital outlier reconciliation adjustment amounts for the discharges occurring in each of the
federal fiscal years spanned by the cost report separately. The sum of columns 2 through 4 must
equal the amount reported on Worksheet E, Part A, line 2.01.
Line 4 (Corresponds to Worksheet E, Part A, Line 3)--Enter the indirect medical education for
managed care patients based on the DRG payment that would have been made if the service had
not been a managed care service. The PS&R will capture, in conjunction with the PPS PRICER,
the simulated payments. Enter the total managed care “simulated payments” from the PS&R.
The PS&R information must be split and reported in columns 2 through 4 and must concur with
the PS&R paid through date used to calculate the cost report for settlement.
Line 5 (Corresponds to Worksheet E, Part A, Line 21)--Enter the ratio calculated from
Worksheet E, Part A, line 21, in columns 2 through 4.
Line 6 (Corresponds to Worksheet E, Part A, Line 22--Calculate the IME payment adjustment as
follows: Multiply the appropriate multiplier of the adjustment factor (currently 1.35) times {((1
+ line 5) to the .405 power) - 1} times {the sum of line 1 + line 4}. The sum of columns 2
through 4 must equal the amount reported on Worksheet E, Part A, line 22.
Line 7 (Corresponds to Worksheet E, Part A, Line 27)-- Enter the ratio calculated from
Worksheet E, Part A, line 27, in columns 2 through 4.
Line 8 (Corresponds to Worksheet E, Part A, Line 28)--IME Add On Adjustment--Enter the sum
of lines 1 and 4, multiplied by the factor on line 7.
Line 9 (Corresponds to Worksheet E, Part A, Line 29)--Total IME Payment--Enter the sum of
lines 6 and 8. The sum of columns 2 through 4 must equal the amount reported on Worksheet E,
Part A, line 29.
Line 10 (Corresponds to Worksheet E, Part A, Line 33)--Enter the DSH percentage calculated
from Worksheet E, Part A, line 33, in columns 2 through 4.
Line 11 (Corresponds to Worksheet E, Part A, Line 34)--Multiply line 10 by line 1. The sum of
columns 2 through 4 must equal the amount reported on Worksheet E, Part A, line 34.
40-176.4
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
Line 12 (Corresponds to Worksheet E, Part A, Line 46)--Prorate in columns 2 through 4 the
amount reported on Worksheet E, Part A, line 46, based on the ratio of days in each applicable
period to total days in the cost reporting period. The sum of columns 2 through 4 must equal the
amount reported on Worksheet E, Part A, line 46.
Line 13 (Corresponds to Worksheet E, Part A, Line 47)--Enter the sum of lines 1, 2, 3, 9, 11 and
12.
Line 14 (Corresponds to Worksheet E, Part A, Line 48)--For SCHs and Medicare
dependent/small rural hospitals, enter the applicable hospital-specific payments. The sum of
columns 2 through 4 must equal the amount reported on Worksheet E Part A, line 48. If
Worksheet E, Part A, line 47 is greater than Worksheet E, Part A, line 48, do not complete this
line.
Line 15 (Corresponds to Worksheet E, Part A, Line 49)--Enter in column 1, the amount from
Worksheet E, Part A, line 49. For SCHs, if line 13, column 1 is greater than line 14, column 1,
enter in columns 2 through 4, the amount reported on line 13, for each applicable column. If
line 14, column 1 is greater than line 13, column 1, enter in columns 2 through 4, the amount
reported on line 14, for each applicable column. For MDH discharges occurring on or after
October 1, 2006, and before October 1, 2012, if line 13, column 1 is greater than line 14, column
1, enter in columns 2 through 4, the amount reported on line 13, for each applicable column. If
line 14, column 1, is greater than line 13, column 1, enter in columns 2 through 4, the amount
on line 13, for each applicable column, plus or minus 75 percent of the difference between line
14 minus line 13 for each applicable column. Hospitals not qualifying as SCH or MDH
providers will enter in columns 2 through 4, the amount from line 13, for each applicable
column. The sum of columns 2 through 4 must equal the amount reported on Worksheet E, Part
A, line 49.
Line 16 (Corresponds to Worksheet E, Part A, Line 50)--Enter in columns 2 through 4, the
amounts computed from line 26, columns 2 through 4. The sum of columns 2 through 4 must
equal the amount reported on Worksheet E, Part A, line 50.
Line 17 (Corresponds to Worksheet E, Part A, Line 54)--Enter the special add-on payment for
new technologies. The PS&R information must be split and reported in columns 2 through 4 and
must concur with the PS&R paid through date used to calculate the cost report for settlement.
Line 18 (Corresponds to Worksheet E, Part A, Line 93)--Enter the capital outlier reconciliation
adjustment amount in columns 2 through 4 accordingly. The sum of columns 2 through 4 must
equal the amount reported on Worksheet E, Part A, line 93.
Line 19 Subtotal--Enter in columns 2 through 4, the sum of amounts on lines 15, 16, 17 and 18.
For SCH, if the hospital specific payment amount on line 14, column 1, is greater than the
federal specific payment amount on line 13, column 1, enter in columns 2 through 4, the sum of
the amounts on lines 15, 16 and 17.
Line 20 (Corresponds to Worksheet L, Part I, Line 1)--Enter the amount of the federal rate
portion of the capital DRG payments for other than outlier during this cost reporting period.
The PS&R information must be split and reported in columns 2 through 4 and must concur with
the PS&R paid through date used to calculate the cost report for settlement. The sum of columns
2 through 4 must equal the amount reported on Worksheet L, Part I, line 1.
Line 21 (Corresponds to Worksheet L, Part I, Line 2)--Enter the amount of the federal rate
portion of the capital outlier payments made for PPS discharges during this cost reporting
period. The PS&R information must be split and reported in columns 2 through 4 and must
concur with the PS&R paid through date used to calculate the cost report for settlement. The
sum of columns 2 through 4 must equal the amount reported on Worksheet L, Part I, line 2.
Rev. 3
40-176.5
4030.1 (Cont.)
FORM CMS-2552-10
10-12
Line 22 (Corresponds to Worksheet L, Part I, Line 5)--Enter the ratio calculated from Worksheet
L, Part I, line 5 in all applicable columns.
Line 23 (Corresponds to Worksheet L, Part I, Line 6)--Multiply line 22 by line 20. The sum of
columns 2 through 4 must equal the amount reported on Worksheet L, Part I, line 6.
Line 24 (Corresponds to Worksheet L, Part I, Line 10)--Enter the percentage calculated from
Worksheet L, Part I, line 10 in all applicable columns.
Line 25 (Corresponds to Worksheet L, Part I, Line 11)--Multiply line 24 by line 20 and enter the
result. The sum of columns 2 through 4 must equal the amount reported on Worksheet L, Part I,
line 11.
Line 26 (Corresponds to Worksheet L, Part I, Line 12)--Enter the sum of lines 20, 21, 23 and 25.
Transfer this amount to line 16. The sum of columns 2 through 4 must equal the amount
reported on Worksheet L, Part I, line 12.
Low-volume adjustment--Effective for discharges occurring during FFYs 2011 and 2012,
compute the amount of the low-volume adjustment as follows:
Line 27--Low-volume adjustment factor--Enter the appropriate adjustment factor in columns 3
and 4.
Line 28 (Corresponds to Worksheet E, Part A, Line 70.96)--Multiply line 19 by line 27. Transfer
this amount to the cost report calculated for settlement, Worksheet E, Part A, line 70.96.
Line 29 (Corresponds to Worksheet E, Part A, Line 70.97)--Multiply line 19 by line 27. Transfer
this amount to the cost report calculated for settlement, Worksheet E, Part A, line 70.97.
40-176.6
Rev. 3
10-12
FORM CMS-2552-10
4030.1 (Cont.)
EXHIBIT 4
LOW VOLUME ADJUSTMENT CALCULATION SCHEDULE
Rev. 3
40-176.7
4030.1 (Cont.)
FORM CMS-2552-10
10-12
This page is reserved for future use.
40-176.8
Rev. 3
10-12
FORM CMS-2552-10
4030.2
4030.2 Part B - Medical and Other Health Services--Use Worksheet E, Part B, to calculate
reimbursement settlement for hospitals, subproviders, and SNFs.
Use a separate copy of Worksheet E, Part B, for each of these reporting situations. If you have
more than one hospital-based subprovider, complete a separate worksheet for each facility.
Enter check marks in the appropriate spaces at the top of each page of Worksheet E to indicate
the component program for which it is used. When the worksheet is completed for a component,
show both the hospital and component numbers. For purposes of prospective payment for
outpatient services when the PCR transition date (applicable to cancer hospitals) (see the
following paragraph), transitional outpatient payment calculation date, or geographic
reclassification date (urban to rural only) (42 CFR 412.103 and 412.230) occurs at other than
the cost report period beginning date, complete subscripted column 1.01 in addition to column 1
for lines 2 through 8 only. Order the subscripted columns chronologically as the transition dates
or geographic reclassification corresponds to your fiscal year. The dates should also agree with
the format on Worksheet D, Part V, columns 2, 2.01, 2.02 and 2.03, etcetera, if applicable.
In accordance with ACA 2010, section 3138, cancer hospitals (as defined in 42 CFR 412.23(f))
must utilize a predetermined PCR to calculate the corresponding transitional outpatient payment
effective for services rendered beginning January 1, 2012. Where the cost reporting period
overlaps a PCR revision date, subscript column 1 as indicated in the preceding paragraph to
correspond to each unique PCR. For calendar year 2012 the PCR for cancer hospitals is 0.91,
but is subject to change every calendar year. Enter the applicable PCR(s) on line 5, column 1
and applicable subscripts. See Federal Register, vol. 76, November 30, 2011, page 74206.
NOTE: If you are not a cancer or children’s hospital or covered by ACA section 3121, do not
complete lines 2 and 5 through 8.
Line Descriptions
Line 1--Enter the cost of medical and other health services for title XVIII, Part B. This amount
also includes the cost of ancillary services furnished to inpatients under the medical and other
health services benefit of Medicare Part B. These services are covered in this manner for
Medicare beneficiaries with Part B coverage only when Part A benefits are not available. Obtain
this amount from Worksheet D, Part V, line 202, columns 6 and 7, for hospitals and enter in
column 1. For SNFs transfer the amount from Worksheet D, Part V, columns 6 and 7.
The following providers are temporarily eligible for hold harmless payments and must use
columns 1 and 1.01 to correspond to the respective portion of the cost reporting period for lines 2
through 8. Rural hospitals with 100 or fewer beds whose reporting period overlaps December
31, 2012 are eligible through December 31, 2012; SCHs and EACHs regardless of bed size
whose reporting period overlaps February 29, 2012 are eligible through February 29, 2012; and
SCHs and EACHs with 100 or fewer beds whose reporting period overlaps December 31, 2012
are eligible through December 31, 2012, (Worksheet S-2, Part I, line 120, column 1 or 2 is “Y”
for yes).
CAHs are not subject to transitional corridor payments, therefore lines 2 through 9 do not apply
to CAHs. Transfer Worksheet D, Part V, columns 6 and 7, line 202.
Line 2--Enter the cost of medical and other health services reimbursed under OPPS from
Worksheet D, Part V, column 5 and applicable subscripts, line 202. Subtract from this amount
outpatient pass through costs reported on Worksheet D, Part IV, line 200, column 13.
Line 3--Enter the gross PPS payments received including payment for drugs and device pass
through payments.
Line 4--Enter the amount of outlier payments made for outpatient PPS services rendered during
the cost reporting period.
Rev. 3
40-177
4030.2 (Cont.)
FORM CMS-2552-10
10-12
Contractors only, add or subtract as applicable to the gross PPS payments the total outlier
reconciliation amount from line 94.
Line 5--Enter the hospital specific payment to cost ratio provided by your contractor. If a new
provider does not file a full cost report for a cost reporting period that ends prior to January 1,
2001, the provider is not eligible for transitional corridor payments and should enter zero (0) on
this line. (See PM A-01-51)
For cancer hospitals enter a PCR of 0.91 for services rendered during calendar year 2012.
Obtain subsequent cancer hospital PCR updates from your contractor or applicable CMS
publications.
Line 6--Enter the result of line 2 times line 5.
If the sum of lines 3 and 4 is < line 6 complete lines 7 and 8, otherwise do not complete lines 7
and 8.
Line 7--Enter the result of the sum of lines 3 and 4 divided by line 6.
Line 8--Enter the transitional corridor payment amount calculated based on the following:
a.
If the sum of lines 3 and 4 is < line 6 and Worksheet S-2, Part I, line 3, column 4
response is 3 or 7 (cancer or children’s hospital), enter the result of line 6 minus the
sum of lines 3 and 4.
In accordance with ACA 2010, section 3121, and MMEA of 2010, section 108, as amended by
the Temporary Payroll Tax Cut Continuation Act of 2011, section 308, and the Middle Class Tax
Relief and Job Creation Act of 2012, section 3002, the outpatient hold harmless provision is
effective for services rendered from January 1, 2010 through February 29, 2012 to all SCHs and
EACHs regardless of bed size; and from March 1, 2012 through December 31, 2012 to all SCHs
and EACHs with 100 or fewer beds; and from January 1, 2010 through December 31, 2012 for
rural hospitals with 100 or fewer beds.
a.
For services rendered January 1, 2010 through December 31, 2012, if Worksheet S-2,
Part I, line 120, columns 1 or 2 is “Y”, enter 85 percent of the result of line 6 minus the
sum of lines 3 and 4.
Line 9--Enter the outpatient ancillary pass through amount from Worksheet D, Part IV, column
13, line 200.
Line 10--If you are an approved CTC, enter the cost of organ acquisition from Worksheet D-4,
Part III, column 2, line 69 when Worksheet E is completed for the hospital or the hospital
component of a health care complex. Make no entry on line 10 in other situations because the
Medicare program reimburses only CTCs for organ acquisition costs.
Line 11--Enter the sum of lines 1 and 10.
Computation of Lesser of Reasonable Cost or Customary Charges--You are paid the lesser of the
reasonable cost of services furnished to beneficiaries or the customary charges made by you for
the same services. This part provides for the computation of the lesser of reasonable cost or
customary charges as defined in 42 CFR 413.13(a).
NOTE: CAHs are not subject to the computation of the lesser of reasonable costs or customary
charges. If the component is an CAH, do not complete lines 12 through 20. Instead,
enter on line 21 the amount computed on line 11.
40-178
Rev. 3
10-12
FORM CMS-2552-10
4030.2 (Cont.)
Line Descriptions
NOTE: If the medical and other health services reported here qualify for exemption from the
application of LCC (see 42 CFR 413.13(c)), also enter the total reasonable cost from
line 11 directly on line 21. Still complete lines 6 through 16 to insure that you meet
one of the criteria for this exemption.
Lines 12 - 20--These lines provide for the accumulation of charges which relate to the reasonable
cost on line 11.
Do not include on these lines: (1) the portion of charges applicable to the excess cost of luxury
items or services (see CMS Pub. 15-1, §2104.3) and (2) charges to beneficiaries for excess costs.
(See CMS Pub. 15-1, §§2570-2577.)
Line 12--For total charges for medical and other services, enter the sum of Worksheet D, Part V,
columns 3 and 4, line 202.
Rev. 3
40-178.1
4030.2 (Cont.)
FORM CMS-2552-10
10-12
This page is reserved for future use.
40-178.2
Rev. 3
10-12
FORM CMS-2552-10
4030.2 (Cont.)
Line 13--If you are an approved CTC, enter the organ acquisition charges from Worksheet D-4,
Part III, column 4, line 69 when Worksheet E is completed for the hospital or the hospital
component of a health care complex.
Line 14--Enter the sum of lines 12 and 13.
Lines 15 - 18--These lines provide for the reduction of program charges when you do not
actually impose such charges on most of the patients liable for payment for services on a charge
basis or fail to make reasonable efforts to collect such charges from those patients. If line 17 is
greater than zero, multiply line 14 by line 17, and enter the result on line 18. If you impose these
charges and make reasonable efforts to collect the charges from patients liable for payment for
services on a charge basis, you are not required to complete lines 15 through 17. Enter on line
18 the amount from line 14. In no instance may the customary charges on line 18 exceed the
actual charges on line 14. (See 42 CFR 413.13(e).)
Line 19--Enter the excess of the customary charges over the reasonable cost. If line 18 exceeds
line 11, enter the difference.
Line 20--Enter the excess of reasonable cost over the customary charges. If line 11, exceeds line
18, enter the difference.
Line 21--Enter the amount from line 11, less any amount reported on line 20 for hospital/services
subject to LCC.
For hospital/services that are not subject to LCC in accordance with 42 CFR 413.13 (e.g., CAHs
or nominal charge public or private hospitals identified on Worksheet S-2, Part I, lines 155-161),
enter the reasonable costs from line 11.
For CAHs enter on this line 101 percent of line 11.
Line 22--Enter the cost of services rendered by interns and residents as follows from Worksheet
D-2.
Provider/Component
Title XVIII
Hospital
Title XVIII
Subprovider
Title XVIII
Skilled
Part I, col. 9,
line 9 plus
line 27; or Part II,
col. 7, line 37; or
Part III, col. 6,
line 45
Part I, col. 9,
lines 10, 11 or 12;
or Part II, col. 7, col.
lines 38, 39 or 40
or Part III, col. 6,
line 46, 47 or 48
Part I, col. 9,
line 13; or Part II,
7, line 41; or
Part III, col. 6,
line 49
Nursing
Facility
Hospital
Line 23--For hospitals or subproviders that have elected to be reimbursed for the services of
teaching physicians on the basis of cost (see 42 CFR 415.160 and CMS Pub. 15-1, §2148), enter
the amount from Worksheet D-5, Part II, column 3, line 21.
Line 24--Enter the sum of lines 3, 4, 8, and 9, all columns.
Computation of reimbursement Settlement
Line 25--Enter the Part B deductibles and the Part B coinsurance billed to Medicare
beneficiaries. DO NOT INCLUDE deductibles or coinsurance billed to program patients for
physicians' professional services. If a hospital bills beneficiaries a discounted amount for
coinsurance, enter on this line the full coinsurance amount not the discounted amount.
Line 26--Enter the deductible and coinsurance relating to the amounts reported on line 24.
Rev. 3
40-179
4030.2 (Cont.)
FORM CMS-2552-10
10-12
NOTE: If these services are exempt from LCC as a result of charges being equal to or less than
60 percent of cost (refer to Worksheet S-2, Part I, lines 155-161 columns 1-5, as
applicable), enter the Part B deductibles billed to program beneficiaries only. Do not
enter any Part B coinsurance. For CAHs enter the deductibles on line 25 and the
coinsurance on line 26.
Line 27--Subtract lines 25 and 26 from lines 21 and 24 respectively. Add to that result the sum
of lines 22 and 23.
NOTE: If these services are exempt from LCC, line 21 minus line 25 times 80 percent plus
lines 22 and 23. Add to that result line 24 minus line 26.
For critical access hospitals (CAHs), enter the lesser of (line 21 minus the sum of lines 25 and
26) or 80 percent times the result of (line 21 minus line 25 minus 101% of lab cost (Worksheet
D, Part V, column 6, lines 60, 61, and subscripts) minus 101% of costs not subject to deductible
and coinsurance (Worksheet D, Part V, column 7, line 200). Add back the aforementioned
101% of lab cost and 101% of cost not subject to deductibles and coinsurance. Add to that result
the sum of lines 22 and 23.
Line 28--Enter in column 1 the amount from Worksheet E-4, line 50. Complete this line for the
hospital component only.
Line 29--Enter in column 1 the amount from Worksheet E-4, line 36. Complete this line for the
hospital component only.
Line 30--Enter in column 1 the sum of columns 1 and 1.01, lines 27 through 29.
Line 31--Enter the amounts paid or payable by workmens' compensation and other primary
payers when program liability is secondary to that of the primary payer. There are six situations
under which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, the services are treated as if they were non-program services for cost reporting
purposes only. (The primary payment satisfies the beneficiary's liability when you accept that
payment as payment in full. This is noted on no-pay bills submitted in these situations.) Include
the patient charges in total charges but not in program charges. In this situation, enter no
primary payer payment on line 31. In addition, exclude amounts paid by other primary payers
for outpatient dialysis services reimbursed under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to the primary payer payment or deductible and coinsurance)
less applicable deductible and coinsurance. Credit primary payer payment toward the
beneficiary's deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered
charges in program charges, and include the charges in charges for cost apportionment purposes.
Enter the primary payer payment on line 31 to the extent that primary payer payment is not
credited toward the beneficiary's deductible and coinsurance. Primary payer payments credited
toward the beneficiary's deductible and coinsurance are not entered on line 31.
40-180
Rev. 3
08-11
FORM CMS-2552-10
4030.2 (Cont.)
Line 32--Enter line 30 minus line 31.
Line 33--Enter the amount of allowable bad debts for deductibles and coinsurance for ESRD
services reimbursed under the composite rate system from Worksheet I-5, line 11.
Allowable bad debts (Exclude bad debts for professional services)
Line 34--Enter from your records allowable bad debts for deductibles and coinsurance net of
recoveries for other services, excluding professional services. Do not include ESRD bad debts.
These are reported on line 33. Bad debts associated with ambulance services rendered (since
these costs are reimbursed on a fee basis) are not allowable. If recoveries exceed the current
year’s bad debts, lines 34 and 35 will be negative.
Line 35--Multiply the amount (including negative amounts) on line 34 by 70 percent (hospitals
and subproviders only). The reduction does not apply to Critical Access Hospitals.
Line 36--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 34.
Line 37--Enter the sum of lines 32, 33 and 34 or 35 (hospitals and subproviders only).
Line 38--Enter the MSP-LCC reconciliation amount. Obtain this amount from the PS&R.
Line 39--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, enter the adjustment. (See CMS Pub. 15-1, §2146.4.)
Specify the adjustment in the space provided.
Enter on line 39.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Line 40--Enter the result of line 37, plus or minus line 39 minus line 38.
Line 41--Enter interim payments from Worksheet E-1, column 4, line 4. For contractor final
settlements, enter the amount reported on line 5.99 on line 42. For contractor purposes it will be
necessary to make a reclassification of the bi-weekly pass through payments from Part A to Part
B and report that Part B portion on line 42. Maintain the necessary documentation to support the
amount of the reclassification.
Line 43--Enter line 40 minus the sum of lines 41 and 42. Transfer this amount to Worksheet S,
Part III, column 3, line as appropriate.
Line 44--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by a applying reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations for
this line.
Lines 45 through 89 were intentionally skipped to accommodate future revisions to this
worksheet.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E, PART B. LINES 90
THROUGH 94 ARE FOR CONTRACTOR USE ONLY.
Line 90--Enter the original outlier amount from line 4 (sum of all columns) prior to the inclusion
of line 94 of Worksheet E, Part B.
Rev. 2
40-181
4031.1
FORM CMS-2552-10
08-11
Line 91--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 100-4,
Chapter 4, §10.7.2.2 - §10.7.2.4.
Line 92--Enter the rate used to calculate the time value of money. (See CMS Pub. 100-4,
Chapter 4, §10.7.2.2 - §10.7.2.4.)
Line 93--Enter the time value of money.
Line 94--Enter sum of lines 91 and 93.
NOTE: If a cost report is reopened more than one time, subscript lines 90 through 93,
respectively, one time for each time the cost report is reopened.
4031.
WORKSHEET E-1 - ANALYSIS OF PAYMENTS TO PROVIDERS FOR
SERVICES
RENDERED
4031.1
Part I - Analysis of Payments to Providers for Services Rendered--
Complete this worksheet for each component of the health care complex which has a separate
provider or subprovider number as shown on Worksheet S-2, Part I. If you have more than one
hospital-based subprovider, complete a separate worksheet for each facility. When the
worksheet is completed for a component, show both the hospital provider number and the
component number. Complete this worksheet only for Medicare interim payments paid by the
contractor. Do not complete it for purposes of reporting interim payments for titles V or XIX or
for reporting payments made under the composite rate for ESRD services. Providers paid on an
interim basis on periodic interim payment (PIP) adjust the interim payments for MSP/LCC
claims.
The following components use the indicated worksheet instead of Worksheet E-1:
•
•
•
Hospital-based HHAs use Worksheet H-5.
Hospital-based outpatient rehabilitation facilities use Worksheet J-4.
RHCs/FQHCs use Worksheet M-5.
The column headings designate two categories of payments:
Columns 1 and 2 - Inpatient Part A
Columns 3 and 4 - Part B
Complete lines 1 through 4. The remainder of the worksheet is completed by your contractor.
All amounts reported on this worksheet must be for services, the costs of which are included in
this cost report.
NOTE: When completing the heading, enter the provider number and the component number
which corresponds to the provider, subprovider, SNF, or swing bed-SNF which you
indicated.
DO NOT reduce any interim payments by recoveries as a result of medical review
adjustments where the recoveries were based on a sample percentage applied to the
universe of claims reviewed and the PS&R was not also adjusted.
DO NOT include fee-schedule payments for ambulance services rendered.
40-182
Rev. 2
10-12
FORM CMS-2552-10
4031.1 (Cont.)
Line Descriptions
Line 1--Enter the total Medicare interim payments paid to you (excluding payments made under
the composite rate for ESRD services), including amounts paid under PPS and pass through
payments. The amount entered must reflect the sum of all interim payments paid on individual
bills (net of adjustment bills) for services rendered in this cost reporting period. The amount
entered must also include amounts withheld from your interim payments due to an offset against
overpayments applicable to the prior cost reporting periods. Do not include (1) any retroactive
lump sum adjustment amounts based on a subsequent revision of the interim rate, (2) tentative or
net settlement amounts, or (3) interim payments payable. If you are reimbursed under the
periodic interim payment method of reimbursement, enter the periodic interim payments
received for this cost reporting period.
Line 2--Enter the total Medicare interim payments (excluding payments made under the ESRD
composite rate) payable on individual bills.
Since the cost in the cost report is on an accrual basis, this line represents the amount of services
rendered in the cost reporting period but not paid as of the end of the cost reporting period.
Also, include in column 4 the total Medicare payments payable for servicing home program
renal dialysis equipment when the provider elected 100 percent cost reimbursement.
Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer as
follows:
Reimbursement
Method
From
Column
Transfer
To
Part B Payments
4
Wkst. E, Part B, line 41
2
2
2
2
2
2
2
Wkst. E, Part A, line 72
Wkst. E-3, Part I, line 19
Wkst. E-3, Part II, line 32
Wkst. E-3, Part III, line 33
Wkst. E-3, Part IV, line 23
Wkst. E-3, Part V, line 31
Wkst. E-3, Part VI, line 16
Part A Payments
IPPS
TEFRA
IPF PPS
IRF PPS
LTC PPS
Cost
SNF PPS Title XVIII
NOTE: For a swing bed-SNF, transfer the column 2, line 4, and column 4, line 4, amounts to
Worksheet E-2, columns 1 and 2, line 20, respectively.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-1.
THROUGH 8 ARE FOR CONTRACTOR USE ONLY.
LINES 5
Line 5--List separately each settlement payment after the cost report is received together with the
date of payment. If the cost report is reopened after the NPR has been issued, continue to report
all settlement payments after the cost report is received separately on this line.
Line 6--Enter the net settlement amount (balance due the provider or balance due the program).
Obtain the amounts as follows:
Rev. 3
40-183
4031.2
FORM CMS-2552-10
Worksheet E-1,
Column as Indicated
2
4
2
2
2
2
2
2
10-12
From
Settlement Worksheet
Wkst. E, Part A, line 74
Wkst. E, Part B, line 43
Wkst. E-3, Part I, line 21
Wkst. E-3, Part II, line 34
Wkst. E-3, Part III, line 35
Wkst. E-3, Part IV, line 25
Wkst. E-3, Part V, line 33
Wkst. E-3, Part VI, line 18
For swing bed-SNF services, column 2 must equal Worksheet E-2, column 1, line 22. Column 4
must equal Worksheet E-2, column 2, line 22.
NOTE: On lines 3, 5, and 6, when a provider to program amount is due, 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.
Line 7--Enter in columns 2 and 4 the sum of lines 4 through 6. Enter amounts due the program
as a negative number. These amounts must agree with amount due provider reported on
Worksheet E, Part A, line 71; Worksheet E, Part B, line 40; Worksheet E-2, line 19; Worksheet
E-3, Part I, line 18; Worksheet E-3, Part II, line 31; Worksheet E-3, Part III, line 32; Worksheet
E-3, Part IV, line 22; Worksheet E-3, Part V, line 30; and Worksheet E-3, Part VI, line 15.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1 and 2,
respectively.
4031.2
Part II - Calculation of Reimbursement Settlement for Health Information Technology-
THIS PART IS COMPLETED BY THE CONTRACTOR FOR STANDARD COST
REPORTING PERIODS AND BY THE CONTRACTOR FOR NONSTANDARD COST
REPORTING PERIODS.
In accordance with the American Recovery and Reinvestment Act (ARRA) of 2009, section
4102, inpatient acute care services under IPPS (providers subject to section 1886(d) of the Act)
and CAHs are eligible for health information technology (HIT) payments.
This part captures relevant data used to compute the HIT payment and records the single HIT
initial payment paid by the contractor to the provider and any corresponding adjustments to this
initial payment.
Data Collection Required for the Health Information Technology Calculation-NOTE: Lines 1 through 7 must transfer data as indicated below for reporting periods
which cover exactly 12 months (referred to as standard cost reporting periods and covers a
range of 360 through 371 days). For cost reporting periods which cover other than exactly
12 months (less than or greater than 12 months (referred to as nonstandard cost reporting
periods and covers a range of less than 360 days or greater than 371 days) lines 1 through 8
must be directly input by the contractor.
NOTE: For standard cost reporting periods, the provider will complete lines 30 and 31 in the
“as filed” cost report and the amount computed on line 32 will be transferred to Worksheet S,
Part III, column 4. For non-standard cost reporting periods, the “as filed” cost report will
display zeros on all lines and a zero will be transferred from line 32 to Worksheet S, Part III,
column 4. The contractor must complete this worksheet for nonstandard cost reporting
periods.
40-184
Rev. 3
10-12
FORM CMS-2552-10
4031.2 (Cont.)
Line 1--As defined in ARRA, section 4102, transfer the total hospital discharges from
Worksheet S-3, Part I, column 15, line 14.
Line 2--Transfer the Medicare days from Worksheet S-3, Part I, column 6, sum of lines 1 and 8
through 12.
Line 3--Transfer the Medicare HMO days from Worksheet S-3, Part I, column 6, line 2.
Line 4--Transfer the total inpatient days from Worksheet S-3, Part I, column 8, sum of lines 1
and 8 through 12.
Line 5--Transfer the hospital charges from Worksheet C, Part I, column 8, line 200.
Line 6--Transfer the hospital charity care charges from Worksheet S-10, column 3, line 20.
Line 7--CAHs only, transfer the reasonable costs to purchase certified HIT technology from
Worksheet S-2, Part I, line 168.
Line 8--Calculate and enter the HIT payment in accordance with ARRA, section 4102 as
indicated below. This line can be overridden by the contractor in instances where the provider’s
circumstances require a customized HIT calculation.
For CAHs, if Worksheet S-2, lines 105 and 167 are both “Y” for yes, enter the result of
{(H1)/(line 4 x H2)} + .20 times the amount on Worksheet S-2, Part I, line 168. (Note: the
result of {(H1)/(line 4 x H2)} + .20 cannot exceed 100 percent.) The resulting amount must be
fully expensed in the current reporting period. H1 = Line 2 plus line 3. H2 = Total charges from
Worksheet C, Part I, column 8, line 200 minus charity care charges from Worksheet S-10,
column 3, line 20 divided by Worksheet C, Part I, column 8, line 200.
OR
For acute care IPPS hospitals (§1886(d) of the Act), if Worksheet S-2, line 105 is “N” for no and
line 167 is “Y” for yes, enter the result of {($2,000,000.00 + H1) x {(H2)/(line 4 x H3)} x H4}.
If line 1 is less than 1,150 discharges then H1 equals 0 (zero). If line 1 equals 1,150 through
23,000 discharges, then H1 equals the result of line 1 minus 1,149 times $200. If line 1 is greater
than or equal to 23,000 discharges then H1 = $4,370,200 [that is: 23,000 minus 1,149 times
$200]. H2 = Line 2 plus line 3. H3 = Total charges from Worksheet C, Part I, column 8, line 200
minus charity care charges from Worksheet S-10, column 3, line 20 divided by Worksheet C,
Part I, column 8, line 200. H4 = The transition factor from Worksheet S-2, Part I, line 169.
Lines 9 - 29--Reserved for future use.
Inpatient Hospital Services Under IPPS & CAH-Line 30--Enter the initial (first) payment received for HIT assets for this cost reporting period.
This initial payment is a single payment for the cost reporting period rather than a series of
periodic interim payments during the period. This line must be completed by the providers for
standard cost reporting periods and by the contractors for nonstandard cost reporting periods.
Line 31--Enter the sum of all additional initial payment adjustments, as applicable for this cost
reporting period. Enter a positive amount on this line if the sum of the initial payment
adjustments represents an increase to the initial payment. Enter a negative amount on this line if
the sum of the initial payment adjustments represents a decrease to the initial payment.
Line 32--Balance Due Provider/(Program)--Calculate and enter the result of line 8 minus the sum
of lines 30 and 31. Transfer this amount to Worksheet S, Part III, column 4, line 1.
Rev. 3
40-185
4032
4032.
FORM CMS-2552-10
10-12
WORKSHEET E-2 - CALCULATION OF REIMBURSEMENT SETTLEMENT SWING BEDS
This worksheet provides for the reimbursement calculation for swing bed services rendered to
program patients under titles V, XVIII, and XIX. It provides for an accumulation of
reimbursable costs determined on various worksheets within the cost report package. It also
provides (under Part B) for the computation of the lesser of 80 percent of reasonable cost after
deductibles or reasonable cost minus coinsurance and deductibles. These worksheets have been
designed so that components must prepare a separate worksheet for swing bed-SNF title XVIII,
Parts A and B, and separate worksheets for swing bed-NF for title V and title XIX. Use column
1 only on the worksheets for title V and title XIX. Indicate the use of each worksheet by
checking the appropriate boxes.
Lines 1 - 9--Enter in the appropriate column on lines 1 through 7 the indicated costs for each
component of the health care complex.
Line 1--Enter the cost of swing bed-SNF inpatient routine services transferred from Worksheet
D-1, Part II, line 66 (title XVIII only). Since swing beds are paid on the basis of SNF PPS, enter
the total PPS payments in column 1 or 2, as applicable, from the provider’s books and records or
the PS&R. (See Vol. 67 FR 147 dated July 31, 2002 and PM A-02-016, change request 1666)
CAHs transfer 101 percent of the amount from Worksheet D-1, part II, line 66.
Do not use lines 2 and 3 for swing bed SNF PPS providers.
Line 2--Enter the cost of swing bed-NF inpatient routine services transferred from Worksheet D1, Part II, line 69 (titles V and XIX only). Make no entry on line 2 when Worksheet E-2 is used
for swing bed-SNF.
Line 3--Enter the amount of ancillary services. CAHs transfer for Title XVIII services 101
percent of the amounts from the applicable worksheets):
Title V
Title XVIII, Part A
Title XVIII, Part B
from
from
from
Title XIX
from
Worksheet D-3, col. 3, line 200
Worksheet D-3, col. 3, line 200
The sum of Worksheet D, Part V, cols. 6 and 7, line
202
Worksheet D-3, col. 3, line 200
Enter title XVIII, Part B amounts only in column 2. Enter all other amounts in column 1.
Line 4--Enter (in column 1 for titles V and XIX and in column 2 for title XVIII) the per diem
cost for interns and residents not in an approved teaching program transferred from Worksheet
D-2, Part I, column 4, line 2.
Line 5--For title XVIII, enter in column 1 the total number of days in which program swing bedSNF patients were inpatients. Transfer these days from Worksheet D-1, Part I, sum of lines 10
and 11. For titles V or XIX, enter in column 1 the total number of days in which program swing
bed-NF patients were inpatients. Transfer these days from Worksheet D-1, Part I, sum of lines
12 and 13. For title XVIII, enter in column 2 the total number of days in which Medicare swing
bed beneficiaries were inpatients and had Medicare Part B coverage. Determine such days
without regard to whether Part A benefits were available. Submit a reconciliation with the cost
report demonstrating the computation of Medicare Part B inpatient days.
40-186
Rev. 3
12-10
FORM CMS-2552-10
4032 (Cont.)
The following reconciliation format is recommended:
Part A
Inpatient
Days
Plus
Part B
Only
Days
Part A Coverage
Minus But No
Part B
Days Coverage
Equals
Medicare
Part B
Days
NOTE: See §4026.1.
Line 6--Enter the amount on line 4 multiplied by the number of days recorded on line 5. Also, if
the hospital qualifies for the exception for graduate medical education payments in 42 CFR
413.77 (d)(1), enter the amount transferred from Worksheet D-2, Part II, column 7, line 30.
Line 7--If Worksheet E-2 is completed for a certified SNF, enter the applicable program's share
of the reasonable compensation paid to physicians for services on utilization review committees
applicable to the SNF.
Line 8--Enter the sum of lines 1 through 3, plus lines 6 and 7 for each column.
Line 9--Enter any amounts paid and/or payable by workmens' compensation and other primary
payers. (See instructions to Worksheet E, Part A, line 60, in §4030.1 for further clarification.)
Line 10--Line 8 minus line 9.
Line 11--Enter the deductible billed to program patients. DO NOT INCLUDE deductible
applicable to physician professional services. Obtain this amount from your records.
Line 12--Enter line 10 minus line 11.
Line 13--Enter from your records the amounts billed to program patients for coinsurance. DO
NOT INCLUDE coinsurance billed to program patients for physician professional services.
Line 14--In column 2, enter 80 percent of the amount on line 12.
Line 15--Enter the lesser of line 12 less line 13 or line 14.
Line 16--Enter any other adjustments. For example, enter an adjustment from changing the
recording of vacation pay from cash basis to accrual basis, etc. (See CMS Pub. 15-1, §2146.4.)
Line 17--When Worksheet E-2 is completed for Medicare, enter the amount of bad debts (net of
bad debt recoveries) for billed deductibles and coinsurance (excluding bad debts for physician
professional services and bad debts arising from covered services paid under a reasonable
charge-based methodology or a fee-schedule) for Part A services in column 1 and for Part B
services in column 2. If recoveries exceed the current year’s bad debts, line 17 will be negative.
Line 18--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 17.
Line 19--For title XVIII, Part A, enter in column 1 the sum of lines 15 and 17 plus or minus line
16. For title XVIII, Part B, enter in column 2 the sum of lines 15 and 17, plus or minus line 16.
For titles V and XIX, enter in column 1 the sum of lines 15 and 17, plus or minus line 16.
Rev. 1
40-187
4032 (Cont.)
FORM CMS-2552-10
12-10
Line 20--For title XVIII, enter in column 1 the amount from the appropriate Worksheet E-1,
column 2, line 4, and enter in column 2 the amount from the appropriate Worksheet E-1, column
4, line 4. For contractor final settlement, report on line 21 the amount from line 5.99 for columns
2 and 4. For titles V and XIX, enter interim payments from your records.
Line 22--Enter the amount recorded on line 19 minus the sum of the amounts on lines 20 and 21.
This amount shows the balance due you or the program. Transfer this amount to Worksheet S,
Part III, columns as appropriate, lines 5 or 6 for the swing bed-SNF or the swing bed-NF,
respectively.
Line 23--Enter the Medicare reimbursement effect of protested items.
Estimate the
reimbursement effect of the non-allowable items by applying reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the supporting details and
computations for this line.
40-188
Rev. 1
08-11
4033.
FORM CMS-2552-10
4033.1
WORKSHEET E-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT
The five parts of Worksheet E-3 are used to calculate reimbursement settlement:
Part I Part II Part III Part IV Part V -
Calculation of Medicare Reimbursement Settlement Under TEFRA
Calculation of Medicare Reimbursement Settlement Under IPF PPS
Calculation of Medicare Reimbursement Settlement Under IRF PPS
Calculation of Medicare Reimbursement Settlement Under LTCH PPS
Calculation of Reimbursement Settlement for Medicare Part A Services - Cost
Reimbursement (CAHs)
Part VI - Calculation of Reimbursement Settlement - All Other Health Services for Part A
Services for Title XVIII PPS SNFs
Part VII - Calculation of Reimbursement Settlement - All Other Health Services for Titles V
or XIX Services
4033.1 Part I - Calculation of Medicare Reimbursement Settlement Under TEFRA--Use
Worksheet E-3, Part I to calculate Medicare reimbursement settlement under TEFRA (includes
cancer and children’s hospitals) for hospitals and subproviders.
Use a separate copy of Worksheet E-3, Part I for each of these reporting situations. Enter check
marks in the appropriate spaces at the top of each page of Worksheet E-3, Part I to indicate the
component for which it is used. When the worksheet is completed for a component, show both
the hospital and component numbers.
Line Descriptions
Line 1--Enter (for TEFRA hospitals and subproviders) the amount from Worksheet D-1, Part II,
line 63.
Line 2--If you are an approved CTC, enter the cost of organ acquisition from Worksheet(s) D-4,
Part III, column 1, line 69 when Worksheet E-3, Part I, is completed for the hospital (or the
hospital component of a health care complex). Make no entry on line 2 in other situations
because the Medicare program reimburses only CTCs for organ acquisition costs.
Line 3--For hospitals or subproviders that have elected to be reimbursed for the services of
teaching physicians on the basis of cost, enter the amount from Worksheet D-5, Part II, column
3, line 20.
Line 4--Enter the sum of lines 1, 2 and 3.
Line 5--Enter the amounts paid or payable by workmens' compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full.
Rev. 2
40-189
4033.1 (Cont.)
FORM CMS-2552-10
08-11
This is noted on no-pay bills submitted in these situations.) Include the patient days and charges
in total patient days and charges but do not include them in program patient days and charges. In
this situation, enter no primary payer payment on line 5. In addition, exclude amounts paid by
other primary payers for outpatient dialysis services reimbursed under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the
beneficiary's deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days
and charges for cost apportionment purposes. Enter the primary payer payment on line 5 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance.
Do not enter on line 5 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 6--Enter line 4 minus line 5.
Line 7--Enter the Part A deductibles.
Line 8--Enter line 6 less line 7.
Line 9--Enter the Part A coinsurance. Include any primary payer amounts applied to Medicare
beneficiaries’ coinsurance in situations where the primary payer payment does not fully satisfy
the obligation of the beneficiary to the provider. Do not include any primary payer payments
applied to Medicare beneficiary coinsurance in situations where the primary payer payment fully
satisfies the obligation of the beneficiary to the provider.
Line 10--Enter the result of subtracting line 9 from line 8.
Line 11--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 11 and 12 will be negative.
Line 12--Multiply the amount (including negative amounts) from line 11 by 70 percent.
Line 13--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 11.
Line 14--Enter the sum of lines 10 and 12.
Line 15--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
Line 16--Enter the routine service other pass through costs from Worksheet D, Part III, column
9, line 30 for a freestanding facility or lines 40 through 42, as applicable, for the corresponding
subproviders. Add to this amount the ancillary service other pass through costs from Worksheet
D, Part IV, column 11, line 200.
40-190
Rev. 2
08-11
FORM CMS-2552-10
4033.1 (Cont.)
Line 17--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, sequestration, etc, enter the adjustment. (See CMS Pub. 151, §2146.4.) Specify the adjustment in the space provided.
Enter on line 17.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Line 18--Enter the sum of lines 14, 15, and 16 plus or minus line 17.
Line 19--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 20 the amount on line 5.99.
Line 21--Enter line 18 minus the sum of lines 19 and 20. Transfer this amount to Worksheet S,
Part III, line as appropriate.
Line 22--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations.
Rev. 2
40-191
4033.2
FORM CMS-2552-10
08-11
4033.2 Part II - Calculation of Medicare Reimbursement Settlement Under IPF PPS--Use
Worksheet E-3, Part II to calculate Medicare reimbursement settlement under IPF PPS for
hospitals and subproviders. (See 42 CFR 412, subpart N.)
Use a separate copy of Worksheet E-3, Part II for each of these reporting situations. Enter check
marks in the appropriate spaces at the top of each page of Worksheet E-3, Part II to indicate the
component for which it is used. When the worksheet is completed for a component, show both
the hospital and component numbers.
Line Descriptions
Line 1--Enter the net Federal IPF PPS payment. This amount excludes payments for outliers,
electroconvulsive therapy (ECT), and the teaching adjustment. Obtain this information from the
PS&R and/or your records.
Line 2--Enter the net IPF outlier payment. Obtain this from the PS&R and/or your accounting
books records.
Line 3--Enter the net IPF payments for ECT. Obtain this from the PS&R and/or your accounting
books and records.
NOTE: Complete only line 4 or line 5, but not both.
Line 4--For providers that trained residents in the most recent cost reporting period filed on or
before November 15, 2004 (response on Worksheet S-2, Part I, line 71, column 1 is “Y” for
yes), enter the unweighted FTE resident count for the most recent cost reporting period filed on
or before November 15, 2004. See FR, volume 69, No. 219, dated November 4, 2004, page
66922 for a detailed explanation.
Line 5--For providers that did not train residents in the most recent cost report filed before
November 15, 2004, but qualify to receive a cap adjustment under §412.424(d)(1)(iii) for
training residents in a newly accredited program(s) after that cost reporting period, enter the
unweighted cap adjustment (response to Worksheet S-2, Part I, line 71, column 2 is “Y” for yes
and column 3 contains a “4” or “5”). Do not complete this line until the fourth program year of
the first new program. If your fiscal year end does not correspond to the program year end, and
this current cost reporting period includes the beginning of the fourth program year of the first
new program, then prorate the cap adjustment accordingly.
Line 6--Enter the current year unweighted FTE resident count for other than the FTEs in the
first 3 program years of the first new program’s existence. If your fiscal year end does not
correspond
to the program year end and the current cost reporting period includes the beginning
of the 4th program year of the first new program, then prorate the count accordingly.
Line 7--Enter the current year unweighted FTE count for residents in new programs. Complete
this line only during the first 3 program years of the first new program’s existence. If your fiscal
year end does not correspond with
the program year end, and the current cost reporting period
includes the beginning of the 4th program year of the first new program, then prorate the count
accordingly.
Line 8--For providers that completed line 4, enter the lower of the FTE count on line 6 or the cap
amount on line 4.
For providers that qualify to receive a cap adjustment under §412.424(d)(1)(iii) during the first 3
program years of the first new program’s existence, enter the FTE count from line 7.
40-192
Rev. 2
08-11
FORM CMS-2552-10
4033.2 (Cont.)
Beginning with the 4th program year of the first new program’s existence, enter the lower of the
FTE count on line 6 or the FTE count on line 5. Add to this count the FTEs on line 7 if your
fiscal year end does not correspond with the teaching
program year end, and this current cost
reporting period includes the beginning of the 4th program year of the first new program.
Line 9--Enter the total IPF patient days divided by the number of days in the cost reporting
period (Worksheet S-3, Part I, column 8, line 1 (independent/freestanding) or 16 and applicable
subscripts (subprovider/provider based) divided by the total number of days in cost reporting
period). This is the average daily census.
Line 10--Enter the medical education adjustment factor by adding 1 to the ratio of line 8 to line
9. Raise that result to the power of .5150. Subtract 1 from this amount to calculate the medical
education adjustment factor. This is expressed mathematically as {(1 + (line 8 / line 9)) to the
.5150 power - 1}.
Line 11--Enter the medical education adjustment by multiplying line 1 by line 10.
Line 12--Enter the adjusted net IPF PPS payments by entering the sum of lines 1, 2, 3, and 11.
Line 13--Enter the amount of Nursing and Allied Health Managed Care payments, if applicable.
Only complete this line if your facility is a freestanding/independent non-IPPS hospital that does
not complete Worksheet E, Part A.
Line 14--If you are an approved CTC, enter the cost of organ acquisition from Worksheet(s) D-4,
Part III, column 1, line 69 when Worksheet E-3, Part II, is completed for the
freestanding/independent IPF (or the hospital based IPF/unit of a health care complex). Make no
entry on line 14 in other situations because the Medicare program reimburses only CTCs for
organ acquisition costs.
Line 15--For IPFs or IPF subproviders that have elected to be reimbursed for the services of
teaching physicians on the basis of cost, enter the amount from Worksheet D-5, Part II, column
3, line 20.
Line 16--Enter the sum of lines 12, 13, 14 and 15.
Line 17--Enter the amounts paid or payable by workmens' compensation and other primary
payers when program liability is secondary to that of the primary payer. There are six situations
under which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.) Include the
patient days and charges in total patient days and charges but do not include them in program
patient days and charges. In this situation, enter no primary payer payment on line 17. In
addition, exclude amounts paid by other primary payers for outpatient dialysis services
reimbursed under the composite rate system.
Rev. 2
40-193
4033.2 (Cont.)
FORM CMS-2552-10
08-11
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the
beneficiary's deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days
and charges for cost apportionment purposes. Enter the primary payer payment on line 17 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance.
Do not enter on line 17 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 18--Enter line 16 minus line 17.
Line 19--Enter the Part A deductibles.
Line 20--Enter line 18 minus line 19.
Line 21--Enter the Part A coinsurance. Include any primary payer amounts applied to Medicare
beneficiaries’ coinsurance in situations where the primary payer payment does not fully satisfy
the obligation of the beneficiary to the provider. Do not include any primary payer payments
applied to Medicare beneficiary coinsurance in situations where the primary payer payment fully
satisfies the obligation of the beneficiary to the provider.
Line 22--Enter the result of subtracting line 21 from line 20.
Line 23--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 23 and 24 will be negative.
Line 24--Multiply the amount (including negative amounts) from Line 23 by 70 percent.
Line 25--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 23.
Line 26--Enter the sum of lines 22 and 24.
Line 27--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
Line 28--Enter the routine service other pass through costs from Worksheet D, Part III, column
9, line 30 for a freestanding facility or line 40 for the IPF subprovider. Add to this amount the
ancillary service other pass through costs from Worksheet D, Part IV, column 11, line 200.
Line 29--Enter the outlier reconciliation amount by entering the sum of lines 51 and 53.
Line 30--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, sequestration, etc, enter the adjustment. (See CMS Pub. 151, §2146.4.) Specify the adjustment in the space provided.
Enter on line 30.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
40-194
Rev. 2
08-11
FORM CMS-2552-10
4033.2(Cont.)
Line 31--Enter the sum of lines 26, and 28 plus or minus lines 29 and 30.
Line 32--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 33 the amount on line 5.99.
Line 34--Enter line 31 minus the sum of lines 32 and 33. Transfer this amount to Worksheet S,
Part III, line as appropriate.
Line 35--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-3, PART II. LINES 50
THROUGH 53 ARE FOR CONTRACTOR USE ONLY.
Line 50--Enter the original outlier amount from worksheet E-3, Part II, line 2.
Line 51--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 100-4,
Chapter 3, §190.7.2.3 - §190.7.2.5.
Line 52--Enter the interest rate used to calculate the time value of money. (see CMS Pub. 100-4,
Chapter 3, §190.7.2.3 - §190.7.2.5.)
Line 53--Enter the time value of money.
NOTE:
If a cost report is reopened more than one time, subscript lines 50 through 53,
respectively, one time for each time the cost report is reopened.
Rev. 2
40-195
4033.3
FORM CMS-2552-10
08-11
4033.3 Part III - Calculation of Medicare Reimbursement Settlement Under IRF PPS--Use
Worksheet E-3, Part III to calculate Medicare reimbursement settlement under IRF PPS for
hospitals and subproviders. (See 42 CFR 412, subpart P.)
Use a separate copy of Worksheet E-3, Part III for each of these reporting situations. Enter
check marks in the appropriate spaces at the top of each page of Worksheet E-3, Part III to
indicate the component for which it is used. When the worksheet is completed for a component,
show both the hospital and component numbers.
Line Descriptions
Line 1--Enter the net Federal IRF PPS payment. The Federal payment includes short stay outlier
amounts. Exclude low income patient (LIP) and outlier payments. Obtain this information from
the PS&R and/or your records.
Line 2--Enter the Medicare SSI ratio from your contractor as applicable for a freestanding IRF
(IRF hospital or facility) or a hospital based IRF (subprovider or subunit).
Line 3--IRF LIP payment, enter the result of {(1 + (line 2) +(L1/L2)) to the .4613 power - 1}
times (line 1). L1 = IRF Medicaid Days from Worksheet S-2, Part I, columns 1 through 6, line
25. L2 = IRF total days from Worksheet S-3, Part I, column 8, lines 1 or 17 and subscripts as
applicable plus employee discount days (S-3, Part I, column 8, line 30 (line 31 for IRF
subproviders)).
Line 4--Enter the IRF outlier payment. Obtain this from the PS&R and/or your records.
NOTE: Complete only line 5 or line 6, but not both.
Line 5--For providers that trained residents in the most recent cost reporting period ending on
or before November 15, 2004 (response to Worksheet S-2, Part I, line 76, column 1 is “Y” for
yes), enter the unweighted FTE resident count for the most recent cost reporting period ending
on or before November 15, 2004.
Line 6-For providers that did not train residents in the most recent cost reporting period ending
on or before November 15, 2004, that qualify to receive a cap adjustment (see FR Vol. 70, No.
156, page 47929, dated August 15, 2005) for training residents in a newly accredited program(s)
after that cost reporting period, enter the unweighted cap adjustment (response to Worksheet S-2,
Part I, line 76, column 2 is “Y” for yes and column 3 contains a “4” or “5”). Do not complete
this line until the fourth program year of the first new program. If your fiscal year end does not
correspond to the program year end, and this current cost reporting period includes the beginning
of the fourth program year of the first new program, then prorate the cap adjustment accordingly.
Line 7--Enter the current year unweighted FTE resident count for other than the FTEs in the
first 3 program years of the first new program’s existence. If your fiscal year end does not
correspond
to the program year end and the current cost reporting period includes the beginning
of the 4th program
year of the first new program, then prorate the count accordingly.
Line 8--Enter the current year unweighted FTE count for residents in new programs. Complete
this line only during the first 3 program years of the first new program’s existence. If your fiscal
year end
40-196
Rev. 2
08-11
FORM CMS-2552-10
4033.3 (Cont.)
does not correspond
with the program year end, and the current cost reporting period includes the
beginning of the 4th program year of the first new program, then prorate the count accordingly.
Line 9--For providers that completed line 5, enter the lower of the FTE count on line 7 or the cap
amount on line 5.
For providers that qualify to receive a cap adjustment (see FR Vol. 70, No. 156, page 47929,
dated August 15, 2005), during the first 3 program years of the first new program’s existence
enter the FTE count from line 8.
Beginning with the 4th program year of the first new program’s existence, enter the lower of the
FTE count on line 7 or the FTE count on line 6. Add to this count the FTEs on line 8 if your
fiscal year end does not correspond with the teaching
program year end, and this current cost
reporting period includes the beginning of the 4th program year of the first new program.
Line 10--Enter the total IRF patient days divided by the number of days in the cost reporting
period (Worksheet S-3, column 8, line 1 (independent/freestanding) or 17 and applicable
subscripts (subprovider/provider based) divided by the total number of days in cost reporting
period). This is the average daily census.
Line 11--Enter the medical education adjustment factor by adding 1 to the ratio of line 9 to line
10. Raise that result to the power of .6876. Subtract 1 from this amount to calculate the medical
education adjustment factor. This is expressed mathematically as {(1 + (line 9 / line 10)) to the
.6876 power - 1}.
Line 12--Enter the medical education adjustment by multiplying line 1 by line 11. Add this
amount to line 13.
Line 13--Enter the sum of lines 1, 3, 4 and 12.
Line 14--Enter the amount of Nursing and Allied Health Managed Care payments, if applicable.
Only complete this line if your facility is a freestanding/independent non-IPPS hospital that does
not complete Worksheet E, Part A.
Line 15--If you are an approved CTC, enter the cost of organ acquisition from Worksheet(s) D-4,
Part III, column 1, line 69 when Worksheet E-3, Part III, is completed for the
freestanding/independent IRF (or the hospital based IRF/unit of a health care complex). Make
no entry on line 15 in other situations because the Medicare program reimburses only CTCs for
organ acquisition costs.
Line 16--For hospitals or subproviders that have elected to be reimbursed for the services of
teaching physicians on the basis of cost, enter the amount from Worksheet D-5, Part II, column
3, line 20.
Line 17--Enter the sum of lines 13, 14, 15 and 16.
Line 18--Enter the amounts paid or payable by workmens' compensation and other primary
payers when program liability is secondary to that of the primary payer. There are six situations
under which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Rev. 2
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
40-197
4033.3 (Cont.)
FORM CMS-2552-10
08-11
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.) Include the
patient days and charges in total patient days and charges but do not include them in program
patient days and charges. In this situation, enter no primary payer payment on line 18. In
addition, exclude amounts paid by other primary payers for outpatient dialysis services
reimbursed under the composite rate system.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the
beneficiary's deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days
and charges for cost apportionment purposes. Enter the primary payer payment on line 18 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance.
Do not enter on line 18 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 19--Enter line 17 minus line 18.
Line 20--Enter the Part A deductibles.
Line 21--Enter line 19 less line 20.
Line 22--Enter the Part A coinsurance. Include any primary payer amounts applied to Medicare
beneficiaries’ coinsurance in situations where the primary payer payment does not fully satisfy
the obligation of the beneficiary to the provider. Do not include any primary payer payments
applied to Medicare beneficiary coinsurance in situations where the primary payer payment fully
satisfies the obligation of the beneficiary to the provider.
Line 23--Enter the result of subtracting line 22 from line 21.
Line 24--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 24 and 25 will be negative.
Line 25--Multiply the amount (including negative amounts) from line 24 by 70 percent.
Line 26--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 24.
Line 27--Enter the sum of lines 23 and 25.
Line 28--Enter the amount from Worksheet E-4, line 49 for the hospital component only.
Line 29--Enter the routine service other pass through costs from Worksheet D, Part III, column
9, line 30 for a freestanding facility or line 41 for IRF the subproviders. Add to this amount the
ancillary service other pass through costs from Worksheet D, Part IV, column 11, line 200.
40-198
Rev. 2
08-11
FORM CMS-2552-10
4033.3 (Cont.)
Line 30--Enter the outlier reconciliation amount by entering the sum of lines 51 and 53.
Line 31--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, sequestration, etc, enter the adjustment. (See CMS Pub. 151, §2146.4.) Specify the adjustment in the space provided.
Enter on line 31.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Line 32--Enter the sum of lines 27, 28, and 29 plus or minus lines 30 and 31.
Line 33--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 34 the amount on line 5.99.
Line 35--Enter line 32 minus the sum of lines 33 and 34. Transfer this amount to Worksheet S,
Part III, line as appropriate.
Line 36--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-3, PART III. LINES 50
THROUGH 53 ARE FOR CONTRACTOR USE ONLY.
Line 50--Enter the original outlier amount from worksheet E-3, Part III, line 4.
Line 51--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 10004, Chapter 3, §140.2.8 - §140.2.10.
Line 52--Enter the interest rate used to calculate the time value of money. (See CMS Pub. 10004, Chapter 3, §140.2.8 - §140.2.10)
Line 53--Enter the time value of money.
NOTE: If a cost report is reopened more than one time, subscript lines 50 through 53,
respectively, one time for each time the cost report is reopened.
Rev. 2
40-199
4033.4
FORM CMS-2552-10
08-11
4033.4 Part IV - Calculation of Medicare Reimbursement Settlement Under LTCH PPS--Use
Worksheet E-3, Part IV to calculate Medicare reimbursement settlement under LTCH PPS for
hospitals and subproviders. (See 42 CFR 412, subpart O.)
Use a separate copy of Worksheet E-3, Part IV for each of these reporting situations. Enter
check marks in the appropriate spaces at the top of each page of Worksheet E-3, Part IV to
indicate the component for which it is used. When the worksheet is completed for a component,
show both the hospital and component numbers.
Line Descriptions
Line 1--Enter the net Federal LTCH PPS payment including short stay outlier payments. Obtain
this information from the PS&R and/or your records.
Line 2--Enter the high cost outlier payments. Obtain this from the PS&R and/or your records.
Line 3--Enter the sum of lines 1 and 2.
Line 4--Enter the amount of Nursing and Allied Health Managed Care payments, if applicable.
Line 5--If you are an approved CTC, enter the cost of organ acquisition from Worksheet(s) D-4,
Part III, column 1, line 69 when Worksheet E-3, Part IV, is completed for the LTCH complex.
Make no entry on line 5 in other situations because the Medicare program reimburses only CTCs
for organ acquisition costs.
Line 6--For hospitals or subproviders that have elected to be reimbursed for the services of
teaching physicians on the basis of cost, enter the amount from Worksheet D-5, Part II, column
3, line 20.
Line 7--Enter the sum of lines 3, 4, 5 and 6.
Line 8--Enter the amounts paid or payable by workmens' compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full. This is noted on no-pay bills submitted in these situations.) Include the
patient days and charges in total patient days and charges but do not include them in program
patient days and charges. In this situation, enter no primary payer payment on line 8. In
addition, exclude amounts paid by other primary payers for outpatient dialysis services
reimbursed under the composite rate system.
40-200
Rev. 2
10-12
FORM CMS-2552-10
4033.4 (Cont.)
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the
beneficiary's deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges, and include the total days and charges in total days
and charges for cost apportionment purposes. Enter the primary payer payment on line 8 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance.
Do not enter on line 8 primary payer payments credited toward the beneficiary's deductible and
coinsurance.
Line 9--Enter line 7 minus line 8.
Line 10--Enter the Part A deductibles.
Line 11--Enter line 9 less line 10.
Line 12--Enter the Part A coinsurance. Include any primary payer amounts applied to Medicare
beneficiaries’ coinsurance in situations where the primary payer payment does not fully satisfy
the obligation of the beneficiary to the provider. Do not include any primary payer payments
applied to Medicare beneficiary coinsurance in situations where the primary payer payment fully
satisfies the obligation of the beneficiary to the provider.
Line 13--Enter the result of subtracting line 12 from line 11.
Line 14--Enter program allowable bad debts reduced by recoveries. If recoveries exceed the
current year’s bad debts, lines 14 and 15 will be negative.
Line 15--Multiply the amount (including negative amounts) from line 14 by 70 percent.
Line 16--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 14.
Line 17--Enter the sum of lines 13 and 15.
Line 18-- Enter the amount from Worksheet E-4, line 49 for the hospital component
(freestanding LTCH) only.
Line 19--Enter the routine service other pass through costs from Worksheet D, Part III, column
9, line 30 for a freestanding facility. Add to this amount the ancillary service other pass through
costs from Worksheet D, Part IV, column 11, line 200.
Line 20--Enter the outlier reconciliation amount by entering the sum of lines 51 and 53.
Line 21--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, sequestration, etc, enter the adjustment. (See CMS Pub. 151, §2146.4.) Specify the adjustment in the space provided.
Enter on line 21.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Rev. 3
40-201
4033.4 (Cont.)
FORM CMS-2552-10
10-12
Line 22--Enter the sum of lines 17, 18, and 19 plus or minus lines 20 and 21.
Line 23--Enter the amount of interim payments from Worksheet E-1, column 2, line 4. For
contractor final settlements, report on line 24 the amount on line 5.99.
Line 25--Enter line 22 minus the sum of lines 23 and 24. Transfer this amount to Worksheet S,
Part III, line as appropriate.
Line 26--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET E-3, PART IV. LINES 50
THROUGH 53 ARE FOR CONTRACTOR USE ONLY.
Line 50--Enter the original outlier amount from Worksheet E-3, Part IV, line 2.
Line 51--Enter the outlier reconciliation adjustment amount in accordance with CMS Pub. 10004, Chapter 3, §150.26 - §150.28.
Line 52--Enter the interest rate used to calculate the time value of money. (see CMS Pub. 10004, Chapter 3, §150.26 - §150.28)
Line 53--Enter the time value of money.
NOTE:
40-202
If a cost report is reopened more than one time, subscript lines 50 through 53,
respectively, one time for each time the cost report is reopened.
Rev. 3
10-12
FORM CMS-2552-10
4033.5
4033.5 Part V - Calculation of Reimbursement Settlement for Medicare Part A Services - Cost
Reimbursement (CAHs)--Use Worksheet E-3, Part V, to calculate reimbursement settlement for
Medicare Part A services furnished by critical access hospitals under cost reimbursement (i.e.,
neither PPS nor TEFRA).
Line Descriptions
Line 1--Enter the appropriate inpatient operating costs:
Hospital (CAH) - Worksheet D-1, Part II, line 49
Line 2--Enter the amount of Nursing and Allied Health Managed Care payments, if applicable.
Only complete this line if your facility is a CAH that does not complete Worksheet E, Part A.
Line 3--If you are approved as a CTC, enter the cost of organ acquisition from Worksheet D-4,
Part III, column 1, line 69 when this worksheet is completed for the hospital (or the hospital
component of a health care complex). Make no entry on line 3 in other situations because the
Medicare program reimburses only CTCs for organ acquisition costs.
Line 4--Enter the sum of lines 1 through 3.
Line 5--Enter the amounts paid or payable by workmens' compensation and other primary payers
when program liability is secondary to that of the primary payer. There are six situations under
which Medicare payment is secondary to a primary payer:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are treated as if they were non-program
services. (The primary payment satisfies the beneficiary's liability when you accept that payment
as payment in full.
This is noted on no-pay bills submitted in these situations.) Include the patient days and charges
in total patient days and charges but not in program patient days and charges. In this situation,
enter no primary payer payment on line 5. In addition, exclude amounts paid by other primary
payers for outpatient dialysis services reimbursed under the composite rate system. However,
when the payment by the primary payer does not satisfy the beneficiary's obligation, the program
pays the lesser of (a) the amount it otherwise pays (without regard to the primary payer payment
or deductible and coinsurance) less the primary payer payment, or (b) the amount it otherwise
pays (without regard to primary payer payment or deductibles and coinsurance) less applicable
deductible and coinsurance. Primary payer payment is credited toward the beneficiary's
deductible and coinsurance obligation.
When the primary payment does not satisfy the beneficiary's liability, include the covered days
and charges in program days and charges and include the total days and charges in total days and
charges for cost apportionment purposes. Enter the primary payer payment on line 5 to the
extent that primary payer payment is not credited toward the beneficiary's deductible and
coinsurance. Do not enter on line 5 primary payer payments credited toward the beneficiary's
deductible and coinsurance.
Rev. 3
40-203
4033.5 (Cont.)
FORM CMS-2552-10
10-12
Line 6--CAHs enter on this line 101 percent of the amount on line 4, minus line 5.
Computation of Lesser of Reasonable Cost or Customary Charges--CAHs are not subject to
this provision for inpatient services.
Line Descriptions
NOTE: Do not complete lines 7 through 16.
Lines 7 - 16--These lines provide for the accumulation of charges which relate to the reasonable
cost on line 6.
Do not include on these lines (1) the portion of charges applicable to the excess cost of luxury
items or services (see CMS Pub. 15-1, §2104.3) and (2) your charges to beneficiaries for excess
costs as described in CMS Pub. 15-1, §§2570-2577.
Line 7--Enter the program inpatient routine service charges from your records for the applicable
component. Include charges for both routine and special care units. The amounts entered
include covered late charges billed to the program when the patient's medical condition is the
cause of the stay past the checkout time. Also, these amounts include charges relating to a stay in
an intensive care type hospital unit for a few hours when your normal practice is to bill for the
partial stay.
Line 8--Enter the total charges for inpatient ancillary services from Worksheet D-3, column 2,
sum of lines 50 through 98.
Line 9--If you are an approved CTC, enter the organ acquisition charges from Worksheet D-4,
Part III, column 3, line 69 when Worksheet E-3, Part V is completed for the hospital or the
hospital component of a health care complex.
Line 10--Enter the sum of lines 7 through 9.
Lines 11 - 14--These lines provide for the reduction of program charges when you do not
actually impose such charges on most of the patients liable for payment for services on a charge
basis or when you fail to make reasonable efforts to collect such charges from those patients. If
line 13 is greater than zero, multiply line 10 by line 13, and enter the result on line 14. If you
impose these charges and make reasonable efforts to collect the charges from patients liable for
payment for services on a charge basis, you are not required to complete lines 11 through 13.
Enter on line 14 the amount from line 10. In no instance may the customary charges on line 14
exceed the actual charges on line 10. (See 42 CFR 413.13(e).)
Line 15--Enter the excess of the customary charges on line 14 over the reasonable cost on line 6.
Line 16--Enter the excess of reasonable cost on line 6 over the customary charges on line 14.
Transfer line 16 to line 21.
Line 17--For hospitals that have elected to be reimbursed for the services of teaching physicians
on the basis of cost, enter amounts from Worksheet D-5, Part II, column 3, line 20.
40-204
Rev. 3
10-12
FORM CMS-2552-10
4033.5 (Cont.)
Computation of Reimbursement Settlement
Line 18--CAHs do not complete this line.
Line 19--Enter the sum of lines 6 and 17.
Line 20--Enter the Part A deductibles billed to Medicare beneficiaries.
Line 21--Enter the amount, if any, recorded on line 16. If you are a nominal charge provider,
enter zero. Do not complete this line.
Line 22--Enter line 19 minus line 20.
Line 23--Enter from PS&R or your records the coinsurance billed to Medicare beneficiaries.
Line 24--Enter line 22 minus line 23.
Line 25--Enter from your records program allowable bad debts net of recoveries. If recoveries
exceed the current year’s bad debts, lines 25 and 26 will be negative.
Line 26--No reduction is required for critical access hospitals.
Line 27--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 25.
Line 28--Enter the sum of lines 24 and 25, or line 26.
Line 29--Enter any other adjustments. For example, if you change the recording of vacation pay
from cash basis to accrual basis, enter the adjustment. (See CMS Pub. 15-1, §2146.4.) Specify
the adjustment in the space provided.
Enter on line 29.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Line 30--Enter line 28, plus or minus line 29.
Line 31--Enter interim payments from Worksheet E-1, column 2, line 4. For contractor final
settlement, report on line 32 the amount from line 5.99.
Line 33--Enter line 30 minus the sum of lines 31 and 32. Transfer this amount to Worksheet S,
Part III, line as appropriate.
Line 34--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations for
this line.
Rev. 3
40-205
4033.6
FORM CMS-2552-10
10-12
4033.6 Part VI - Calculation of Reimbursement Settlement - All Other Health Services for
Title XVIII Part A PPS SNF Services-- For title XVIII SNFs reimbursed under PPS, complete
this part for settlement of Part A services. For Part B services, all SNFs complete Worksheet E,
Part B.
When this part is completed for a component, show both the hospital and component numbers.
Computation of Net Costs of Covered Services
Line Descriptions
Prospective Payment Amount
Line 1--Compute the sum of the following amounts obtained your books and records or from the
PS&R:
•
The Resource Utilization Group (RUG) payments made for PPS discharges during the
cost reporting period, and
•
The RUG payments made for PPS transfers during the cost reporting period.
Line 2--Enter the amount from Worksheet D, Part III, column 9, line 44.
Line 3--Enter the amount from Worksheet D, Part IV, column 11, line 200.
Line 4--Enter the sum of lines 1 through 3.
Line 5--Do not use this line as vaccine costs are included on line 1 of Worksheet E, Part B. Line
5 is shaded on Worksheet E-3, Part VI.
Line 6--Enter any deductible amounts imposed.
Line 7--Enter any coinsurance amounts.
Line 8--Enter from your records program allowable bad debts for deductibles and coinsurance
net of bad debt recoveries. If recoveries exceed the current year’s bad debts, lines 8 and 9 will
be negative.
Line 9--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 8.
Line 10--DRA 2005 SNF Bad Debt--Calculate this line as follows: [((line 8 - line 9) *.7) + line
9]. This is the adjusted SNF reimbursable bad debt in accordance with DRA 2005, section 5004.
Line 11--Enter the title XVIII reasonable compensation paid to physicians for services on
utilization review committees to an SNF. Include on this line the amount eliminated from total
costs on Worksheet A-8. Transfer this amount from Worksheet D-1, Part III, line 85.
Line 12--Enter the result of line 4 plus line 5 minus the sum of lines 6 and 7 plus lines 10 and 11.
Line 13--Enter the amounts paid or payable by workmens' compensation and other primary
payers where program liability is secondary to that of the primary payer for inpatient services.
Enter only the primary payer amounts applicable to Part A routine and ancillary services.
Line 14--Enter any other adjustments. For example, if you change the recording of vacation pay
from the cash basis to accrual basis, sequestration, etc., enter the adjustment. (See CMS Pub. 151, §2146.4.) Specify the adjustment in the space provided.
40-206
Rev. 3
10-12
FORM CMS-2552-10
4033.6 (Cont.)
Enter on line 14.99 the program share of any recovery of accelerated depreciation applicable to
prior periods resulting from your termination or a decrease in Medicare utilization. (See Pub.
15-1, §§136 - 136.16 and 42 CFR 413.134(d)(3)(i).) Identify this line as “Recovery of
Accelerated Depreciation.”
Line 15--Enter the result of line 12, plus or minus 14, minus line 13.
Line 16--For title XVIII, enter the total interim payments from Worksheet E-1, column 2, line 4.
For contractor final settlement, report on line 17 the amount from line 5.99.
Line 18--Enter line 15 minus the sum of the amounts on lines 16 and 17. Transfer this amount to
Worksheet S, Part III, line as appropriate.
Line 19--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations.
Rev. 3
40-207
4033.7
FORM CMS-2552-10
10-12
4033.7 Part VII - Calculation of Reimbursement Settlement - All Other Health Services for
Titles V or XIX Services--Worksheet E-3 calculates reimbursement for titles V or XIX services
for hospitals, subproviders, other nursing facilities and ICF/MRs.
Use a separate copy of this part for each of these reporting situations. Enter check marks in the
appropriate spaces at the top of each page of this part to indicate the component and program for
which it is used. When this part is completed for a component, show both the hospital and
component numbers. Enter check marks in the appropriate spaces to indicate the applicable
reimbursement method for inpatient services (e.g., TEFRA, OTHER).
Computation of Net Costs of Covered Services
Line Descriptions
Line 1--Enter the appropriate inpatient operating costs.
Cost Reimbursement
Hospital/CAH or Subprovider - Worksheet D-1, Part II, line 49
Skilled Nursing Facility, Other Nursing Facility, ICF/MR - Worksheet D-1, Part III, line 86.
If Worksheet S-2, line 92 is answered “yes”, and multiple Worksheets D-1 are prepared, add
the multiple Worksheets D-1 and enter the result.
TEFRA
Hospital or Subprovider - Worksheet D-1, Part II, line 63
NOTE: If you are a new provider reimbursed under TEFRA, use Worksheet D-1, Part II, line
49.
Line 2--Enter the cost of outpatient services for titles V or XIX which is the sum of Worksheet
D, Part V, columns 6 and 7 and subscripts where applicable.
Line 3--For titles V and XIX, enter in column 1 the amount paid or payable by the State program
for organ acquisition.
Line 4--Enter the sum of lines 1 through 3.
Line 5--Enter in column 1 the amounts paid or payable by workmens' compensation and other
primary payers where program liability is secondary to that of the primary payer for inpatient
services for titles V and XIX.
Line 6--Enter in column 2 the primary payer amounts applicable to outpatient services for titles
V and XIX.
Line 7--Enter line 4 minus the sum of lines 5 and 6.
Computation of Lesser of Reasonable Cost or Customary Charges--You are paid the lesser of the
reasonable cost of services furnished to beneficiaries or your customary charges for the same
services. This part provides for the computation of the lesser of reasonable cost or customary
charges as defined in 42 CFR 413.13(a).
Line Descriptions
Lines 8 - 11--These lines provide for the accumulation of charges which relate to the reasonable
cost on line 4.
40-208
Rev. 3
10-12
FORM CMS-2552-10
4033.7 (Cont.)
Do not include on these lines (1) the portion of charges applicable to the excess cost of luxury
items or services (see CMS Pub. 15-1, §2104.3) and (2) your charges to beneficiaries for excess
costs as described in CMS Pub. 15-1, §§2570-2577.
Line 8--Enter in column 1 the program inpatient routine service charges from your records for
the applicable component for titles V and XIX. This includes charges for both routine and
special care units.
The amounts entered on line 8 include covered late charges billed to the program when the
patient's medical condition is the cause of the stay past the checkout time. Also, these amounts
include charges relating to a stay in an intensive care type hospital unit for a few hours when
your normal practice is to bill for the partial stay.
Line 9--For titles V and XIX, enter the sum of the appropriate program ancillary charges from
Worksheet D, Part V, columns 3 and/or 4 plus subscripts as applicable, line 202 in column 2.
Enter charges from Worksheet D-3, column 2, line 202 in column 1.
Line 10--Enter in column 1 for titles V and XIX the organ acquisition charges from line 3.
Line 11--Enter in column 1 for titles V and XIX the amount of the incentive resulting from the
target amount computation on Worksheet D-1, Part II, line 58, if applicable.
Line 12--Enter the sum of the amounts recorded on lines 8 through 11.
Lines 13 - 16--These lines provide for the reduction of program charges when you do not
actually impose such charges on most of the patients liable for payment for services on a charge
basis or fail to make reasonable efforts to collect such charges from those patients. If line 15 is
greater than zero, multiply line 12 by line 15, and enter the result on line 16. If you do impose
these charges and make reasonable efforts to collect the charges from patients liable for payment
for services on a charge basis, you are not required to complete lines 13 through 15. Enter on
line 16 the amount from line 12. In no instance may the customary charges on line 16 exceed the
actual charges on line 12.
Line 17--Enter the excess of the customary charges over the reasonable cost. If the amount on
line 16 is greater than the amount on line 4, enter the excess.
Line 18--Enter the excess of total reasonable cost over the total customary charges. If the
amount on line 4 exceeds the amount on line 16, enter the excess.
Line 19--Enter for titles V or XIX, columns 1 and 2, the cost of services rendered by interns and
residents as follows from Worksheet D-2:
Col. 1
Title V
Col. 2
Title V
Col. 1
Title XIX
Col. 2
Title XIX
Hospital
Part I,
col. 8,
line 9
Part I,
col. 8,
line 27
Part I,
col. 10,
line 9
Part I,
col. 10,
line 27
Subprovider
Part I,
col. 8,
lines 10-12
as applicable
Part I,
col. 10,
lines 10-12
as applicable
Nursing Facility, ICF/MR
Part I,
col. 8,
line 14
Part I,
col. 10,
line 14
Rev. 3
40-209
4033.7 (Cont.)
FORM CMS-2552-10
10-12
Line 20--For hospitals or subproviders that have elected to be reimbursed for the services of
teaching physicians on the basis of cost, enter the amounts from Worksheet D-5, Part II, column
3.
Col. 1
Col. 2
Col. 1
Col. 2
Title V
Title V
Title XIX
Title XIX
Line 18
Line 19
Line 22
Line 23
Line 21--Enter the lesser of line 4 or line 16. If this is a CAH or otherwise exempt from lower of
cost or charges, transfer the amount from line 4.
Prospective Payment Amount
NOTE:
Lines 22 through 26 must only be completed for PPS providers.
Line 22--Input the total IPPS payments for titles V and/or XIX, as applicable, in column 1. Enter
the total OPPS payments for titles V and/or XIX, as applicable, in column 2. Obtain this from
your books and records.
Line 23--Enter the amount of outlier payments made for IPPS discharges during the period, in
column 1. Enter the outlier payment for OPPS in column 2.
Line 24--Enter in column 1 the payment for inpatient program capital costs from Worksheet L,
Part I, line 12; or Part II, line 5, as applicable.
Line 25--Enter in column 1 the result of Worksheet L, Part III, line 13 less Worksheet L, Part III,
line 17. If this amount is negative, enter zero on this line.
Line 26--Enter the routine and ancillary service other pass through costs, respectively, from
Worksheet D, Part III, column 9, line 200 and from Worksheet D, Part IV, column 11, line 200,
in column 1. Enter the amount from Worksheet D, Part IV, column 13, line 200, in column 2.
Line 27--Enter the sum of lines 22 through 26, in columns 1 and 2 respectively.
Line 28--For titles V and XIX only, enter the customary charges for IPPS in column 1 and OPPS
in column 2.
Line 29--For titles V and XIX, enter the sum of lines 21 and 27, in columns 1 and 2, respectively.
Computation of Reimbursement Settlement
Line 30--Enter the amount, if any, from line 18, in columns 1 and 2, respectively.
Line 31--Enter the sum of lines 19 and 20 plus line 29 minus lines 5 and 6, in columns 1 and 2
respectively.
Line 32--Enter any deductible amounts imposed in columns 1 and 2 respectively.
Line 33--Enter any coinsurance amounts imposed in columns 1 and 2 respectively.
Line 34--Enter from your records reimbursable bad debts for deductibles and coinsurance net of
bad debt recoveries in columns 1 and 2 respectively.
40-210
Rev. 3
10-12
FORM CMS-2552-10
4033.7 (Cont.)
Line 35--Enter in column 1 the reasonable compensation paid to physicians for services on
utilization review committees to an SNF. Include the amount on this line in the amount
eliminated from total costs on Worksheet A-8. Transfer this amount from Worksheet D-1, Part
III, line 85.
Line 36--Enter the sum of lines 31, 34, and 35 minus the sum of lines 32 and 33 in columns 1
and 2, respectively.
Line 37--Enter any other adjustments in columns 1 and 2, respectively. For example, if you
change the recording of vacation pay from the cash basis to the accrual basis, enter the
adjustment. (See CMS Pub. 15-1, §2146.4.) Specify the adjustment in the space provided.
Line 38--Enter the result of line 36 plus or minus line 37 in columns 1 and 2, respectively.
Line 39--Enter the amount from Worksheet E-4, line 31 in column 1.
Line 40--Enter the sum of lines 38 and 39 in columns 1 and 2, respectively.
Line 41--For titles V and XIX, obtain interim payments from your records and enter in columns
1 and 2, respectively.
Line 42--Enter the result of line 40 minus line 41, in columns 1 and 2, respectively. Transfer the
sum of columns 1 and 2 to Worksheet S, Part III, column 1 (Title V) or column 5 (Title XIX), line
as appropriate.
Line 43--Enter the program reimbursement effect of protested items.
Estimate the
reimbursement effect of the nonallowable items by applying a reasonable methodology which
closely approximates the actual effect of the item as if it had been determined through the normal
cost finding process. (See §115.2.) Attach a schedule showing the details and computations.
Rev. 3
40-211
4034
FORM CMS-2552-10
4034.
10-12
WORKSHEET E-4 - DIRECT GRADUATE MEDICAL EDUCATION (GME) AND
ESRD OUTPATIENT DIRECT MEDICAL EDUCATION COSTS
Use this worksheet to calculate each program's payment (i.e., titles XVIII, V, and XIX) for direct
graduate medical education (GME) costs as determined under 42 CFR 413.75 through 413.83.
This worksheet applies to the direct graduate medical education cost applicable to interns and
residents in approved teaching programs in hospitals and hospital-based providers. Complete
this worksheet if the response to line 56 of Worksheet S-2, Part I is yes. The direct medical
education costs of the nursing school and paramedical education programs continue to be paid on
a reasonable cost basis as determined under 42 CFR 413.85. However, the nursing school and
paramedical education costs, formerly paid through the ESRD composite rate as an exception,
are paid on this worksheet on the basis of reasonable cost under 42 CFR 413.85. Effective for
cost reporting periods beginning on or after October 1, 1997 the unweighted direct graduate
medical education FTE is limited to the hospital’s FTE count for the most recent cost reporting
period ending on or before December 31, 1996. This limit applies to allopathic and osteopathic
residents but excludes dentistry and podiatry. The GME payment is also based on the inclusion
of Medicare HMO patients treated in the hospital. This worksheet will also calculate payment
for direct GME as determined under 42 CFR 413.79(c)(3) and (4) and IME as determined under
42 CFR 412.105(f)(1)(iv)(B) and (C) for hospitals that received an adjustment (reduction or
increase) to their FTE resident caps for direct GME and/or IME under section 422 of Public Law
108-173.
NOTE: Do not complete this worksheet for a cost reporting period prior to the base period
used for calculating the per resident amount (PRA) in situations where the hospital did
not train residents in approved residency training programs or did not participate in the
Medicare program during the base period but either condition changed in a cost
reporting period beginning on or after July 1, 1985. 42 CFR 413.77(e)(1) specified
that in this situation, any GME costs for the cost reporting period prior to the base
period are reimbursed on a reasonable cost basis.
Also, do not complete this worksheet for residents training in the general acute care
part of a CAH since the associated costs are reimbursed on a reasonable cost basis.
However, complete this worksheet for residents training in an IPF or an IRF unit of a
CAH.
Complete this worksheet if this is the first month in which residents were on duty during the first
month of the cost reporting period or if residents were on duty during the entire prior cost
reporting period. (See 42 CFR 413.77(e)(1).)
This worksheet consists of five sections:
1.
2.
3.
4.
5.
Computation of Total Direct GME Amount
Computation of Program Patient Load
Direct Medical Education Costs for ESRD Composite Rate - Title XVIII only
Apportionment of Medicare Reasonable Cost (title XVIII only)
Allocation of Medicare Direct GME Costs Between Part A and Part B
Computation of Total Direct GME Amount--This section computes the total approved amount.
Line Descriptions
Line 1--Enter the unweighted resident FTE count for allopathic and osteopathic programs for the
most recent cost reporting period ending on or before December 31, 1996. If this cost report is
less than a full 12 months, contact your contractor. (42 CFR 413.79(c)(2)) Also include here the
30 percent increase to the count for qualified rural hospitals (42 CFR 413.79(c)(2)(i)), and the
increase due to primary care residents that were on approved leaves of absence (42 CFR
413.79(i)). Temporarily reduce the cap of a hospital that closed a program(s), if the regulations
at 42 CFR 413.79(h)(3)(ii) are applicable. (Effective 10/1/2001.)
40-212
Rev. 3
10-12
FORM CMS-2552-10
4034 (Cont.)
Line 2--Enter the unweighted resident FTE count for allopathic and osteopathic programs that
meet the criteria for an adjustment to the cap for new programs in accordance with 42 CFR
413.79(e). For hospitals qualifying for a cap adjustment under 42 CFR 413.79(e)(1), the cap is
effective beginning with the fourth program year of the first new program accredited or begun on
or after January 1, 1995. For hospitals qualifying for a cap adjustment under 42 CFR
413.79(e)(2), the cap for each new program accredited or begun on or after January 1, 1995, and
before August 6, 1997, is effective in the fourth program year of each of those new programs
(see 66 FR August 1, 2001, 39881). The cap adjustment reported on this line should not include
any resident FTEs that were already included in the cap on line 1. Also enter the unweighted
allopathic or osteopathic FTE count for residents in all years of the rural track program that meet
the criteria for an add-on to the cap under 42 CFR 413.79(k). If the rural track program is a new
program under 42 CFR 413.79(l) and qualifies for a cap adjustment under 413.79(e)(1) or (e)(3),
do not report FTE residents in the rural track program on this line until the fourth program year
of the rural track program. Report these FTEs on line 15.
Line 3--Enter the section 422 reduction amount to the direct GME cap as specified under 42 CFR
§413.79(c)(3).
Line 3.01--Enter the section 5503 reduction amount to the direct GME cap as specified under 42
CFR §413.79(m). If this cost report straddles July 1, 2011, then calculate the prorated section
5503 reduction amount off the cost report and enter the result on this line. (Prorate the cap
reduction amount by multiplying it by the ratio of the number of days from July 1, 2011, to the
end of the cost reporting period to the total number of days in the cost reporting period).
Otherwise enter the full cap reduction amount.
Line 4--Enter the adjustment (increase or decrease) for the unweighted resident FTE count for
allopathic or osteopathic programs for affiliated programs in accordance with 42 CFR 413.75(b),
413.79(f), and (63 FR 26 336 May 12, 1998) ), and (67 FR 50069 August 1, 2002).
Line 4.01--Enter, as applicable, all or a portion of the amount of the FTE cap slots the hospital
was awarded under section 5503 of ACA. The amount of the section 5503 award that is reported
on this line is the amount of the section 5503 award that is being “used” in this cost reporting
period. In the 5-year evaluation period following implementation of section 5503 (that is, July 1,
2011 through June 30, 2016), at least 75 percent of the slots are to be “used” for additional
primary care and/or general surgery residents, while 25 percent of the amount that is reported
may be (but need not be) “used” for other purposes. During the 5-year evaluation period,
failure to meet the requirements at 42 CFR section 413.79(n)(2) of the regulations means loss of
a hospital’s section 5503 slots. Therefore, do not automatically report the full amount of the
section 5503 slots; only enter the amount of the section 5503 award that equates to at least 75
percent of the FTEs being “used” for additional primary care and/or general surgery FTEs, and
no more than 25 percent being used for other FTEs. If, during the 5-year evaluation period,
your hospital has not added any primary care or general surgery residents in accordance with
receipt of the section 5503 award, leave this line blank and do not report any of the section 5503
award on this line in this cost reporting period. If this cost report straddles July 1, 2011, then
calculate the applicable prorated section 5503 amount of increase to the cap off the cost report
and enter the result on this line. (The prorated cap increase amount is to be calculated by
multiplying the number of FTE cap slots that would be reported for the entire cost reporting
period in accordance with the preceding instructions by the ratio of the number of days from
July 1, 2011 to the end of the cost reporting period to the total number of days in the cost
reporting period).
Line 4.02--Enter the amount of increase if the hospital was awarded FTE cap slots from a closed
teaching hospital under section 5506 of ACA. Further subscript this line (lines 4.03 through
4.20) as necessary if the hospital receives FTE cap slot awards on more than one occasion under
section 5506. Refer to the letter from CMS awarding this hospital the slots under section 5506 to
determine the effective date of the cap increase. If the section 5506 award is phased in over
more than one effective date, only report the portions of the section 5506 award as they become
effective. If the effective date of the cap increase is not the same as your fiscal year begin date,
then prorate the cap
Rev. 3
40-213
4034 (Cont.)
FORM CMS-2552-10
10-12
increase accordingly. (Prorate the cap increase amount by multiplying it by the ratio of the
number of days from the effective date of the cap increase to the end of the cost reporting period
to the total number of days in the cost reporting period.)
Line 5--Enter the result of line 1 plus line 2 minus line 3 minus line 3.01 plus or minus line 4
plus line 4.01 plus line 4.02 plus subscripts as applicable. However, if the resulting cap is less
than zero, enter zero on this line.
Line 6--Enter the unweighted resident FTE count for allopathic or osteopathic programs for the
current year from your records, other than those in the initial years of the program , i.e., the
program has not yet completed one cycle of the program (the “period of years” or the minimum
accredited length of the program. The residents in programs within the “period of years” are
exempt from the rolling average rules. (42 CFR 413.79(d)(5) and (e).) Contact your contractor
for instructions on how to complete this line if you have a new program for which the period of
years is less than or greater than 3 years. Exclude FTE residents displaced by hospital or
program closures that are in excess of the cap for which a temporary cap adjustment is needed
(42 CFR 413.79(h)).
Line 7--Enter the lesser of lines 5 or 6.
Line 8--Enter in column 1, the weighted FTE count for primary care physicians and OB/GYN
residents in an allopathic or osteopathic program for the current year other than those in the
period of years of the program that meet the criteria for an exception to the rolling average rules.
Enter in column 2, the weighted FTE count for all other physicians in an allopathic or
osteopathic program for the current year other than those in the initial years of the program that
meet the criteria for an exception to the rolling average rules. (42 CFR 413.79(d)(5) and (e)).
Exclude FTE residents displaced by hospital or program closures that are in excess of the cap for
which a temporary cap adjustment is needed (42 CFR 413.79(h)).
Line 9--If line 6 is less than or equal to line 5, enter the amounts from line 8, columns 1 and 2, in
columns 1 and 2 of this line. Otherwise, multiply the amount in each column of line 8 by (line
5/line 6). Enter in column 3 the sum of columns 1 and 2. (42 CFR 413.79(c)(2)(iii).)
Line 10--Enter in column 2 the weighted dental and podiatric resident FTE count for the current
year.
Line 11--Enter in column 1, the amount from column 1, line 9. Enter in column 2, the sum of the
amounts in column 2, lines 9 and 10.
Line 12--Enter in column 1, the weighted FTE count for primary care residents for the prior year,
other than those in the initial years of the program that meet the criteria for an exception to the
averaging rules (42 CFR 413.79(d)(5). However, if the period of years during which the FTE
residents in any of your new training programs were exempted from the rolling average has
expired (see 42 CFR 413.79(d)(5), also enter on this line the count of FTE residents in that
specific primary care program included in Form 2552-96, line 3.22 or Form 2552-10, sum of
lines 15 and 16 of the prior year’s cost report. If subject to the cap in the prior year Form 255296 cost report, report the result of line 3.07 times (line 3.04/line 3.05). If subject to the cap in the
prior year Form 2552-10 cost report, report the result of column 1, line 8 times (line 5/line 6).
Enter in column 2, the weighted FTE count for nonprimary care residents for the prior year, other
than those in the initial years of the program that meet the criteria for an exception to the
averaging rules (42 CFR 413.79(d)(5)). However, if the period of years during which the FTE
residents in any of your new training programs were exempted from the rolling average has
expired (see 42 CFR 413.79(d)(5)), also enter on this line the count of FTE residents in that
specific nonprimary care program included in Form 2552-96, line 3.16 or Form 2552-10, sum of
lines 15 and 16 of the prior year’s cost report. If subject to the cap in the prior year Form 255296 cost report, report the result of line 3.08 times (line 3.04/line 3.05) plus line 3.11. If subject to
the cap in the prior year Form 2552-10 cost report, report the result of column 2, line 8 times
(line 5/line 6) plus line 10.
40-214
Rev. 3
10-12
FORM CMS-2552-10
4034 (Cont.)
Line 13--Enter in column 1, the weighted FTE count for primary care residents for the cost
reporting year before last, other than those in the initial years of the program that meet the
criteria for an exception to the averaging rules (42 CFR 413.79(d)(5)). However, if the period of
years during which the FTE residents in any of your new training programs were exempted from
the rolling average has expired (see 42 CFR 413.79(d)(5)), also enter on this line the count of
FTE residents in that specific primary care program included in Form 2552-96, line 3.22 or for
2552-10, sum of lines 15 and 16 of that year’s cost report. If subject to the cap in the year before
last Form 2552-96 cost report, report the result of line 3.07 times (line 3.04/line 3.05). If subject
to the cap in that year Form 2552-10 cost report, report the result of column 1, line 8 times (line
5/line 6).
Enter in column 2, the weighted FTE count for nonprimary care residents for the cost reporting
year before last, other than those in the initial years of the program that meet the criteria for an
exception to the averaging rules (42 CFR 413.79(d)(5)). However, if the period of years during
which the FTE residents in any of your new training programs were exempted from the rolling
average has expired (see 42 CFR 413.79(d)(5)), also enter on this line the count of FTE residents
in that specific nonprimary care program included in Form 2552-96, line 3.16 or Form 2552-10,
sum of lines 15 and 16 of that year’s cost report. If subject to the cap in the cost reporting year
before last, Form 2552-96 cost report, report the result of line 3.08 times (line 3.04/line 3.05)
plus line 3.11. If subject to the cap in that year Form 2552-10 cost report, report the result of
column 2, line 8 times (line 5/line 6) plus line 10.
Line 14--Enter the rolling average FTE count in each column, by adding lines 11 through 13 and
dividing by 3.
Line 15--Enter the weighted number of FTE residents in the initial years of a program that meets
the exception to the rolling average rules in column 1 for primary care and in column 2 for
nonprimary care FTEs.
Line 16--Enter the temporary weighted FTE residents that were displaced by program or a
hospital closure in column 1 for primary care and in column 2 for nonprimary care FTEs, which
you would not be able to count without a temporary cap adjustment. (42 CFR 413.79(h).)
Line 17--Enter the sum of lines 14 through 16.
Line 18-- Enter in column 1, the primary care and OB/GYN per resident amount. Enter in
column 2, the nonprimary care per resident amount.
Line 19--Enter the result of multiplying lines 17 times line 18. Enter in column 3, the sum of
columns 1 and 2.
Line 20--Section 422 Direct GME FTE Cap--Enter the number of unweighted allopathic and
osteopathic direct GME FTE resident cap slots the hospital received under 42 CFR
§413.79(c)(4).
Line 21--Direct GME FTE Resident Unweighted Count Over/Under the Cap--Subtract line 7
from line 6 and enter the result here. If the result is zero or negative, the hospital does not need
to use the direct GME section 422 additional cap and lines 22 through 24 will not be completed.
Line 22--Section 422 Allowable Direct GME FTE Resident Count--If the count on line 21 is less
than or equal to the count on line 20, then divide line 8 by line 6, and multiply the resulting ratio
by the amount on line 21. If the count on line 21 is greater than the count on line 20, then divide
line 8 by line 6, and multiply the resulting ratio by the amount on line 20.
Line 23--Enter the locality adjusted national average per resident amount as specified at 42 CFR
section 413.77(g), inflated to the hospital’s cost reporting period.
Line 24--Enter the product of lines 22 and 23. This is the allowable section 422 GME cost.
Rev. 3
40-215
4034 (Cont.)
FORM CMS-2552-10
10-12
Line 25--Enter the sum of lines 19 and 24. This is the total Part A direct GME cost.
Computation of Program Patient Load--This section computes the ratio of program inpatient
days to the total inpatient days. For this calculation, total inpatient days include inpatient days of
the hospital along with its subproviders, including distinct part units excluded from the
prospective payment system. Record hospital inpatient days of Medicare beneficiaries whose
stays are paid by risk basis HMOs and organ acquisition days as non-Medicare days. Do not
count inpatient days applicable to nursery, hospital-based SNFs and other nursing facilities, and
other non-hospital level of care units for the purpose of determining the Medicare patient load.
Line Descriptions
Line 26--Enter in column 1, for title XVIII, the sum of the days reported on Worksheet S-3, Part
I, column 6, lines 1, 8 through 12, and 16 through 18, and subscripts, as applicable. For titles V
or XIX, enter the amounts from columns 5 or 7, respectively, sum of lines 1, 8 through 12, and
16 through 18, and subscripts, as applicable. For title XVIII, enter in column 2, Medicare
managed care days from Worksheet S-3, Part I, column 6, lines 2, 3 and 4. For title XIX, enter in
column 2, Medicaid managed care days from Worksheet S-3, Part I, column 7, lines 2, 3 and 4.
Line 27--Transfer to columns 1 and 2, respectively, the sum of the days reported on Worksheet
S-3, Part I, column 8, lines 1, 8 through 12, and 16 through 18 and subscripts as applicable.
Line 28--In each column, divide line 26 by line 27 and enter the result (expressed as a decimal).
Column 1 is the Title XVIII Part A inpatient utilization and column 2 is the Medicare managed
care inpatient utilization.
Line 29--Multiply the amount on line 25, column 1, by the amount reported in each column of
line 28.
Line 30--In column 2, enter the amount on line 29, column 2 multiplied by the reduction factor
reported in the FR dated August 1, 2000, Vol. 65, section D and E, pages 47038 and 47039. This
is the reduction for direct GME payments for Medicare managed care (Medicare+Choice).
Line 31--Enter the sum of columns 1 and 2, line 29, less the amount in column 2, line 30.
Direct Medical Education Costs for ESRD Composite Rate Title XVIII Only--This section
computes the title XVIII nursing school and paramedical education costs applicable to the ESRD
composite rate. These costs are reimbursable based on the reasonable cost principles under 42
CFR 413.85 separate from the ESRD composite rate.
Line Descriptions
Line 32--Enter the amount from Worksheet B, Part I, sum of columns 20 and 23, lines 74 and 94.
Line 33--Enter the amount from Worksheet C, Part I, column 8, sum of lines 74 and 94. This
amount represents the total charges for renal and home dialysis.
Line 34--Divide line 32 by line 33, and enter the result. This amount represents the ratio of
ESRD direct medical education costs to total ESRD charges.
Line 35--Enter from your records the Medicare outpatient ESRD charges.
Line 36--Enter the result of multiplying line 34 by line 35. This represents the Medicare
outpatient ESRD costs. Transfer this amount to Worksheet E, Part B, line 29.
40-216
Rev. 3
08-11
FORM CMS-2552-10
4034 (Cont.)
Apportionment of Medicare Reasonable Cost of GME--This section determines the ratio of
Medicare reasonable costs applicable to Part A and Part B. The allowable costs of GME on
which the per resident amounts are established include GME costs attributable to the entire
hospital complex (including non-hospital portions of a health care complex). Therefore, the
reasonable costs used in the apportionment between Part A and Part B include the hospital,
hospital-based providers, and distinct part units. Do not complete this section for titles V and
XIX.
Line Descriptions
Line 37--Include the Part A reasonable cost for the entire hospital complex computed by adding
the following amounts:
•
Hospital and Subprovider(s) - Sum of each Worksheet D-1, Part II, line 49;
•
Hospital-Based HHAs - Worksheet H-4, Part I, column 1, line 1;
•
Swing Bed-SNF - Worksheet E-2, line 1, column 1;
•
Hospital-Based PPS SNF - Sum of Worksheet D-1, Part III, line 74 and Worksheet E3, Part VI, column 1, line 4.
Line 38--Enter the organ acquisition costs from Worksheet(s) D-4, Part III, column 1, line 69.
Line 39--Enter the cost of teaching physicians from Worksheet(s) D-5, Part II, column 3, line 20.
Line 40--Enter the total Medicare Part A primary payer amounts for the hospital complex from
the applicable worksheets.
•
PPS hospital and/or subproviders - Worksheet E, Part A, line 60;
•
TEFRA hospital and/or subproviders - Worksheet E-3, Part I, line 5;
•
IPF PPS hospital and/or subproviders - Worksheet E-3, Part II, line 17;
•
IRF PPS hospital and/or subproviders - Worksheet E-3, Part III, line 18;
•
LTC PPS hospital - Worksheet E-3, Part IV, line 8;
•
Cost reimbursed hospital and/or subproviders - Worksheet E-3, Part V, line 5;
•
Hospital-based HHAs - Each Worksheet H-4, Part I, column 1, line 9;
•
Swing Bed SNF and/or NF - Worksheet E-2, column 1, line 9; and
•
Hospital-based PPS SNF - Worksheet E-3, Part VI, column 1, line 13.
Line 41--Enter the sum of lines 37 through 39 minus line 40.
Rev. 2
40-216.1
4034 (Cont.)
FORM CMS-2552-10
08-11
Line 42--Enter the Part B Medicare reasonable cost. Enter the sum of the amounts on each title
XVIII Worksheet E, Part B, columns 1 and 1.01, sum of lines 1, 2, 9, 10, 22, and 23; Worksheet
E-2, column 2, line 8; Worksheet H-4, Part I, sum of columns 2 and 3, line 1; Worksheet J-3,
column 1, line 1; and Worksheet M-3, line 16.
Line 43--Enter the Part B primary payer amounts. Enter the sum of the amounts on each
Worksheet E, Part B, line 31; Worksheet E-2, column 2, line 9; Worksheet H-4, Part I, sum of
columns 2 and 3, line 9; and Worksheet J-3, line 4.
Line 44--Enter line 42 minus line 43
Line 45--Enter the sum of lines 41 and 44.
Line 46--Divide line 41 by line 45, and enter the result.
Line 47--Divide line 44 by line 45, and enter the result.
Allocation of Medicare Direct GME Costs Between Part A and Part B--Use this section to
compute the GME payments for title XVIII, Part A and Part B, and to compute the total GME
payments applicable to titles V and XIX.
Line Descriptions
Line 48--Enter the amount from line 31.
Line 49--Complete for title XVIII only. Multiply line 46 by line 48, and enter the result. If you
are a hospital subject to IPPS, transfer this amount to Worksheet E, Part A, line 52. Although
this amount includes the Part A GME payments for subproviders, for ease of computation,
transfer this amount to the primary hospital component worksheet only. If you are freestanding
facility subject to TEFRA, transfer this amount to Worksheet E-3, Part I, line 15. If you are a
freestanding IPF PPS, transfer this amount to Worksheet E-3, Part II, line 27. If you are a
freestanding IRF PPS, transfer this amount to Worksheet E-3, Part III, line 28. If you are a
freestanding LTCH PPS, transfer this amount to Worksheet E-3, Part IV, line 18.
IPF or IRF subproviders of a CAH, transfer this amount to Worksheet E-3, Part II, line 27 or
Worksheet E-3, Part III, line 28, respectively.
Line 50--Complete for title XVIII only. Multiply line 47 by line 48, and enter the result.
Transfer this amount to Worksheet E, Part B, line 28. Although this amount includes the Part B
GME payments for subproviders, for ease of computation, transfer this amount to the hospital
component only.
SECTIONS 4035 THROUGH 4039 ARE RESERVED FOR FUTURE USE.
40-216.2
Rev. 2
08-11
4040.
FORM CMS-2552-10
4040
FINANCIAL STATEMENT WORKSHEETS
Prepare these worksheets from your accounting books and records.
Complete all worksheets in the "G" series. Complete Worksheets G and G-1 if you maintain
fund-type accounting records, complete separate amounts for General, Specific Purpose,
Endowment and Plant funds on Worksheets G and G-1. If you do not maintain fund-type
accounting records, complete the general fund column only. Cost reports received with
incomplete G worksheets are returned to you for completion. If you do not follow this
procedure, you are considered as having failed to file a cost report. Where applicable,
Worksheets G, G-1, G-2 and G-3 must be consistent with financial statements prepared by
Certified Public Accountants.
4040.1 Worksheet G - Balance Sheet--If the lines on the Worksheet G are not sufficient, use
lines 5 (Other receivables), 9 (Other current assets), 44 (Other current liabilities), and 49 (Other
long term liabilities), as appropriate, to report the sum of account balances and adjustments.
Maintain supporting documentation or subscript the appropriate lines.
Enter accumulated depreciation as a negative amount.
Column 1--General Fund--Use only this fund column when you do not maintain fund-type
accounting records. This fund is similar to a general ledger account and records all assets and
liabilities of the entity
Column 2--Specific Purpose Fund--These accounts are used for funds held for specific purposes
such as research and education.
Column 3--Endowment Fund--These accounts are for amounts restricted for endowment
purposes.
Column 4--Plant Fund--These accounts are for amounts restricted for the replacement and
expansion of the plant.
Line 1--Cash on Hand and in Banks--The amounts on this line represent the amount of cash on
deposit in banks and immediately available for use in financing activities, amounts on hand for
minor disbursements and amounts invested in savings accounts and certificates of deposit.
Typical accounts would be cash, general checking accounts, payroll checking accounts, other
checking accounts, imprest cash funds, saving accounts, certificates of deposit, treasury bills and
treasury notes and other cash accounts.
Line 2--Temporary Investments--The amounts on this line represent current securities evidenced
by certificates of ownership or indebtedness. Typical accounts would be marketable securities
and other current investments.
Line 3--Notes Receivable--The amounts on this line represent current unpaid amounts evidenced
by certificates of indebtedness.
Line 4--Accounts Receivable--Include on this line all unpaid inpatient and outpatient billings.
Include direct billings to patients for deductibles, co-insurance and other patient chargeable items
if they are not included elsewhere.
Line 6--Less: Allowance for Uncollectable Notes and Accounts--These are valuation (or contraasset) accounts whose credit balances represent the estimated amount of uncollectible
receivables from patients and third-party payers. Enter this amount as a negative.
Rev. 2
40-217
4040.1 (Cont.)
FORM CMS-2552-10
08-11
Line 7--Inventory--Enter the costs of unused hospital supplies. Perpetual inventory records may
be maintained and adjusted periodically to physical count. The extent of inventory control and
detailed record-keeping will depend upon the size and organizational complexity of the hospital.
Hospital inventories may be valued by any generally accepted method, but the method must be
consistently applied from year to year.
Line 8--Prepaid Expenses--Enter the costs incurred which are properly chargeable to a future
accounting period.
Line 9--Other Current Assets --These balances include other current assets not included in other
asset categories.
Line 10--Due from Other Funds--There are four funds: General Fund, Specific Purpose Fund,
Endowment Fund and Plant Fund. These are represented in columns 1 through 4, respectively.
Amounts reported in each column should be the amount due from other funds in another column
on Worksheet G, line 43 (Due to Other Funds).
The sum of the amounts on line 10, columns 1 through 4 must equal the sum of the amounts on
line 43, columns 1 through 4.
Line 12--Land--This balance reflects the cost of land used in hospital operations. Included here
is the cost of off-site sewer and water lines, public utility, charges for servicing the land,
governmental assessments for street paving and sewers, the cost of permanent roadways and of
grading of a non-depreciable nature. Unlike building and equipment, land does not deteriorate
with use or with the passage of time; therefore, no depreciation is accumulated.
The cost of land includes (1) the cash purchase price, (2) closing costs such as title and attorney’s
fees, (3) real estate broker’s commission, and (4) accrued property taxes and other liens on the
land assumed by the purchaser.
Land 13--Land Improvements--Amounts on this line include structural additions made to land,
such as driveways, parking lots, sidewalks; as well as the cost of shrubbery, fences and walls,
landscaping, on-site sewer and water lines, and underground sprinklers. The cost of land
improvements includes all expenditures necessary to make the improvements ready for their
intended use.
Line 15--Buildings--This line includes the cost of all buildings and subsequent additions used in
hospital operations (including purchase price, closing costs, (attorney fees, title insurance, etc.),
and real estate broker commission). Included are all architectural, consulting and legal fees
related to the acquisition or construction of buildings, and interest paid for construction
financing.
Line 17--Leasehold Improvements--All expenditures for the improvement of a leasehold used in
hospital operations are included on this line.
Line 19--Fixed Equipment--Include the cost of building equipment that has the following general
characteristics:
1. Affixed to the building, not subject to transfer or removal.
2. A life of more than one year, but less than that of the building to which it is affixed.
3. Used in hospital operations.
Fixed equipment includes such items as boilers, generators, engines, pumps, and refrigeration
machinery, wiring, electrical fixtures, plumbing, elevators, heating system, air conditioning
system, etc.
40-218
Rev. 2
08-11
FORM CMS-2552-10
4040.1 (Cont.)
Line 21--Automobiles and Trucks--Enter the cost of automobiles and trucks used in hospital
operations.
Line 23--Major movable Equipment--Costs of equipment included on this line has the following
general characteristics:
1. Ability to be moved, as distinguished from fixed equipment (but not automobiles or
trucks).
2. A more or less fixed location in the building.
3. A unit cost large enough to justify the expense incident to control by means of an
equipment ledger and greater than or equal to $5,000.
4. Sufficient individuality and size to make control feasible by means of identification tags.
5. A minimum life of usually three years or more.
6. Used in hospital operations.
Line 25--Minor Equipment-Depreciable--Costs of equipment included on this line has the
following general characteristics:
1. Ability to be moved, as distinguished from fixed equipment.
2. A more or less fixed location in the building
3. A unit cost large enough to justify the expense incident to control by means of an
equipment ledger but less than $5,000.
4. Sufficient individuality and size to make control feasible by means of identification tags.
5. A minimum life of usually three years or more.
6. Used in hospital operations.
Line 27--Health Information Technology (HIT) Designated Assets--The amounts included here
are the acquisition costs of HIT acquired assets in accordance with ARRA 2009, section 4102.
Acute care hospitals are required to depreciate such assets in accordance with their applicable
depreciation schedules. CAHs are required to identify such assets on this line, but do not
depreciate such assets as they will be fully expensed during the year of acquisition.
Line 29--Minor Equipment-Nondepreciable--Costs of equipment included on this line has the
following general characteristics:
1. Location generally not fixed; subject to requisition or use by various departments of the
hospital.
2. Relatively small size.
3. Subject to storeroom control.
4. Fairly large number in use.
5. Generally a useful life of usually approximately three years or less.
6. Used in hospital operations.
Minor equipment includes such items as, but is not limited to wastebaskets, bed pans, syringes,
catheters, basins, glassware, silverware, pots and pans, sheets, blankets, ladders, and surgical
instruments.
Lines 14, 16, 18, 20, 22, 24, 26 and 28--Less Accumulated Depreciation--These balances,
respectively, include the depreciation accumulated on the related assets used in hospital
operations. Enter this amount as a negative.
Line 31--Investments--This field contains the cost of investments purchased with hospital funds
and the fair market value (at date of donation) of securities donated to the hospital.
Line 32--Deposits on Leases--Report the amount of deposits on leases. This includes security
deposits.
Rev. 2
40-219
4040.1 (Cont.)
FORM CMS-2552-10
08-11
Line 33--Due to Owners/Officers--Report the amount loaned to the hospital by owners and/or
officers.
Line 34--Other Assets--This is the amount of assets not reported on line 9 (other current assets)
or any other line 1 through 33. This could include intangible assets such as goodwill,
unamortized loan costs and other organization costs.
Line 35--Total Other Assets--Sum of lines 31 through 34.
Line 36--Total Assets--Sum of lines 11, 30 and 35.
Line 37--Accounts Payable--This amount reflects the amounts due trade creditors and others for
supplies and services purchased.
Line 38--Salaries, Wages and Fees Payable--This amount reflects the actual or estimated
liabilities of the hospital for salaries and wages/fees payable.
Line 39--Payroll Taxes Payable--This amount reflects the actual or estimated liabilities of the
hospital for amounts payable for payroll taxes withheld from salaries and wages, payroll taxes to
be paid by the hospital and other payroll deductions, such as hospitalization insurance premiums.
Line 40--Notes and Loans Payable (Short-Term)--The amounts on this line represent current
amounts owing as evidenced by certificates of indebtedness coming due in the next 12 months.
Line 41--Deferred Income--Deferred income is received or accrued income which is applicable
to services to be rendered within the next accounting period. Deferred income applicable to
accounting periods extending beyond the next accounting period is included as other current
liabilities. These amounts also reflect the effects of any timing differences between book and tax
or third-party reimbursement accounting.
Line 42--Accelerated Payments--Accelerated payments are payments not yet due to be repaid to
the contractor.
Line 43--Due to Other Funds--There are four funds: General Fund, Specific Purpose Fund,
Endowment Fund and Plant Fund. These are in columns 1 through 4 respectively. Amounts are
reported in the fund owing the amount. Each amount recorded as “due to” must also be reported
on Worksheet G, line 10 (Due From Other Funds).
The sum of the amounts on line 10, columns 1 through 4 must equal the sum of the amounts on
line 41, columns 1 through 4.
Line 44--Other Current Liabilities--This line is used to record any current liabilities not reported
on lines 37 through 43.
Line 45--Total Current Liabilities--Enter the sum of lines 37 through 44.
Line 46--Mortgage Payable--This amounts reflects the long-term financing obligation used to
purchase real estate/property.
Line 47--Notes Payable--These amounts reflect liabilities of the hospital to vendors, banks and
other, evidenced by promissory notes due and payable longer than one year.
40-220
Rev. 2
12-10
FORM CMS-2552-10
4040.1 (Cont.)
Line 48--Unsecured Loans--These amounts are not loaned on the basis of collateral.
Line 49--Other Long-Term Liabilities--This line is used to record any long-term liabilities not
reported on lines 46 through 48.
Line 50--Total Long-Term Liabilities--Enter the sum of lines 46 through 49.
Line 51--Total Liabilities--Enter the sum of lines 45 and 50.
Line 52--General Fund Balance--This represents the difference between the total of General
Fund assets and General Fund Liabilities in column 1. This amount usually equals the end of
period fund balance on Worksheet G-1, column 2, line 19.
Line 53--Specific Purpose Fund--This represents the difference between the total of Specific
Purpose Fund assets and Specific Purpose Fund Liabilities in column 2.
Line 54--Donor Created - Endowment Fund Balance - Restricted--The sum of the amounts on
lines 54, 55 and 56, represent the difference between the total of Endowment Fund assets and
Endowment Fund Liabilities in column 3.
Line 55--Donor Created - Endowment Fund Balance - Unrestricted.
Line 56--Governing Body Created - Endowment Fund Balance.
Line 57--Plant Fund Balance - Invested in Plant--The sum of the amounts on lines 57 and 58,
represent the difference between the total of Plant Fund assets and Plant Fund Liabilities in
column 4.
Line 58--Plant Fund Balance - Reserves for Plant Improvement, Replacement and Expansion-The credit balances of the restricted funds reported on lines 54 through 56, represent the net
amount of each restricted fund’s assets available for its designated purpose. The accounts should
be credited for all income earned on restricted fund assets, as well as gains on the disposal of
such assets. If, however, such items are treated as General Fund income (considering legal
requirements and donor intent), the restricted Fund Balance account is charged, and the Due to
General Fund account credited, for such income.
For Investor-Owned Corporations, the accounts on lines 53 through 58 include stock, paid in
capital and retained earnings. For Investor-Owned Partnerships, the amounts on lines 53 through
58 include capital and partner’s draw. For Investor-Owned - Division of a Corporation, the
amounts on lines 53 through 58 include the division’s or subsidiary’s stock, paid in capital and
divisional equity.
Line 59--Total Fund Balances--Enter the sum of lines 52 through 58.
Line 60--Total Liabilities and Fund Balances--Enter the sum of lines 51 and 59.
For each Fund, the amount on line 36 equals the amount on line 60.
Rev. 1
40-221
4040.2
4040.2
FORM CMS-2552-10
12-10
Worksheet G-1 - Statement of Changes in Fund Balances--
Columns 1 and 2--General Fund.
Columns 3 and 4--Specific Purpose Fund--These accounts are used for funds held for specific
purposes such as research and education.
Columns 5 and 6--Endowment Fund--These accounts are for amounts restricted for endowment
purposes.
Columns 7 and 8--Plant Fund--These accounts are for amounts restricted for the replacement and
expansion of the plant.
Line 1--Fund Balance at Beginning of Period--The fund balance at the beginning of the period
comes from the prior year cost report Worksheet G-1, line 19, columns 2, 4, 6 and 8,
respectively.
Line 2--Net Income--Transfer to column 2, the amount from Worksheet G-3, line 29. Columns
1, 3, 4, 5, 6, 7 and 8 are not completed.
Line 3--Total--For column 2, enter the sum of lines 1 and 2. Leave columns 1, 3, 5 and 7 blank.
For columns 4, 6 and 8, bring down the amount on line 1.
Lines 4 through 9--Additions--Most income is included in the net income reported on line 2.
Any increases affecting the fund balance not included in net income are reported on these lines.
A description (not exceeding 36 characters) is entered for each entry on lines 4 through 9.
Line 10--Total Additions--In columns 2, 4, 6 and 8, enter the sum of lines 4 through 9 columns 1,
3, 5 and 7, respectively.
Line 11--Subtotals--Enter the sum of lines 3 and 10 for columns 2, 4, 6 and 8. Leave columns 1,
3, 5 and 7 blank.
Lines 12 through 17--Deductions--Most expenses are included in the net income reported on line
2. Any decreases affecting the fund balance not included in net income are reported on these
lines. A description (not exceeding 36 characters) is entered for each entry on lines 12 through
17.
Line 18--Total Deductions--In columns 2, 4, 6 and 8, enter the sum of lines 12 through 17,
columns 1, 3, 5 and 7, respectively.
Line 19--Fund Balance at the end of Period per Balance Sheet--Enter the result of line 11 minus
line 18 for columns 2, 4, 6 and 8. Leave columns 1, 3, 5 and 7 blank. The amount in line 19,
column 2 must agree with Worksheet G, line 52, column 1. The amount on line 19, column 4
must agree with Worksheet G, line 53, column 2. The amount on line 19, column 6 must agree
with the sum of Worksheet G, column 3, lines 54 through 56. The amount on line 19, column 8
must agree with the sum of Worksheet G, column 4, lines 57 and 58.
These amounts will also be used to start next year’s Worksheet G-1.
40-222
Rev. 1
08-11
FORM CMS-2552-10
4040.3
4040.3 Worksheet G-2, Parts I & II - Statement of Patient Revenues and Operating Expenses-This worksheet requires the reporting of total patient revenues for the entire facility and
operating expenses for the entire facility. If cost report total revenues and total expenses differ
from those on your filed financial statements, submit a reconciliation report with the cost report
submission. If you have more than one hospital-based HHA and/or more than one outpatient
rehabilitation provider, subscript the appropriate lines on Worksheet G-2, Part I, to report the
revenue for each multiple based facility separately.
Part I - Patient Revenues--Enter total patient revenues associated with the appropriate cost
centers on lines 1-9, 11-15, and 18-25.
Line 1--Hospital--Enter revenues generated by the hospital component of the complex. Obtain
these amounts from your accounting books and/or records.
Line 2--Subprovider - IPF--Enter revenues generated by the IPF (also referred to as the IPF
excluded unit) of the complex. Obtain this amount from your accounting books and/or records.
Line 3--Subprovider - IRF--Enter revenues generated by the IRF (also referred to as the IRF
excluded unit) of the complex. Obtain this amount from your accounting books and/or records.
Line 4--Subprovider - Other--Enter revenues generated by components identified as subproviders
of the complex that were not identified on lines 2 or 3. Subscript this line as necessary. Obtain
these amounts from your accounting books and/or records.
Line 5--Swing Bed - SNF--Enter the swing bed - SNF revenue from your accounting books
and/or records.
Line 6--Swing Bed - NF--Enter the swing bed - NF revenue from your accounting books and/or
records.
Line 7--Skilled Nursing Facility--Enter the skilled nursing facility revenue from your accounting
books and/or records.
Line 8--Nursing Facility--Enter the nursing facility revenue from your accounting books and/or
records.
Line 9--Other Long Term Care-- Enter the revenue generated from other long term care
subproviders from your accounting books and/or records. Subscript this line as necessary.
Line 10--Total General Inpatient Routine Care--Sum of lines 1 through 9.
Line 11--Intensive Care Unit--Enter the intensive care unit revenue from your accounting books
and/or records.
Line 12--Coronary Care Unit--Enter the coronary care unit revenue from your accounting books
and/or records.
Line 13--Burn Intensive Care Unit--Enter the burn intensive care unit revenue from your
accounting books and/or records.
Line 14--Surgical Intensive Care Unit--Enter the surgical intensive care unit revenue from your
accounting books and/or records.
Rev. 2
40-223
4040.3 (Cont.)
FORM CMS-2552-10
08-11
Line 15--Other Special Care-- Enter all other intensive care unit revenue not identified on lines
11 through 14 from your accounting books and/or records. Subscript this line as necessary.
Line 16--Total Intensive Care Type Inpatient Hospital--Sum of lines 11 through 15.
Line 17--Total Inpatient Routine Care Services--Sum of lines 10 and 16.
Line 18--Ancillary Services--Enter in the appropriate column revenue from inpatient ancillary
services and outpatient ancillary services from your accounting books and/or records.
Line 19--Outpatient Services--Enter in the appropriate column revenue from outpatient ancillary
services from your accounting books and/or records.
Line 20--Rural Health Clinic--Enter rural health clinic revenue from your accounting books
and/or records. Subscript this line to identify each rural health clinic separately.
Line 21--Federally Qualified Health Center--Enter federally qualified health center revenue from
your accounting books and/or records. Subscript this line to identify each federally qualified
health center separately.
Line 22--Home Health Agency--Enter home health agency revenue from your accounting books
and/or records. If there is more than one home health agency, include the revenues for all home
health agencies on this line.
Line 23--Ambulance Services--Enter from your accounting books and/or records the revenue
relative to the ambulance service cost reported on Worksheet A, line 95.
Line 24--Outpatient Rehabilitation Providers--Enter in column 2 only, the revenue generated
from CMHC, CORF, outpatient therapy providers (OPTs, OOTs and OSPs), and any other
outpatient rehabilitation providers. Subscript this line to identify each outpatient rehabilitation
provider separately. Obtain this information from your accounting books and/or records.
Line 25--Ambulatory Surgical Center(s)--Enter from your accounting books and/or records the
revenue relative to the Ambulatory Surgical Center costs report on Worksheet A, lines 75 and
115.
Line 26--Hospice--Enter from your accounting books and/or records in the appropriate column,
the revenue generated from hospice services rendered. If there is more than one hospice, include
the revenues for all hospices on this line.
Line 27--Enter in the appropriate column all other revenues not identified on lines 18 through 26.
Line 28--Total Patient Revenues--Enter the sum of lines 17 through 27.
Column 3--For lines 1 - 28, enter the sum of columns 1 and 2, as applicable, in column 3.
Part II - Operating Expenses--Enter the expenses incurred that arise during the ordinary course of
operating the hospital complex.
Line 29--Operating Expenses--This amount is transferred from Worksheet A, line 200, column 3.
Lines 30-35--Add (Specify)--Identify on these lines additional operating expenses not included
in line 27.
Line 36--Total Additions--Enter on line 36, column 2, the sum of lines 30 to 35, column 1.
40-224
Rev. 2
10-12
FORM CMS-2552-10
4040.4
Lines 37 - 41--Deduct (specify)-- Identify on these lines deductions from operating expenses not
accounted for included in line 29.
Line 42--Total Deductions--Enter on line 42, column 2, the sum of lines 37 to 41, column 1.
Line 43--Total Operating Expenses--Enter on line 43, column 2, the result of line 29, column 2
plus line 36, column 2, less line 42, column 2.
4040.4 Worksheet G-3 - Statement of Revenues and Expenses-This worksheet requires the reporting of total revenues for the entire facility and total operating
expenses for the entire facility. If cost report total revenues and total expenses differ from those
on your filed financial statements, submit a reconciliation report with the cost report submission.
Line 1--Total Patient Revenue--Transfer from Worksheet G-2, Part I, line 28, column 3.
Line 2--Less: Allowance and Discounts on Patient’s Accounts--Enter on this line total patient
revenues not received. This includes:
Provision for Bad Debts,
Contractual Adjustments,
Charity Discounts,
Teaching Allowances,
Policy Discounts,
Administrative Adjustments, and
Other Deductions from Revenue
Line 3--Net Patient Revenues--Subtract line 2 from line 1.
Line 4--Less: Total Operating Expenses--Transfer from Worksheet G-2, Part II, line 43.
Line 5--Net Income from Service to Patients--Subtract line 4 from line 3.
Lines 6 - 23--Enter on the appropriate line 6 through 23 all other revenue not reported on line 1.
Obtain these amounts from your accounting books and/or records.
Line 24--Other (Specify)--Enter from hospital books. Enter all other revenue not reported on
lines 6 through 23. Obtain this from your accounting books and/or records. Subscript this line
as necessary.
Line 25--Total Other Income--Enter the sum of lines 6 through 24.
Line 26--Total--Enter the sum of lines 5 and 25.
Line 27--Other Expenses (Specify)--Enter all other expenses not reported on lines 6 through 24.
Subscript this line as necessary.
Line 28--Total Other Expenses--Enter the sum of line 27 and subscripts.
Line 29--Net Income (or Loss) for the Period--Enter the result of line 26 minus line 28.
Rev. 3
40-225
4041
4041.
FORM CMS-2552-10
10-12
WORKSHEET H - ANALYSIS OF PROVIDER-BASED HOME HEALTH AGENCY
COSTS
This worksheet provides for the recording of direct HHA costs such as salaries, fringe benefits,
transportation, and contracted services as well as other costs from your accounting books and
records to arrive at the identifiable agency cost. This data is required by 42 CFR 413.20. It also
provides for the necessary reclassifications and adjustments to certain accounts prior to the cost
finding calculations. The direct costs reported in columns 1, 2 and 4 are obtained from your
accounting books and records. All of the cost centers listed do not apply to all agencies.
The HHA must maintain the records necessary to determine the split in salary (and employeerelated benefits) between two or more cost centers and must adequately substantiate the method
used to split the salary and employee-related benefits. These records must be available for audit
by your contractor. Your contractor can accept or reject the method used to determine the split
in salary. Any deviation or change in methodology to determine splits in salary and employee
benefits must be requested in writing and approved by your contractor before any change is
effectuated. Where approval of a method has been requested in writing and this approval has
been received (prior to the beginning of the cost reporting period), the approved method remains
in effect for the requested period and all subsequent periods until you request in writing to
change to another method or until your contractor determines that the method is no longer valid
due to changes in your operations.
Column 1--Enter all salaries and wages (a salary is the gross amount paid to the employee before
taxes and other items are withheld, including deferred compensation, overtime, incentive pay,
and bonuses) for the HHA in this column for the actual work performed within the specific area
or cost center. For example, if the administrator spends 100 percent of his/her time in the HHA
and performs skilled nursing care which accounts for 25 percent of that person’s time, then 75
percent of the administrator’s salary is entered on line 5 (administrative and general-HHA) and
25 percent of the administrator’s salary is entered on line 6 (skilled nursing care). Enter the sum
of column 1, lines 1 through 23 on line 24.
Column 2--Enter all payroll-related employee benefits for the HHA in the appropriate cost center
in this column. See CMS Pub. 15-1, §§2144 - 2145 for a definition of fringe benefits. Entries
are made using the same basis as that used for reporting salaries and wages in column 1.
Therefore, using the same example as given for column 1, 75 percent of the administrator’s
payroll-related fringe benefits is entered on line 5 (administrative and general - HHA) and 25
percent of the administrator’s payroll-related fringe benefits is entered on line 6 (skilled nursing
care). Enter the sum of column 2, lines 1 through 23 on line 24.
Report payroll-related employee benefits in the cost center where the applicable employee’s
compensation is reported. This assignment is performed on an actual basis or upon the following
basis:
•
FICA based on actual expense by cost center;
•
Pension and retirement and health insurance (non union) based on gross salaries of
participating individuals by cost centers;
•
Union health and welfare based on gross salaries of participating union members by
cost center; and
•
All other payroll-related benefits based on gross salaries by cost center.
40-226
Rev. 3
12-10
FORM CMS-2552-10
4041 (Cont.)
Include nonpayroll-related employee benefits in the administrative and general-HHA cost center.
Costs for such items as personal education, recreation activities, and day care are included in the
administrative and general - HHA cost center.
Column 3--If the transportation costs, i.e., owning or renting vehicles, public transportation
expenses, or payments to employees for driving their private vehicles can be directly assigned to
a particular cost center, enter those costs in the appropriate cost center. If these costs are not
identifiable to a particular cost center, enter them on line 4. Enter the sum of column 3, lines 1
through 23 on line 24.
Column 4--Enter the contracted and purchased services amounts in the appropriate cost center in
this column. If a contracted/purchased service covers more than one cost center, then include the
amount applicable to each cost center on each affected cost center line. Enter the sum of column
4, lines 1 through 23 on line 24.
Column 5--From your books and records, enter on the applicable lines all other identifiable costs
which have not been reported in columns 1 through 4. Enter the sum of column 5, lines 1
through 23 on line 24.
Column 6--Add the amounts in columns 1 through 5 for each cost center, and enter the totals in
column 6.
Column 7--Enter any reclassifications among the cost center expenses listed in column 6 which
are needed to effect proper cost allocation. This column need not be completed by all providers,
but is completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. Show reductions to expenses as negative amounts.
Column 8--Add column 7 to column 6, and extend the net balances to column 8.
Column 9--In accordance with 42 CFR 413ff, enter on the appropriate lines the amounts of any
adjustments to expenses required under the Medicare principles of reimbursement. (See §4016.)
Column 10--Adjust the amounts in column 8 by the amounts in column 9, and extend the net
balance to column 10.
Transfer the amounts in column 10, lines 1 through 24, to the corresponding lines on Worksheet
H-1, Part I, column 0.
Line Descriptions
Lines 1 and 2--These cost centers include depreciation, leases and rentals for the use of facilities
and/or equipment, interest incurred in acquiring land or depreciable assets used for patient care,
insurance on depreciable assets used for patient care, and taxes on land or depreciable assets used
for patient care.
Line 3--Enter the direct expenses incurred in the operation and maintenance of the plant and
equipment, maintaining general cleanliness and sanitation of the plant, and protecting employees,
visitors, and agency property.
Line 4--Enter all of the cost of transportation except those costs previously directly assigned in
column 3. This cost is allocated during the cost finding process.
Rev. 1
40-227
4041 (Cont.)
FORM CMS-2552-10
12-10
Line 5--Use this cost center to record the expenses of several costs which benefit the entire
facility. Examples include fiscal services, legal services, accounting, data processing, taxes, and
malpractice costs.
Line 6--Skilled nursing care is a service that must be provided by or under the supervision of a
registered nurse. The complexity of the service, as well as the condition of the patient, are
factors to be considered when determining whether skilled nursing services are required.
Additionally, the skilled nursing services must be required under the plan of treatment.
Line 7--Enter the direct costs of physical therapy services by or under the direction of a
registered physical therapist as prescribed by a physician. The therapist provides evaluation,
treatment planning, instruction, and consultation.
Line 8--These services include (1) teaching of compensatory techniques to permit an individual
with a physical impairment or limitation to engage in daily activities; (2) evaluation of an
individual's level of independent functioning; (3) selection and teaching of task-oriented
therapeutic activities to restore sensory-integrative function; and (4) assessment of an
individual's vocational potential, except when the assessment is related solely to vocational
rehabilitation.
Line 9--These are services for the diagnosis and treatment of speech and language disorders that
create difficulties in communication.
Line 10--These services include (1) assessment of the social and emotional factors related to the
individual's illness, need for care, response to treatment, and adjustment to care furnished by the
facility; (2) casework services to assist in resolving social or emotional problems that may have
an adverse effect on the beneficiary's ability to respond to treatment; and (3) assessment of the
relationship of the individual's medical and nursing requirements to his or her home situation,
financial resources, and the community resources available upon discharge from facility care.
Line 11--Enter the cost of home health aide services. The primary function of a home health
aide is the personal care of a patient. The services of a home health aide are given under the
supervision of a registered professional nurse and, if appropriate, a physical, speech, or
occupational therapist. The assignment of a home health aide to a case must be made in
accordance with a written plan of treatment established by a physician which indicates the
patient's need for personal care services. The specific personal care services to be provided by
the home health aide must be determined by a registered professional nurse and not by the home
health aide.
Line 12--The cost of medical supplies reported in this cost center are those costs which are
directly identifiable supplies furnished to individual patients and for which a separate charge is
made. These supplies are generally specified in the patient’s plan of treatment and furnished
under the specific direction of the patient’s physician.
Medical supplies which are not reported on this line are those minor medical and surgical
supplies which would not be expected to be specifically identified in the plan of treatment or for
which a separate charge is not made. These supplies (e.g., cotton balls, alcohol prep) are items
that are frequently furnished to patients in small quantities (even though in certain situations,
these items may be used in greater quantity) and are reported in the administrative and general
(A&G) cost center.
Line 13--Enter the costs of vaccines exclusive of the cost of administering the vaccines. A visit
by an HHA nurse for the sole purpose of administering a vaccine is not covered as an HHA visit
under the home health benefit, even though the patient may be an eligible home health
beneficiary receiving services under a home health plan of treatment. Section 1862(a)(1)(B) of
the Act excludes Medicare coverage of vaccines and their administration other than the Part B
coverage contained in §1861 of the Act.
40-228
Rev. 1
08-11
FORM CMS-2552-10
4041 (Cont.)
If the vaccine is administered in the course of an otherwise covered home health visit, the visit is
covered as usual, but the cost and charges for the vaccine and its administration must be
excluded from the cost and charges of the visit. The HHA is entitled to separate payment for the
vaccine and its administration under the Part B vaccine benefit.
The cost of administering pneumococcal, influenza, and hepatitis B vaccines is reimbursed under
the outpatient prospective payment system (OPPS), but the actual cost of the pneumococcal,
influenza, and hepatitis B vaccines are cost reimbursed. Additionally, the cost of administering
the osteoporosis drugs are included in the skilled nursing visit while the actual cost of the
osteoporosis drug is reimbursed at reasonable cost.
Enter on this line the vaccine and drug cost (exclusive of the cost to administer these vaccines)
incurred for pneumococcal, influenza, and hepatitis B vaccines as well as osteoporosis drugs.
Some of the expenses includable in this cost center are the costs of syringes, cotton balls,
bandages, etc., but the cost of travel is not permissible as a cost of administering vaccines, nor is
the travel cost includable in the A&G cost center. The travel cost is non-reimbursable. Attach a
schedule detailing the methodology employed to develop the administration of these vaccines.
These vaccines are reimbursable under Part B only.
Line 14--Enter the direct expenses incurred in renting or selling durable medical equipment
(DME) items to the patient for the purpose of carrying out the plan of treatment. Also, include
all the direct expenses incurred by you in requisitioning and issuing the DME to patients.
Lines 15-23--Lines 15-23 identify nonreimbursable services commonly provided by a home
health agency. These include home dialysis aide services (line 15), respiratory therapy (line 16),
private duty nursing (line 17), clinic (line 18), health promotion activities (line 19), day care
program (line 20), home delivered meals program (line 21), and homemaker service (line 22).
The cost of all other nonreimbursable services are aggregated on line 23. If you are reporting
costs for telemedicine, these costs are to be reported on line 23.50. Use this line throughout all
applicable worksheets.
Rev. 2
40-229
4042
4042.
FORM CMS-2552-10
08-11
WORKSHEET H-1 - COST ALLOCATION - HHA GENERAL SERVICE COST
Worksheet H-1, Part I, provides for the allocation of the expenses of each HHA general service
cost center to those cost centers which receive the services. The cost centers serviced by the
general service cost centers include all cost centers within the home health agency, i.e., other
general service cost centers, reimbursable cost centers, and nonreimbursable cost centers. Obtain
the total direct expenses from Worksheet H, column 10. To facilitate transferring amounts from
Worksheet H to Worksheet H-1, Part I, the same cost centers with corresponding line numbers
(lines 1 through 24) are listed on both worksheets.
Worksheet H-1, Part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the home health agency general service cost centers on Worksheet H-1,
Part I. If there is a difference between the total accumulated costs reported on the Part II
statistics and the total accumulated costs calculated on Part I, use the reconciliation column on
Part II for reporting any adjustments. See §4020 for the appropriate usage of the reconciliation
columns. For componentized A&G cost centers, the accumulated cost center line number must
match the reconciliation column number.
To facilitate the allocation process, the general format of Parts I and II are identical. The column
and line numbers for each general service cost center are identical on both parts. In addition, the
line numbers for each general, reimbursable, and nonreimbursable cost centers are identical on
the two parts of the worksheet. The cost centers and line numbers are also consistent with
Worksheet H.
The statistical bases shown at the top of each column on Worksheet H-1, Part II, are the
recommended bases of allocation of the cost centers indicated. If a different basis of allocation
is used, the provider must indicate the basis of allocation actually used at the top of the column.
Most cost centers are allocated on different statistical bases. However, for those cost centers
where the basis is the same (e.g., square feet), the total statistical base over which the costs are to
be allocated will differ because of the prior elimination of cost centers that have been closed.
When closing the general service cost center, first close those cost centers that render the most
services to and receive the least services from other cost centers. The cost centers are listed in
this sequence from left to right on the worksheet. However, the circumstances of an agency may
be such that a more accurate result is obtained by allocating to certain cost centers in a sequence
different from that followed on these worksheets.
NOTE: The HHA can elect to change the order of allocation and/or allocation statistics, as
appropriate, for the current cost reporting period if a request is received by the
contractor, in writing, 90 days prior to the end of that reporting period. The contractor
has 60 days to make a decision and notify the provider of that decision or the change is
automatically accepted. The change must be shown to more accurately allocate the
overhead or demonstrate simplification in maintaining the changed statistics. If a
change in statistics is requested, the provider must maintain both sets of statistics until
an approval is made. If both sets are not maintained and the request is denied, the
provider reverts back to the previously approved methodology. The provider must
include with the request all supporting documentation and a thorough explanation of
why the alternative approach should be used. (See CMS Pub. 15-1, §2313.)
EXCEPTION:
40-230
A small freestanding HHA, as defined in 42 CFR 413.24(d), does not have to
request written permission to use the procedures outlined for small HHAs
below.
Rev. 2
08-11
FORM CMS-2552-10
4042 (Cont.)
On Worksheet H-1, Part II, enter on the first line in the column of the cost center being allocated
the total statistical base over which the expenses are allocated (e.g., in column 1, capital-related buildings and fixtures, enter on line 1 the total square feet of the building on which depreciation
was taken). For all cost centers to which the capital-related cost is allocated, enter that portion of
the total statistical base applicable to each. The sum of the statistical base applied to each cost
center receiving the services must equal the total base entered on the first line. Use accumulated
cost for allocating administrative and general expenses.
Do not include any statistics related to services furnished under arrangements unless:
• Both Medicare and non-Medicare costs of arranged for services are recorded in your
records; or
• Your contractor determines that you are able to (and do) gross up the costs and charges
for services to non-Medicare patients so that both cost and charges are recorded as if you
had furnished such services directly to all patients. (See CMS Pub. 15-1, §2314.)
Enter on Worksheet H-1, Part II, line 25, the total expenses of the cost center to be allocated.
Obtain this amount from Worksheet H-1, Part I, from the same column and line number used to
enter the statistical base on Worksheet H-1, Part II. In the case of capital-related costs buildings and fixtures, this amount is on Worksheet H-1, Part I, column 1, line 1.
NOTE: On Worksheet H-1, Parts I and II, the first line of each column must equal line 24 of
the column. Therefore, when totaling a column exclude from line 24 the amount on
the first line of that column.
Divide the amount entered on Worksheet H-1, Part II, line 25 by the total statistical base entered
in the same column on the first line. Enter the resulting unit cost multiplier on line 26. Round
the unit cost multiplier to six decimal places.
Multiply the unit cost multiplier by that portion of the total statistical base applicable to each cost
center receiving the services rendered. Enter the result of each computation on Worksheet H-1,
Part I, in the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving costs, the total
expenses (line 24) of all of the cost centers receiving the allocation on Worksheet H-1, Part I,
must equal the amount entered on the first line of the cost center being allocated.
The preceding procedures must be performed for each general service cost center. Each cost
center must be completed on both Part I and Part II before proceeding to the next cost center.
After all the costs of the general service cost centers have been allocated on Worksheet H-1, Part
I, enter in column 6, line 24 the sum of the expenses on lines 6 through 23. The total expenses
entered in column 6, line 24, equals the total expenses entered in column 0, line 24.
Column Descriptions
Column 1--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures such as insurance, interest, rent, and real estate taxes are combined in this cost center to
facilitate cost allocation. Allocate all expenses to the cost centers on the basis of square footage
of the occupied area. The square footage may be weighted if the person who occupies a certain
area of space spends their time in more than one function. For example, if a person spends 10
percent of time in one function, 20 percent in another function, and 70 percent in still another
function, the square footage may be weighted according to the percentages of 10 percent, 20
percent, and 70 percent to the applicable functions.
Rev. 2
40-231
4042 (Cont.)
FORM CMS-2552-10
08-11
Column 2--Allocate all expenses (e.g., interest, personal property tax) for movable equipment to
the appropriate cost centers on the basis of dollar value.
Column 3--Allocate all expenses for plant operation and maintenance based on square feet.
Column 4--The cost of vehicles owned or rented by the agency and all other transportation costs
which were not directly assigned to another cost center on Worksheet H, column 3, is included in
this cost center. Allocate this expense to the cost centers to which it applies on the basis of miles
applicable to each cost center.
This basis of allocation is not mandatory and a provider may use weighted trips rather than actual
miles as a basis of allocation for transportation costs which are not directly assigned. However,
an HHA must request the use of the alternative method in accordance with CMS Pub. 15-1,
§2313. The HHA must maintain adequate records to substantiate the use of this allocation.
Column 5--The A&G expenses are allocated on the basis of accumulated costs after
reclassifications and adjustments. Therefore, obtain the amounts to be entered on Worksheet H1, Part II, column 5, from Worksheet H-1, Part I, columns 0 through 4.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
A&G costs applicable to contracted services may be excluded from the total cost (Worksheet H1, Part I, column 0) for purposes of determining the basis of allocation (Worksheet H-1, Part II,
column 5) of the A&G costs. This procedure may be followed when the HHA contracts for
services to be performed for the HHA and the contract identifies the A&G costs applicable to the
purchased services. The contracted A&G costs must be added back to the applicable cost center
after allocation of the HHA A&G cost before the reimbursable costs are transferred to Worksheet
H-2. A separate worksheet must be included to display the breakout of the contracted A&G
costs from the applicable cost centers before allocation and the adding back of these costs after
allocation. Contractor approval does not have to be secured in order to use the above described
method of cost finding for A&G.
Column 6--For lines 6 through 23, add the amounts on each line in columns 4A and 5, and enter
the result for each line in this column.
Transfer the amounts in column 6 to Worksheet H-2, Part I, column 0, as follows:
From Worksheet H-1,
Part I, Column 6
Line 6
7
40-232
To Worksheet H-2,
Part I, Column 0___
Line 2
3
Rev. 2
08-11
FORM CMS-2552-10
From Worksheet H-1,
Part I, Column 6
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Rev. 2
4042 (Cont.)
To Worksheet H-2,
Part I, Column 0_
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
40-233
4043
4043.
FORM CMS-2552-10
08-11
WORKSHEET H-2 - ALLOCATION OF GENERAL SERVICE COSTS TO HHA
COST CENTERS
Use this worksheet only if you operate a certified hospital-based HHA as part of your complex.
If you have more than one hospital-based HHA, complete a separate worksheet for each facility.
4043.1 Part I - Allocation of General Service Costs to HHA Cost Centers.--Worksheet H-2,
Part I, provides for the allocation of the expenses of each general service cost center of the
hospital to those cost centers which receive the services. Worksheet H-2, Part II provides for the
proration of the statistical data needed to equitably allocate the expenses of the general service
cost centers on Worksheet H-2, Part I.
Obtain the total direct expenses (column 0, line 20) from Worksheet A, column 7, line 101.
Obtain the cost center allocations (column 0, lines 1 through 19) from Worksheet H-1, Part I,
lines as indicated, the sum of which agrees with the amount entered on column 0, line 20. The
amounts on line 20, columns 0 through 23 and column 25 must agree with the corresponding
amounts on Worksheet B, Part I, columns 0 through 23 and column 25, line 101. Complete the
amounts entered on lines 1 through 19, columns 1 through 23 and column 25 in accordance with
the instructions in §4043.2.
NOTE: Worksheet B, Part I, established the method used to reimburse direct graduate medical
education cost (i.e., reasonable cost or the per resident amount). Therefore, this
worksheet must follow that method. If Worksheet B, Part I, column 25, excluded the
costs of interns and residents, column 25 on this worksheet must also exclude these
costs.
In column 24, Part I, enter the total of columns 4A through 23.
In column 27, Part I, enter on line 21, the unit cost multiplier (column 26, line 1, divided by the
sum of column 26, line 20 minus column 26, line 1). Round the unit cost multiplier to 6 decimal
places. Multiply each amount in column 26, lines 2 through 19 by the unit cost multiplier on line
21, and enter the result on the corresponding line of column 27. On line 20, enter the total of the
amounts on lines 2 through 19. The total on line 20 must equal the amount in column 26, line 1.
In column 28, Part I, enter on lines 2 through 19 the sum of columns 26 and 27. The total on line
20 must equal the total in column 27, line 20.
4043.2 Part II - Allocation of General Service Costs to HHA Cost Centers -Statistical Basis-To facilitate the allocation process, the general format of Worksheet H-2, Parts I and II, is
identical. Worksheet H-2, Part II, provides for the proration of the statistical data needed to
equitably allocate the expenses of the hospital’s general service cost centers on Worksheet H-2,
Part I.
The statistical basis shown at the top of each column on Worksheet H-2, Part II, is the
recommended basis of allocation of the cost center indicated.
Lines 1 through 19--On Worksheet H-2, Part II, for all cost centers to which the general service
cost center is being allocated, enter that portion of the total statistical base applicable to each.
40-234
Rev. 2
08-11
FORM CMS-2552-10
4043.2 (Cont.)
Line 20--Enter the total of lines 1 through 19 for each column. The total in each column must be
the same as shown for the corresponding column on Worksheet B-1, line 101.
Line 21--Enter the total expenses for the cost center allocated. Obtain this amount from
Worksheet B, Part I, line 101, from the same column used to enter the statistical base on
Worksheet H-2, Part II (e.g., in the case of capital-related cost buildings and fixtures, this amount
is on Worksheet B, Part I, column 1, line 101).
Line 22--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 21
by the total statistic entered in the same column on line 20. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistic applicable to each cost center
receiving the services. Enter the result of each computation on Worksheet H-2, Part I, in the
corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (line 20, Part I) must equal the total cost on line 21, Part II.
Perform the preceding procedures for each general service cost center.
Rev. 2
40-235
4044
FORM CMS-2552-10
4044.
WORKSHEET H-3 - APPORTIONMENT OF PATIENT SERVICE COSTS
08-11
This worksheet provides for the apportionment of home health patient service costs to titles V,
XVIII, and XIX. Titles V and XIX use the columns identified as Part A for each program.
4044.1 Part I - Computation of the Aggregate Program Cost.--This part provides for the
computation of the total cost and reasonable program cost by discipline based on program
patient care visits as required by 42 CFR 413.20, 42 CFR 413.24 and 42 CFR 484.200. HHA
services rendered on or after October 1, 2000, §1895 of the Social Security Act requires a home
health agency to be paid based on a prospective payment system subject to periodic updates.
Cost Per Visit Computation
Column Descriptions
Column 1--Enter the cost for each discipline from Worksheet H-2, Part I, column 28, lines as
indicated. Enter the total on line 7.
Column 2--Where the hospital complex maintains separate Physical Therapy, Occupational
Therapy and/or Speech Pathology departments, and these departments provide services to
patients of the hospital’s HHA, transfer the amounts from Worksheet H-3 Part II, column 3, lines
1 through 3 to lines 2 through 4 as appropriate. Enter the total on line 7.
Column 3--Enter the sum of columns 1 and 2.
Column 4--Enter the total agency visits from your records for each type of discipline on lines 1
through 6. Total visits reported in column 4 reflect visits rendered for the entire fiscal year and
equal the visits reported on S-3, Part I, regardless of when the episode was completed.
Column 5--Compute the average cost per visit for each type of discipline. Divide the number of
visits (column 4) into the cost (column 3) for each discipline.
Columns 6 and 9--To determine title XVIII, Part A, V, and XIX cost of service, multiply the
number of Medicare covered visits in completed episodes made to beneficiaries (column 6)
(from your records) by the average cost per visit amount in column 5 for each discipline. Enter
the product in column 9.
NOTE: Statistics in column 7, lines 1 through 7, reflect statistics for services that are part of a
home health plan, and thus not subject to deductibles and coinsurance. OBRA 1990
provides for the limited coverage of injectable drugs for osteoporosis. While covered
as a home health benefit under Part B, these services are subject to deductibles and
coinsurance. Report charges for osteoporosis injections in column 8, line 16, in
addition to statistics for services that are not part of a home health plan.
Columns 7 and 10--To determine the Medicare Part B cost of service, not subject to deductibles
and coinsurance, multiply the number of Medicare covered visits made in completed episodes to
Part B beneficiaries (column 7) (from your records) by the average cost per visit amount in
column 5 for each discipline. Enter the product in column 10. Note if the PS&R reports Part B
services separately as "subject to and not subject to” deductibles and coinsurance, add the two
reports together for each discipline.
Columns 6, 7, 9, 10 and 12--Enter visits and costs as applicable in columns 6, 7, 9, 10, and 12.
40-236
Rev. 2
10-12
FORM CMS-2552-10
4044.1 (Cont.)
NOTE: The sum of visits reported in columns 6 and 7 must equal the corresponding amounts
on Worksheet S-4, column 5, lines 21, 23, 25, 27, 29 and 31, respectively. These visits
are reported for episodes completed during the fiscal year.
Columns 8 and 11--Do not use these columns.
Column 12--Enter the total program cost for each discipline (sum of columns 9 and 10). Add the
amounts on lines 1 through 6, and enter this total on line 7.
Visits by CBSA--Lines 8 through 14--HHAs are paid for home health services under Title XVIII
on the basis of the geographic location at which the service is furnished. Enter for each
discipline the CBSA code of the location where the home health service was furnished.
Subscript each discipline line to accommodate multiple CBSAs serviced by your home health
agency.
Column Descriptions
Column 1--Enter the CBSA code in which the corresponding HHA visits were rendered for each
discipline on lines 8 through 13.
Columns 2 and 3--Enter the visit count for each of the corresponding disciplines for each CBSA.
Column 4, lines 8 through 14--These lines are shaded to prevent data input.
Line 14--Enter the total program visits for each discipline by adding lines 8 through 13 and
subscripts, and enter this total on line 14.
Supplies and Drugs Cost Computation.--Certain services covered by the program and furnished
by a home health agency are not included in the cost per visit for apportionment purposes. Since
an average cost per visit and HHA PPS do not apply to these items, develop and apply the ratio
of total cost to total charges to program charges to arrive at the program cost for these services.
Column 1--Enter the facility costs in column 1, lines 15 and 16, from Worksheet H-2, Part I,
column 28, lines 8 and 9, respectively.
Column 2--Enter the shared ancillary costs from Worksheet H-3, Part II, column 3, lines 4 and 5,
respectively.
Columns 3 through 5--In column 3, enter the sum total of columns 1 and 2 on lines 15 and 16,
respectively. Enter in column 4, lines 15 and 16, respectively, the total charges for such services
in accordance with the instructions in §4041, lines 12 and 13. Develop a ratio of total cost
(column 3) to total charges (column 4) (from your records), and enter this ratio in column 5.
Columns 6 through 8--Enter in the appropriate column the program charges for drugs and
medical supplies charged to patients subject to cost reimbursement. The actual vaccine/drug cost
for pneumococcal, influenza, hepatitis B and osteoporosis are cost reimbursed.
Do not enter charges for drugs and medical supplies subject to reimbursement on the basis of a
fee schedule.
Rev. 3
40-237
4044.2
FORM CMS-2552-10
10-12
Line Descriptions for Columns 6 through 8
Line 15--Columns 6 through 11 are shaded to prevent the input of medical supplies charged to
patients as all medical supplies are covered under the HHA PPS benefit.
Line 16--This line represents pneumococcal, influenza, and hepatitis B vaccine costs and
injectable osteoporosis drugs, but not the administration of these medications. Enter the program
covered charges for drugs charged to patients for items not reimbursed on the basis of a fee
schedule or OPPS. Enter in column 7 the program charges for pneumococcal vaccine and
influenza vaccine exclusive of their respective administration costs. Enter in column 8 the
program charges for hepatitis B vaccine and injectable osteoporosis drugs exclusive of their
respective administration costs.
Columns 6 and 9--To determine the Medicare cost, multiply the program charges (column 6) by
the ratio (column 5) for each line. Enter the product in column 9.
Columns 7 and 10--To determine the Medicare Part B cost, multiply the Medicare charges
(column 7) by the ratio (column 5) for each line. Enter the product in column 10.
Columns 8 and 11--To determine the Medicare Part B cost, multiply the Medicare charges
(column 8) by the ratio (column 5) for each line. Enter the result in column 11.
4044.2 Part II - Apportionment of Cost of HHA Services Furnished by Shared Hospital
Departments.--Use this part only where the hospital complex maintains a separate department for
any of the cost centers listed on lines 1 through 5 of this part of the worksheet, and these
departments provide services to patients of the hospital's HHA. Subscript lines 1-5, as
applicable, if subscripted on Worksheet C, Part I.
Column 1--Where applicable, enter in column 1 the cost to charge ratio from Worksheet C, Part
I, column 9, lines as indicated.
Column 2--Where hospital departments provide services to the HHA, enter on the appropriate
lines the charges applicable to the hospital-based home health agency.
Column 3--Multiply the amounts in column 2 by the ratios in column 1, and enter the result in
column 3. Transfer the amounts in column 3 to Worksheet H-3, Part I as indicated. If lines 1-5
are subscripted, transfer the aggregate of each line.
40-238
Rev. 3
08-11
4045.
FORM CMS-2552-10
4045.1
WORKSHEET H-4 - CALCULATION OF HHA REIMBURSEMENT
SETTLEMENT
This worksheet provides for the reimbursement calculation of titles V, XVIII Parts A and B, and
XIX. This computation is required by 42 CFR 413.9, 42 CFR 413.13, and 42 CFR 413.30.
Worksheet H-4 consists of the following two parts:
Part I
Part II
-
Computation of the Lesser of Reasonable Cost or Customary Charges
Computation of HHA Reimbursement Settlement
4045.1 Part I - Computation of Lesser of Reasonable Cost or Customary Charges.--Services
not paid based on a fee schedule or OPPS are paid the lesser of the reasonable cost of services
furnished to beneficiaries or the customary charges made by the providers for the same services.
This part provides for the computation of the lesser of reasonable cost or customary charges as
defined in 42 CFR 413.13(a).
NOTE: Nominal charge providers are not subject to the lesser of cost or charges (LCC).
Therefore, a nominal charge provider only completes lines 1, 2, and 9 of Part I.
Transfer the resulting cost to line 10 of Part II.
Line Descriptions
Line 1--This line provides for the computation of reasonable cost reimbursed program services.
Enter the cost of services from Worksheet H-3, Part I as follows:
To Worksheet H-4, Line 1
From Worksheet H-3,
Col. 1, Part A
Part I, col. 9, line 16
Col. 2, Part B - Not subject to
deductibles and coinsurance
Part I, col. 10, line 16
Col. 3, Part B - Subject to
deductibles and coinsurance
Part I, col. 11, line 16
The above table reflects the transfer of the cost of pneumococcal and influenza vaccines from
Worksheet H-3, Part I, column 10, line 16, to column 2 of this worksheet, and the cost of
hepatitis B vaccines and injectable osteoporosis drugs from worksheet H-3, Part I, column 11,
line 9 to column 3 of this worksheet.
Lines 2 through 6--These lines provide for the accumulation of charges which relate to the
reasonable cost on line 1. Do not include on these lines (1) the portion of charges applicable to
the excess costs of luxury items or services (see CMS Pub. 15-1, §2104.3) and (2) provider
charges to beneficiaries for excess costs as described in CMS Pub. 15-1, §2570. When provider
operating costs include amounts that flow from the provision of luxury items or services, such
amounts are not allowable in computing reimbursable costs.
Enter only the charges for applicable Medicare covered pneumococcal, influenza and hepatitis B
vaccines and injectable osteoporosis drugs which are all cost reimbursed.
Line 2--Enter from your records in the applicable column the program charges for Part A, Part B
not subject to deductibles and coinsurance, and Part B subject to deductibles and coinsurance.
Rev. 2
40-239
4045.1 (Cont.)
FORM CMS-2552-10
08-11
Enter in column 2 the charges for Medicare covered pneumococcal and influenza vaccines (from
worksheet H-3, line 16, column 7). In column 3, enter the charges for Medicare covered
hepatitis B vaccines and osteoporosis drugs (from worksheet H-3, line 16, column 8).
Lines 3 through 6--These lines provide for the reduction of program charges when the provider
does not actually impose such charges (in the case of most patients liable for payment for
services on a charge basis) or fails to make reasonable efforts to collect such charges from those
patients. If line 5 is greater than zero, multiply line 2 by line 5, and enter the result on line 6.
Providers which do impose these charges and make reasonable efforts to collect the charges from
patients liable for payment for services on a charge basis are not required to complete lines 3, 4,
and 5, but enter on line 6 the amount from line 2. (See 42 CFR 413.13(b).) In no instance may
the customary charges on line 6 exceed the actual charges on line 2.
Line 7--Enter in each column the excess of total customary charges (line 6) over the total
reasonable cost (line 1). In situations when, in any column, the total charges on line 6 are less
than the total cost on line 1 of the applicable column, enter zero on line 7.
Line 8--Enter in each column the excess of total reasonable cost (line 1) over total customary
charges (line 6). In situations when, in any column, the total cost on line 1 is less than the
customary charges on line 6 of the applicable column, enter zero on line 8.
Line 9--Enter the amounts paid or payable by workmens' compensation and other primary payers
where program liability is secondary to that of the primary payer. There are several situations
under which program payment is secondary to a primary payer. Some of the most frequent
situations in which the Medicare program is a secondary payer include:
•
•
•
•
•
•
Workmens' compensation,
No fault coverage,
General liability coverage,
Working aged provisions,
Disability provisions, and
Working ESRD beneficiary provisions.
Generally, when payment by the primary payer satisfies the total liability of the program
beneficiary, for cost reporting purposes only, the services are considered to be nonprogram
services. (The primary payment satisfies the beneficiary's liability when the provider accepts
that payment as payment in full. The provider notes this on no-pay bills submitted in these
situations.) The patient visits and charges are included in total patient visits and charges, but are
not included in program patient visits and charges. In this situation, no primary payer payment is
entered on line 9.
However, when the payment by the primary payer does not satisfy the beneficiary's obligation,
the program pays the lesser of (a) the amount it otherwise pays (without regard to the primary
payer payment or deductible and coinsurance) less the primary payer payment, or (b) the amount
it otherwise pays (without regard to primary payer payment or deductibles and coinsurance) less
applicable deductible and coinsurance. Primary payer payment is credited toward the
beneficiary's deductible and coinsurance obligation.
When the primary payer payment does not satisfy the beneficiary's liability, include the covered
days and charges in both program visits and charges and total visits and charges for cost
apportionment purposes. Enter the primary payer payment on line 9 to the extent that primary
payer payment is not credited toward the beneficiary's deductible and coinsurance. Do not enter
on line 9 the primary payer payments that are credited toward the beneficiary's deductible and
coinsurance. The primary payer rules are more fully explained in 42 CFR 411.
40-240
Rev. 2
08-11
4045.2
FORM CMS-2552-10
4045.2
Part II - Computation of HHA Reimbursement Settlement.--
Line 10--Enter in column 1 the amount in Part I, column 1, line 1 less the amount in column 1,
line 9. Enter in column 2 the sum of the amounts from Part I, columns 2 and 3, line 1 less the
sum of the amounts in columns 2 and 3 on line 9. This line will only include pneumococcal,
influenza, hepatitis B and injectable osteoporosis drugs reduced by primary payor amounts.
Lines 11 through 24--Enter in column 1 only for lines 11 through 14, as applicable, the
appropriate PPS reimbursement amount for each episode of care payment category as indicated
on the worksheet. Enter in column 1 only on lines 15 and 16, as applicable, the appropriate PPS
outlier reimbursement amount for each episode of care payment category as indicated on the
worksheet. Enter on lines 18 through 20 the total DME, oxygen, prosthetics and orthotics
payments, respectively, associated with home health PPS services (bill types 32 and 33). For
lines 18 through 20 do not include any payments associated with services paid under bill type
34X. Obtain these amounts from your PS&R report.
Line 21--Enter in column 2 the Part B deductibles billed to program patients. Include any
amounts of deductibles satisfied by primary payer payments.
Line 23--If there is an excess of reasonable cost over customary charges in any column on line 8,
enter the amount of the excess in the appropriate column.
Line 25--Enter in column 2 all coinsurance billable to program beneficiaries including amounts
satisfied by primary payer payments. Coinsurance is applicable for services reimbursable under
§1832(a)(2) of the Act.
NOTE: If the component qualifies as a nominal charge provider, enter 20 percent of the costs
subject to coinsurance on this line. Compute this amount by subtracting Part B
deductibles on line 21 and primary payment amounts in column 3, line 9 from Part B
costs subject to coinsurance in column 3, line 1. Multiply the resulting amount by 20
percent and enter it on this line.
Line 27--Enter the allowable bad debts in the appropriate columns. If recoveries exceed the
current year’s bad debts, line 27 will be negative.
Line 28--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 27.
Line 29--Enter the result of line 26 plus 27.
Line 30--Enter any other adjustments. For example, enter an adjustment from changing the
recording of vacation pay from the cash basis to accrual basis. (See CMS Pub. 15-1, §2146.4.)
Line 31--Enter the result of line 29 plus or minus line 30.
Line 32--Enter the interim payment amount from Worksheet H-5, line 4. For contractor final
settlement, report on line 33 the amount from Worksheet H-5, line 5.99. For titles V and XIX,
enter the interim payments from your records.
Rev. 2
40-241
4045.2 (Cont.)
FORM CMS-2552-10
08-11
Line 34--The amounts show the balance due the provider or the program. Transfer to
Worksheet S, Part III, line 9 as applicable.
Line 35--Enter the program reimbursement effect of protested items. The reimbursement effect
of the nonallowable items is estimated by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal cost
finding process. (See §115.2.) A schedule showing the supporting details and computations for
this line must be attached.
40-242
Rev. 2
10-12
4046.
FORM CMS-2552-10
4046
WORKSHEET H-5 - ANALYSIS OF PAYMENTS TO PROVIDER-BASED HOME
HEALTH AGENCIES FOR SERVICES RENDERED TO PROGRAM
BENEFICIARIES
Complete this worksheet for Medicare interim payments only. (See 42 CFR 413.64.)
The column headings designate two categories of payments: Part A and Part B.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor. Do not include on this worksheet any payments made for DME or
medical supplies charged to patients that are paid on the basis of a fee schedule.
Line Descriptions
Line 1--Enter the total Medicare interim payments paid to the HHA for cost and HHA PPS
reimbursed services. The amount entered reflects payments for all episodes concluded in this
fiscal year. Do not include any payments received for fee scheduled services. The amount
entered reflects the sum of all interim payments paid on individual bills (net of adjustment bills)
for services rendered in this cost reporting period. The amount entered includes amounts
withheld from your interim payments due to an offset against overpayments applicable to prior
cost reporting periods. It does not include any retroactive lump sum adjustment amounts based
on a subsequent revision of the interim rate, or tentative or net settlement amounts, nor does it
include interim payments payable. If you are reimbursed under the periodic interim payment
method of reimbursement, enter the periodic interim payments received for this cost reporting
period.
Line 2--Enter the total Medicare interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period, but not paid as of the end of the cost reporting period, and does not include
payments reported on line 1.
Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4--Enter the total amount of the interim payments (sum of lines 1, 2, and 3.99). Transfer
these totals to the appropriate column on Worksheet H-4, Part II, line 32.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET H-5. THE REMAINDER
OF THE WORKSHEET IS COMPLETED BY YOUR CONTRACTOR.
Line 5--List separately each tentative settlement payment after desk review together with the
date of payment. If the cost report is reopened after the NPR has been issued, report all
settlement payments prior to the current reopening settlement on line 5.
Line 6--Enter the net settlement amount (balance due to the provider or balance due to the
program) for the NPR, or, if this settlement is after a reopening of the NPR, for this reopening.
Enter in column 2 the amount on Worksheet H-4, Part II, column 1, line 34. Enter in column 4
the amount on Worksheet H-4, Part II, column 2, line 34.
NOTE: On lines 3, 5, and 6, when an amount is due from the provider to the program, show
the amount and date on which you agree to the amount of repayment, even though total
repayment is not accomplished until a later date.
Line 7--Enter the total of the amounts on lines 4, 5.99, and 6. Enter in column 2 the amount on
Worksheet H-4, Part II, column 1, line 31. Enter in column 4 the amount on Worksheet H-4,
Part II, column 2, line 31.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1 and 2,
respectively.
Rev. 3
40-243
4047
4047.
FORM CMS-2552-10
10-12
ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS
This worksheet provides for the analysis of the direct and indirect expenses related to the renal
dialysis cost centers, allocation of cost between inpatient and outpatient renal dialysis services
where separate cost centers are not maintained, and the allocation of the cost to the various
modes of outpatient dialysis treatment. The ancillary renal dialysis cost center is serviced by the
general cost centers and includes all reimbursable cost centers within the provider organization
which provide services to the renal dialysis department. The cost used in the analysis for the
renal dialysis department is obtained, in part, from Worksheets A; B, Part I; and C. Complete a
separate Worksheet I series for lines 74 and 94 of Worksheet A. In other words, complete one
Worksheet I series for line 74 and one for line 94, if appropriate.
4048.
WORKSHEET I-1 - ANALYSIS OF RENAL DIALYSIS DEPARTMENT COSTS
This part provides for recording the direct salaries and other direct expenses applicable to the
total inpatient and outpatient renal dialysis cost center or outpatient renal dialysis cost center
where you maintain a separate and distinct outpatient renal dialysis cost center. If you have
more than one renal dialysis department, and/or more than one home dialysis department, submit
one Worksheet I series combining the renal dialysis departments and a separate Worksheet I
series combining the home dialysis departments. You must also have on file, as supporting
documentation, a Worksheet I series for each renal dialysis department and for each home
dialysis department along with the appropriate workpapers. File this documentation with
exception requests in accordance with CMS Pub. 15-1, §2720. Do not combine the cost of the
renal dialysis with home program dialysis reported separately on Worksheet A, lines 74 and 94.
This worksheet also provides for recording the indirect expenses applicable to the total renal or
outpatient renal dialysis department obtained from Worksheet B, Part I, columns 1 through 23,
line 74 as adjusted for post stepdown adjustments, if any. When completing a separate
Worksheet I for home program dialysis, transfer the direct expenses from Worksheet B, Part I,
columns 1 through 23, line 94. Do not combine the cost of the renal department with home
program dialysis. These costs are listed separately on Worksheet A, lines 74 and 94,
respectively.
Column Descriptions
Column 1--Enter on lines 1 through 8 the amounts included from Worksheet A, column 7 for
salaries only. Enter on lines 10 through 16 and 18 through 26 the amounts from Worksheet B,
Part I, all columns for lines 74 and 94. The subtotal on Worksheet I-1, line 27 agrees with the
sum of Worksheet B, Part I, column 26, line 74 or line 94 if a home dialysis cost center was
established and used on Worksheet A.
Column 2--This column lists the statistical bases for allocating costs on Worksheet I-3.
Column 3--Enter paid hours per type of staff listed on lines 1 through 6.
Column 4--Enter full time equivalents by dividing column 3 by 2080 hours.
Line Descriptions
Lines 1 - 6--Enter on these lines the direct patients care salaries after adjustments and
reclassification that you reported in column 7 of Worksheet A. Direct patient care salary
includes only the salary of staff providing direct patient care services. Also include fee paid to
non-employees providing direct patient care services. Time spent furnishing administrative or
management services by direct patient care personnel is reported on line 8, non-patient care
salary.
40-244
Rev. 3
08-11
FORM CMS-2552-10
4048 (Cont.)
Line 7--Include on this line amounts paid to physicians for their administrative services of
managing the renal department. These payments are subject to the limitation contained in
§2723.3 of CMS Pub. 15-1. Also include payments to physicians for their medical services if the
box on line 21 of Worksheet S-5 is marked the initial method. A complete description of the
initial method is in CMS Pub. 15-1, §2715. For a renal provider to be paid under the initial
method, all renal physicians at the provider must elect the initial method. Under the initial
method, renal physicians are paid by the provider for their routine renal medical services and the
provider's composite payment rate is increased according to 42 CFR 414.313. No payment to
physicians for patient medical services should appear on this line if the monthly capitation
payment (MCP) box is marked on Worksheet S-5. Under the MCP, contractors pay physicians
directly for their medical services.
Line 8--Enter the amount of salaries paid non-patient care personnel after reclassifications and
adjustments that you report in column 7 of Worksheet A.
Lines 10 through 16--Include on the appropriate lines costs directly charged to the renal
department after reclassifications and adjustments. Report other direct costs on line 16 that
cannot be specifically identified on lines 11 through 15.
Lines 17--Add lines 9 through 16. The total in column 1 must agree with the total on Worksheet
A, column 7 for line 74 or line 94, as appropriate.
Lines 18 through 26--Enter the allocated general service costs from Worksheet B, Part I, lines 74
or 94 as listed in the chart below.
NOTE: Line 25 should exclude the costs of EPO and Aranesp administered to ESRD patients
in the renal department and home program identified on Worksheet B-2, lines 1, 2, 3 or
4.
Worksheet I-1,
Part I, Column 1,
Line Number
18
General Service Cost Centers
Capital-Related CostsBuildings and Fixtures
Worksheet B,
Part I, Lines 74
or 94, Columns
1
19
Capital-Related CostsMoveable Equipment
2
20
Employee Benefits
4
21
Administrative and General
5
22
Maintenance & Repairs, Operation
of Plant and Housekeeping
Sum of 6, 7,
and 9
23
Medical Education Programs
Sum of 20, 21, 22,
23, and 25 (medical
education only)
Rev. 2
40-245
4048 (Cont.)
FORM CMS-2552-10
08-11
24
Central Services & Supplies
14
25
Pharmacy
15
26
Other Allocated Costs
Sum of 8, 10,
11, 12, 13, 16,
17, 18, and 19
Line 27--Add lines 18 through 26. This total must agree with the total on Worksheet B, column
26, line 74 or line 94 if a home dialysis cost center was established, less the adjustments for EPO
and Aranesp reported on Worksheet B-2, lines 1, 2, 3, or 4 as appropriate.
Lines 28, 29, and 30--These lines provide for the allocation of costs associated with routine
dialysis services furnished to renal patients from other ancillary departments. Enter the cost to
charge ratio from Worksheet C, Part I, column 9. Payment for routine laboratory services, as
defined in the Medicare Benefit Policy Manual (100-02 IOM), chapter 11 (ESRD), §30.2, is paid
for under the composite payment rate. No separate payment is made for routine laboratory tests.
The costs of these services are allocated to the renal department based on the provider’s
laboratory cost to charge ratio from Worksheet C, Part I, column 9, line 60. Providers must
maintain a log of routine laboratory charges for allocating routine laboratory costs to the renal
department. The lab charges reported on Worksheet C do not include the lab charges for ESRD
therefore those charges must be grossed up in accordance with Pub. 15-1,§ 2314. The cost to
charge ratio must be recalculated and applied against the charges reported in column 3 of this
worksheet. Do not gross up ESRD charges. Instead, the cost to charge ratio for lab charges
reported on Worksheet C will be used.
Line 31--Enter the sum lines 27 through 30.
40-246
Rev. 2
08-11
4049.
FORM CMS-2552-10
4049
WORKSHEET I-2 - ALLOCATION OF RENAL DEPARTMENT COSTS TO
TREATMENT MODALITIES
The purpose of this schedule is to allocate costs to the different services furnished in the renal
department. Line 1 combines the costs reported on Worksheet I-1 for allocating costs to the
different services furnished in the renal department.
Line 1--Add the costs from Worksheet I-1, and transfer these amounts to line 1 in the following
manner:
Worksheet I-2
Worksheet I-2 Column
Worksheet I-1
Capital & Main Building Costs
1
Sum of lines 11, 18, and 22
Capital, Machine & Repair Costs
2
Sum of lines 12, 13, and 19
Registered Nurses Direct Patient Care
Salary
3
Line 1
Other Direct Patient Care Salary
4
Sum of lines 2, 3, 4, 5, and 6
Employee Benefits
5
Sum of lines 10 and 20
Drugs
6
Sum of lines 15 and 25
Medical Supplies
7
Sum of lines 14 and 24
Routine Ancillary Services
8
Sum of lines 28, 29, and 30
Subtotal
9
Not applicable
Overhead
10
Sum of lines 7, 8, 16, 21, and 26
Complete columns 1 through 8 and 10 in conjunction with Worksheet I-3, which contains the
statistical bases for allocating costs to the proper lines. For each line item in columns 1 through
8 and 10, multiply the statistic entered in the corresponding line and column of Worksheet I-3 by
the unit cost multiplier on line 18.
Lines 2 through 11--These lines identify the type of dialysis treatments that are paid for under the
composite payment rate system. The total costs (column 11) for these individual dialysis
services are transferred to Worksheet I-4.
Transfer the total on Worksheet I-2, column 11 to Worksheet I-4 per the following instructions.
From Worksheet I-2, Column 11
Line 2
Line 3
Line 4
Line 5
Line 6
Line 7
Line 8
Line 9
Line 10
Line 11
Rev. 2
To Worksheet I-4, Column 2
Line
Line
Line
Line
Line
Line
Line
Line
Line
Line
1
2
3
4
5
6
7
8
9
10
40-247
4049 (Cont.)
FORM CMS-2552-10
08-11
If you complete a Worksheet I-2 for the renal department and the home program dialysis
department, complete a separate Worksheet I-4.
Lines 12 through 16--These services are not paid for under the composite payment rate system.
Therefore, the costs of these services are not transferred to Worksheet I-4. Exclude these costs in
the calculation of reimbursement composite payment rate bad debts. (See 42 CFR 413.178(d).)
Line 12.--Report inpatient costs. Inpatient dialysis services are paid under the DRG system for
Medicare patients.
Line 13.--Report the costs of support services furnished to Method II home patients. Payment
for Method II home patient dialysis services are subject to the rules in 42 CFR 414.330. Under
Method II, a renal provider is only allowed to bill for support services and not dialysis equipment
or supplies. Payment for support services is limited to the lower of the provider’s reasonable cost
or the payment limit as defined in the regulation, which is $121.15 per patient per month. This
amount includes payment for support services and routine laboratory tests furnished to home
patients.
Line 14.--Report the direct costs of EPO net of discounts furnished in the renal department.
Include all costs for patients receiving outpatient, home, or training dialysis treatments. This
amount includes EPO cost furnished in the renal department or any other department if furnished
to an end stage renal dialysis patient. Enter EPO amount for informational purposes only. This
amount is not included in the total on line 17.
Line 15.--Report the direct costs of Aranesp net of discounts furnished in the renal department.
Include all costs for patients receiving outpatient, home, or training dialysis treatments. This
amount includes Aranesp cost furnished in the renal department or any other department if
furnished to an end stage renal dialysis patient. Enter Aranesp amount for informational
purposes only. This amount is not included in the total on line 17.
Line 16.--Report the costs of other services furnished and billed in the renal department that are
paid for outside the composite payment rate.
Line 17--Add columns and enter totals. Since lines 14 and 15, column 9 are shaded, no costs for
EPO and Aranesp are included in the total for line 17, column 9 and column 6, lines 14 and 15
should be excluded from total.
Line 18--Enter the amount of medical educational program costs from Worksheet I-1, line 23.
Payment for medical educational program costs allocated to the renal department is not included
in the composite payment rate.
Line 19--Add lines 17 and 18. This total agrees with the sum of Worksheet I-1, column 1, line
31.
Column Description
Columns 1 through 8--For each line, multiply the unit cost multiplier on Worksheet I-3, line 18
by the statistical base, and enter the result on the corresponding line and column on Worksheet I2.
Column 9--Add columns 1 through 8 for each line, except lines 14 (EPO) and 15 (Aranesp), and
enter the total.
Column 10--Multiply the unit cost multiplier on Worksheet I-3, column 10, line 18 by the line
amounts in column 9 of Worksheet I-2, and enter the amount in column 10.
Column 11--Add columns 9 and 10 for each line, and enter the result.
40-248
Rev. 2
08-11
4050.
FORM CMS-2552-10
4050
WORKSHEET I-3 - DIRECT AND INDIRECT RENAL DIALYSIS COST
ALLOCATION - STATISTICAL BASIS
To accomplish the allocation of your direct and indirect costs reported on Worksheet I-1 to the
different services provided in the department, you must maintain renal department statistics. To
facilitate the allocation process, the format of Worksheets I-2 and I-3 is identical.
Line 1--Transfer the amounts on Worksheet I-2, line 1, columns 1 through 10 to Worksheet I-3,
line 1, columns 1 through 10.
Lines 2 through 16--Enter on these lines and in the appropriate columns, the statistic for
allocating costs to the appropriate line item. The statistical basis used in each column is defined
in the column heading and on Worksheet I-1.
NOTE: If you wish to change your allocation basis for a particular general cost center, you
must receive written approval from your contractor before the start of your cost
reporting period for which the alternative method is used. (See §4017 for Worksheets
B and B-1.)
Line 12--Enter, in the area provided, the number of inpatient dialysis treatments furnished during
the cost reporting period.
Line 17--Add the statistical basis for each column, except columns 9 and 10.
Line 18--Calculate the unit cost multiplier by dividing the amount on line 1 by the total statistical
basis on line 17 for each column. Multiply the unit cost multiplier by the statistical base, and
enter the cost on the appropriate line and column number on Worksheet I-2.
Column Descriptions
Column 1--Use the square footage of the renal department to allocate capital and maintenance
building costs.
Column 2--Use percentage of time to allocate capital and maintenance equipment costs.
Columns 3 and 4--Use paid hours to allocate registered nurses and direct patient care salary.
Column 5--Use total direct patient care salaries in columns 4 and 5 of Worksheet I-2 to allocate
employee benefits.
Columns 6 and 7--Use cost of requisitions to allocate drug and medical supply costs.
Column 8--Use routine laboratory charges to allocate laboratory costs.
Column 10--Use subtotal costs in column 9, Worksheet I-2 to allocate overhead cost. To
compute the unit cost multiplier, transfer the amount from Worksheet I-2, line 17, column 9 to
Worksheet I-3, line 17, column 10. Do not allocate overhead costs to lines 14 (EPO) or 15
(Aranesp).
Rev. 2
40-249
4051
4051.
FORM CMS-2552-10
08-11
WORKSHEET I-4 - COMPUTATION OF AVERAGE COST PER TREATMENT
FOR OUTPATIENT RENAL DIALYSIS
This worksheet records the apportionment of total outpatient cost to the types of dialysis
treatment furnished by you and shows the computation of expenses of dialysis items and services
that you furnished to Medicare dialysis patients. This information is used for overall program
evaluation, determining the appropriateness of program reimbursement rates, and meeting
statutory requirements for determining the cost of ESRD care.
Complete separate worksheets to report the costs of the renal dialysis department and the home
program dialysis department.
If you have more than one renal dialysis and/or home dialysis department, submit one Worksheet
I-4 combining the renal dialysis departments and/or one Worksheet I-4 combining the home
dialysis departments as only one average composite rate will apply to each modality. Enter on
the combined Worksheet I-4 each provider’s satellite number if you are separately certified as a
satellite facility.
In accordance with section 1881(b)(12)(A) of the Act, as added by section 623(d)(1) of MMA
2003, the ESRD payment is replaced by a calculated ESRD composite rate.
Columns 1 through 3 refer to total outpatient statistics, i.e., to all outpatient dialysis services
furnished, whether reimbursed directly by the program or not.
Column 1--Enter on the appropriate lines the total number of outpatient treatments by type for all
renal dialysis patients from your records. These statistics include all treatments furnished to all
patients in the outpatient renal department, both Medicare and non-Medicare.
Column 2--Enter on the appropriate lines the total cost transferred from Worksheet I-2, columns
11, lines as appropriate.
Column 3--Determine the amounts entered on the appropriate lines by dividing the cost entered
on each line in column 2 by the number of treatments entered on each line in column 1.
Line 9--Report continuous ambulatory peritoneal dialysis (CAPD) in terms of weeks. Compute
patient weeks by totaling the number of weeks each Method I patient was dialyzed at home using
CAPD.
Line 10--Report continuous cycling peritoneal dialysis (CCPD) in terms of weeks. Compute
patient weeks by totaling the number of weeks each Method I patient was dialyzed at home by
CCPD.
Medicare Treatments
Columns 4 through 7 refer only to treatments furnished to Medicare beneficiaries that were billed
to the facility and reimbursed by the program directly. (Amounts entered in these columns are
reconcilable to your records.)
40-250
Rev. 2
10-12
FORM CMS-2552-10
4051 (Cont.)
Column 4--Enter on the appropriate lines the number of treatments billed to the Medicare
program directly. Obtain this information from your records and/or the PS&R.
Column 5--Determine the amounts entered on the appropriate lines by multiplying the number of
treatments entered on each line in column 4 by the average cost per treatment entered on the
corresponding line in column 3. Transfer the total expenses from this column, line 11 to
Worksheet I-5, line 1. If you complete a Worksheet I-4 for renal dialysis and a Worksheet I-4
for home dialysis, add the sum of the cost from this column, line 11, and transfer the total to
Worksheet I-5, line 1.
Column 6--Total Program Payment--Enter the total program payment by the type of treatment
for the reporting period. Since this amount is calculated on a patient basis and is case mix
adjusted, the total program payment will be provider specific for each modality.
The ESRD composite payment rate is an average payment calculated based on the total Medicare
payments by type of treatment divided by the total ESRD treatments.
Column 7--Average Payment Rate--Enter the total average payment rate by the type of treatment
for the reporting period. Determine the amounts entered on the appropriate lines by dividing the
total payments on each corresponding line in column 6 by the number of treatments entered on
each line in column 4.
Line 11--Enter in columns 1 and 4 the sum total of lines 1 through 8. Enter in columns 2, 5, and
6 the sum total of lines 1 through 10.
Transfer the total payment from column 6, line 11 to Worksheet I-5, line 2.
Rev. 3
40-251
4052
4052.
FORM CMS-2552-10
10-12
WORKSHEET I-5 - CALCULATION OF REIMBURSABLE BAD DEBTS - TITLE
XVIII - PART B
This worksheet provides for the calculation of reimbursable Part B bad debts relating to
outpatient renal dialysis treatments. If you have completed more than one Worksheet I-2 (i.e.,
one for renal dialysis department and one for home program dialysis), make a consolidated bad
debt computation.
Line 1--Enter the amount from Worksheet I-4, column 5, line 11.
Line 2--Enter the amount from Worksheet I-4, column 6, line 11 (net of deductibles).
Line 3--Enter the amount shown in your records for deductibles billed to Medicare (Part B) for
dialysis treatments.
Line 4--Enter the amount shown in your records for coinsurance billed to Medicare (Part B) for
dialysis treatments.
The amounts on lines 3 and 4 must exclude coinsurance and deductible amounts for services
other than dialysis treatments (e.g., Epoetin and Aranesp).
Line 5--Enter the uncollectible portion of the amounts entered on lines 3 and 4 reduced by any
amount recovered during the cost reporting period.
Line 6--Reserved for future use.
Line 7--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be included in the amount on line
5.
Line 8--Enter the sum of lines 3 and 4, less line 5.
Line 9--Subtract line 3 from line 2, and enter 80 percent of the difference.
Line 10--Enter the result of line 1 minus the sum of lines 8 and 9. If the result is negative, enter
zero and do not complete line 11.
Line 11--Enter the lesser of line 5 or line 10. Transfer this amount to Worksheet E, Part B, line
33.
40-252
Rev. 3
08-11
4053.
FORM CMS-2552-10
4053.2
WORKSHEET J-1 - ALLOCATION OF GENERAL SERVICE COSTS TO
COMMUNITY MENTAL HEALTH CENTERS
Use this worksheet only if you operate as part of your complex a certified hospital-based
community mental health center (CMHC) furnishing services to Medicare titles XVIII, title XIX,
and V. Additionally, while comprehensive outpatient rehabilitation facilities (CORFs),
outpatient rehabilitation facilities (ORFs) which generally furnish outpatient physical therapy
(OPT), outpatient occupational therapy (OOT), or outpatient speech pathology (OSP) services,
do not complete the J series worksheets they must complete the applicable Worksheet A cost
center for the purpose of overhead allocation. Only those cost centers that represent services for
which the facility is certified are used. If you have more than one hospital-based CMHC,
complete a separate worksheet for each facility.
4053.1 Part I - Allocation of General Service Costs to Community Mental Health Center Cost
Centers.--Worksheet J-1, Part I, provides for the allocation of the expenses of each general
service cost center to those cost centers which receive the services. Obtain the total direct
expenses (column 0, line 22) from Worksheet A, column 7, lines as appropriate:
Component
From Worksheet A, Column 7
CMHC
line 99 and subscripts
Obtain the cost center allocations (column 0, lines 1 through 21) from your records, the sum of
which must equal the amount entered on column 0, line 22. The amounts on line 22, columns 0
through 23 and column 25 must equal the corresponding amounts on Worksheet B, Part I,
columns 0 through 23 and column 25, lines as appropriate:
Component
CMHC
Worksheet B, Part I, Columns 0 through 23 and 25
line 99 and subscripts
Complete the amounts entered on lines 1 through 21, columns 1 through 23 and column 25 in
accordance with the instructions contained in §4053.2.
NOTE: Worksheet B, Part I, established the method used to reimburse direct graduate medical
education cost (i.e., reasonable cost or the per resident amount). Therefore, this
worksheet must follow that method. If Worksheet B, Part I, column 25, excluded the
costs of interns and residents, column 25 on this worksheet must also exclude these
costs.
In column 24, Part I, enter the total of columns 4A through 23.
In column 27, Part I, enter the unit cost multiplier (column 26, line 1 divided by the sum of
column 26, line 22 minus column 26, line 1) on line 23. Round the unit cost multiplier to six
decimal places. Multiply each amount in column 26, lines 2 through 21, by the unit cost
multiplier on line 23, and enter the result on the corresponding line of column 27. On line 22,
enter the total of the amounts on lines 2 through 21. The total on line 22 equals the amount in
column 26, line 1.
In column 28, Part I, enter on lines 2 through 21 the sum of columns 26 and 27. The total on line
22 equals the total in column 26, line 22.
4053.2 Part II - Allocation of General Service Costs to Community Mental Health Center Cost
Centers - Statistical Basis.--Worksheet J-1, Part II, provides for the proration of the statistical
data needed to equitably allocate the expenses of the hospital’s general service cost centers on
Worksheet J-1, Part I. If there is a difference between the total accumulated costs reported on the
Part II statistics and the total accumulated costs calculated on Part I, use the reconciliation
column on Part II for reporting any
Rev. 2
40-253
4053.2 (Cont.)
FORM CMS-2552-10
08-11
adjustments. See §4020 for the appropriate usage of the reconciliation columns. For subscripted
(componentized) A&G cost centers, the accumulated cost center line must match the
reconciliation column number.
To facilitate the allocation process, the general format of Worksheet J-1, Parts I and II, is
identical. The statistical basis shown at the top of each column on Worksheet J-1, Part II, is the
recommended basis of allocation of the cost center indicated and must be consistent with the
statistical basis utilized on Worksheet B, Part I.
Lines 1 through 21--On Worksheet J-1, Part II, for all cost centers to which the general service
cost center is being allocated, enter that portion of the total statistical base applicable to each.
Line 22--Enter the total of lines 1 through 21 for each column. The total in each column must be
the same as shown for the corresponding column on Worksheet B-1, lines as appropriate:
Component
CMHC
Worksheet B-1, Corresponding Column
line 99
Line 23--Enter the total expenses for the cost center allocated. Obtain this amount from
Worksheet B, Part I, lines as appropriate (see §4020), from the same column used to enter the
statistical base on Worksheet J-1, Part II (e.g., for a CMHC provider, in the case of capitalrelated cost buildings and fixtures, this amount is on Worksheet B, Part I, column 1, line 99).
Line 24--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 23
by the total statistic entered in the same column on line 22. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistic applicable to each cost center
receiving the services. Enter the result of each computation on Worksheet J-1, Part I, in the
corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (line 22, Part I) must equal the total cost on line 23, Part II.
Perform the preceding procedures for each general service cost center.
40-254
Rev. 2
08-11
4054.
FORM CMS-2552-10
4054
WORKSHEET J-2 - COMPUTATION OF COMMUNITY MENTAL HEALTH
CENTER PROVIDER COSTS
Use this worksheet only if you operate a hospital-based CMHC. If you have more than one
hospital-based CMHC, complete a separate worksheet for each facility.
4054.1
Part I - Apportionment of CMHC Cost Centers.--
Column 1--Enter on each line the total cost for the cost center as previously computed on
Worksheet J-1, Part I, column 28. To facilitate the apportionment process, the line numbers are
the same on both worksheets. Do not transfer lines 19 and 20 from Worksheet J-1.
Column 2--Enter the charges for each cost center. Obtain the charges from your records.
Column 3--For each cost center, enter the ratio derived by dividing the cost in column 1 by the
charges in column 2.
Columns 4, 6, and 8-- For each cost center, enter the charges from your records for title V in
column 4 and title XIX in column 8. Enter 0 (zero) for each line in column 6 for title XVIII
charges as CMHCs are reimbursed under OPPS. Not all facilities are eligible to participate in all
programs.
Columns 5, 7, and 9--For each cost center, enter the costs obtained by multiplying the charges in
columns 4, 6, and 8, by the ratio in column 3.
Line 20--Enter the totals of lines 1 through 19 in columns 1, 2, and 4 through 9.
4054.2 Part II - Apportionment of Cost of CMHC Services Furnished by Shared Hospital
Departments.--Use this part only when the hospital complex maintains a separate department for
any of the cost centers listed on this worksheet, and the department provides services to patients
of the hospital's CMHC.
Column 3--For each of the cost centers listed, enter the ratio of cost to charges that is shown on
Worksheet C, Part I, column 9 from the appropriate line for each cost center.
Columns 4, 6, and 8--For each cost center, enter the charges from your records for title V in
column 4 and title XIX in column 8. Enter 0 (zero) for each line in column 6 for title XVIII
charges as CMHCs are reimbursed under OPPS.
Columns 5, 7, and 9--For each cost center, enter the costs obtained by multiplying the charges in
columns 4, 6, and 8, respectively, by the ratio in column 3.
Line 28--Enter the totals for columns 4 through 9.
Line 29--Enter the total costs from Part I, columns 5, 7, and 9, line 20 plus columns 5, 7, and 9,
line 28 respectively and transfer to Worksheet J-3, line 1.
4055.
WORKSHEET J-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT –
COMMUNITY MENTAL HEALTH CENTER PROVIDER SERVICES
Submit a separate Worksheet J-3 for each title (V, XVIII, or XIX) under which reimbursement is
claimed. If you have more than one hospital-based CMHC, complete a separate worksheet for
each facility.
Line 1--Enter the cost of the component's services from Worksheet J-2, Part II, line 29 from
columns 5, 7, or 9, as applicable (column 5 for title V, column 7 for title XVIII (enter 0 (zero)),
and column 9 for title XIX).
Rev. 2
40-255
4055 (Cont.)
FORM CMS-2552-10
08-11
Line 2--Enter the gross PPS payments received for services rendered during the cost reporting
period excluding outliers. Obtain this amount from the PS&R and/or your records.
Line 3--Enter the total outliers payments received. Obtain this amount from the PS&R and/or
your records.
Line 4--Enter the amounts paid and payable by workmens' compensation and other primary
payers where program liability is secondary to that of the primary payer (from your records).
Line 5--Title XVIII CMHCs enter the result obtained by subtracting line 4 from the sum of lines
2 and 3. Titles V and XIX providers not reimbursed under PPS enter the total reasonable costs
by subtracting line 4 from line 1.
Line 6--Enter the charges for the applicable program services from Worksheet J-2, sum of Parts I
and II, Columns 4, 6, and 8 as appropriate, lines 20 and 28.
Lines 7 through 10--These lines provide for the reduction of program charges where the provider
does not actually impose charges on most of the patients liable for payment for services on a
charge basis or fails to make reasonable efforts to collect such charges from those patients. If
line 9 is greater than zero, enter on line 10 the product of multiplying the ratio on line 9 by line 6.
Providers that do impose charges and make reasonable efforts to collect the charges from
patients liable for payment for services on a charge basis are not required to complete lines 7, 8,
and 9, but enter on line 10 the amount from line 6. (See 42 CFR 413.13(e).) In no instance may
the customary charges on line 10 exceed the actual charges on line 6.
Do not include on these lines (1) the portion of charges applicable to the excess costs of luxury
items or services (see CMS Pub. 15-1, §2104.3) and (2) provider charges to beneficiaries for
excess costs as described in CMS Pub. 15-1, §2570. When provider operating costs include
amounts that flow from the provision of luxury items or services, such amounts are not allowable
in computing reimbursable costs.
Lines 11 and 12--Lines 11 and 12 provide for the computation of the lesser of reasonable cost or
customary charges as defined in 42 CFR 413.13(a).
Enter on line 11 the excess of total customary charges (line 10) over the total reasonable cost
(line 5). In situations where the total charges on line 10 are less than the total cost on line 5, enter
zero (0) on line 11.
Enter on line 12 the excess of total reasonable cost (line 5) over total customary charges (line
10). In situations when in any column the total cost on line 5 is less than the customary charges
on line 10, enter zero (0) on line 12.
NOTE: CMHCs not subject to reasonable cost reimbursement do not complete lines 11 and 12.
Line 13--Enter the total reasonable costs from line 5.
Line 14--Enter the Part B deductibles billed to program patients (from your records) excluding
coinsurance amounts.
Line 16--If there is an excess of reasonable cost over customary charges, enter the amount from
line 12.
Line 18--CMHCs enter 0 (zero) as these services are reimbursed under OPPS. For titles V and
XIX, enter 100 percent less the applicable coinsurance.
40-256
Rev. 2
10-12
FORM CMS-2552-10
4055 (Cont.)
Line 19--Enter the actual coinsurance billed to program patients (from your records).
Line 20--For title XVIII, enter the difference of line 17 minus line 19. For titles V and XIX,
enter the difference of line 18 minus line 19.
Line 21--Enter allowable bad debts, net of recoveries, applicable to any deductibles and
coinsurance (from your records). If recoveries exceed the current year’s bad debts, line 21 will
be negative.
Line 22--This line is reserved for future use.
Line 23--Enter the gross allowable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 21.
Line 24--CMHCs enter the result of line 20 plus line 21.
Line 25--Enter any other adjustment. For example, if you change the recording of vacation pay
from the cash basis to the accrual basis (see CMS Pub. 15-1 §2146.4), enter the adjustment.
Specify the adjustment in the space provided.
Line 26--Enter the result of line 24 plus or minus line 25.
Line 27--Enter the total interim payments applicable to this cost reporting period. For title
XVIII, transfer this amount from Worksheet J-4, column 2, line 4.
Line 28--For contractor final settlement, report on this line the amount from Worksheet J-4, line
5.99.
Line 29--Enter the balance due provider/program (line 26 minus lines 27 and 28), and transfer
this amount to Worksheet S, Part III, columns as appropriate, lines as appropriate.
Line 30--Enter the program reimbursement effect of nonallowable cost report items which you
are disputing. Compute the reimbursement effect in accordance with §115.2. Attach a schedule
showing the supporting details and computation.
Rev. 3
40-257
4056
4056.
FORM CMS-2552-10
10-12
WORKSHEET J-4 - ANALYSIS OF PAYMENTS TO HOSPITAL-BASED
COMMUNITY MENTAL HEALTH CENTER FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES
Complete this worksheet for Medicare interim payments only. If you have more than one
hospital-based CMHC, complete a separate worksheet for each facility.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor.
Line Descriptions
Line 1--Enter the total program interim payments paid to the CMHC. The amount entered
reflects the sum of all interim payments paid on individual bills (net of adjustment bills) for
services rendered in this cost reporting period. The amount entered includes amounts withheld
from the component's interim payments due to an offset against overpayments to the component
applicable to prior cost reporting periods. It does not include any retroactive lump sum
adjustment amounts based on a subsequent revision of the interim rate, or tentative or net
settlement amounts, nor does it include interim payments payable.
Line 2--Enter the total program interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period, but not paid as of the end of the cost reporting period. It does not include
payments reported on line 1.
Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4--Transfer the total interim payments to the title XVIII Worksheet J-3, line 27.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET J-4. LINES 5 THROUGH 7
ARE FOR CONTRACTOR USE ONLY.
Line 5--List separately each tentative settlement payment after desk review together with the
date of payment. If the cost report is reopened after the NPR has been issued, report all
settlement payments prior to the current reopening settlement on line 5.
Line 6--Enter the net settlement amount (balance due to the provider or balance due to the
program) for the NPR, or, if this settlement is after a reopening of the NPR, for this reopening.
NOTE: On lines 3, 5, and 6, when an amount is due from the provider to the 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.
Line 7--Enter the sum of the amounts on lines 4, 5.99, and 6 in column 2. The amount in column
2 must equal the amount on Worksheet J-3, line 26.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1 and 2,
respectively.
40-258
Rev. 3
08-11
FORM CMS-2552-10
4057
4057. WORKSHEET K - ANALYSIS OF PROVIDER-BASED HOSPICE COSTS
In accordance with 42 CFR 413.20, the methods of determining costs payable under title XVIII
involve making use of data available from the institution's basic accounts, as usually maintained,
to arrive at equitable and proper payment for services. The K series Worksheets must be
completed by all hospital-based hospices. This worksheet provides for recording the trial balance
of expense accounts from your accounting books and records. It also provides for
reclassification and adjustments to certain accounts. The cost centers on this worksheet are listed
in a manner, which facilitates the transfer of the various cost center data to the cost finding
worksheets (e.g., on Worksheets K, K-4, Parts I & II, the line numbers are consistent, and the
total line is set at 39). Not all of the cost centers listed apply to all providers using these forms.
Column 1--Obtain salaries to be reported from Worksheet K-1, column 9, line 3-38.
Column 2--Obtain employee benefits to be reported from Worksheet K-2 column 9, lines 3-38.
Column 3--If the transportation costs, i.e., owning or renting vehicles, public transportation
expenses, or payments to employees for driving their private vehicles can be directly identified
to a particular cost center, enter those costs in the appropriate cost center. If these costs are not
identified to a particular cost center enter them on line 27.
Column 4--Obtain the contracted services to be reported from Worksheet K-3, col. 9, lines 3-38.
Column 5--Enter in the applicable lines all costs which have not been reported in columns 1
through 4.
Column 6--Enter the sum of columns 1 through 5 for each cost center.
Column 7--Enter any reclassifications among cost center expenses in column 6 which are needed
to effect proper cost allocation. This column need not be completed by all providers, but is
completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. Show reductions to expenses as negative amounts.
Column 8--Adjust the amounts entered in column 6 by the amounts in column 7 (increases and
decreases) and extend the net balances to column 8. The total of column 8, line 39 must equal
the total of column 6, line 39.
Column 9--In accordance with 42 CFR 413.9(c)(3), enter on the appropriate lines the amounts of
any adjustments to expenses required under Medicare principles of reimbursements. (See
§4016.)
Column 10--Adjust the amounts in column 8 by the amounts in column 9, (increases or
decreases) and extend the net balances to column 10.
Transfer the amount in column 10, line 1 through 38 to the corresponding lines on Worksheet K4, Part I, column 0, lines 1 through 38.
LINE DESCRIPTIONS
Lines 1 and 2--Capital Related Cost - Buildings and Fixtures and Capital Related Cost -Movable
Equipment--These cost centers should include depreciation, leases and rentals for the use of the
facilities and/or equipment, interest incurred in acquiring land and depreciable assets used for
patient care, insurance on depreciable assets used for patient care and taxes on land or
depreciable assets used for patient care.
Rev. 2
40-259
4057 (Cont.)
FORM CMS-2552-10
08-11
Do not include in these cost centers the following costs: costs incurred for the repair or
maintenance of equipment or facilities; amounts included in the rentals or lease or lease
payments for repair and/or maintenance agreements; interest expense incurred to borrow
working capital or for any purpose other than the acquisition of land or depreciable assets used
for patient care; general liability of depreciable assets; or taxes other than those assessed on the
basis of some valuation of land or depreciable assets used for patient care.
Line 3--Plant Operation and Maintenance--This cost center contains the direct expenses incurred
in the operation and maintenance of the plant and equipment, maintaining general cleanliness
and sanitation of plant, and protecting the employees, visitors, and agency property.
Plant Operation and Maintenance include the maintenance and service of utility systems such as
heat, light, water, air conditioning and air treatment. This cost center also includes the cost of
maintenance and repair of building, parking facilities and equipment, painting, elevator
maintenance, performance of minor renovation of buildings, and equipment. The maintenance of
grounds such as landscape and paved areas, streets on the property, sidewalk, fenced areas,
fencing, external recreation areas and parking facilities are part of this cost center. The care or
cleaning of the interior physical plant, including the care of floors, walls, ceilings, partitions,
windows (inside and outside), fixtures and furnishings, and emptying of trash containers, as well
as the costs of similar services purchased from an outside organization which maintains the
safety and well-being of personnel, visitors and the provider’s facilities, are all included in this
cost center.
Line 4--Transportation-Staff--Enter all of the cost of transportation except those costs previously
directly assigned in column 3. This cost is allocated during the cost finding process.
Line 5--Volunteer Service Coordination--Enter all of the cost associated with the coordination of
service volunteers. This includes recruitment and training costs.
Line 6--Administrative and General--Use this cost center to record expenses of several costs
which benefit the entire facility. If the option to componentize (also known as fragmentation or
subscripting) administrative and general costs into more than one cost center is elected, eliminate
line 6. Componentized A&G lines must begin with subscripted line 6.01 and continue in
sequential order (i.e., 6.01 A&G shared costs, 6.02 A&G reimbursable costs, etcetera) Examples
include fiscal services, legal services, accounting, data processing, taxes, and malpractice costs.
Line 7--Inpatient - General Care--This cost center includes costs applicable to patients who
receive this level of care because their condition is such that they can no longer be maintained at
home. Generally, they require pain control or management of acute and severe clinical problems
which cannot be managed in other settings. The costs incurred on this line are those direct costs
of furnishing routine and ancillary services associated with inpatient general care for which other
provisions are not made on this worksheet.
Costs incurred by a hospice in furnishing direct patient care services to patients receiving general
inpatient care either directly from the hospice or under a contractual arrangement in an inpatient
facility is to be included in the visiting service costs section.
For a hospice that maintains its own inpatient beds, these costs include (but are not limited to)
the costs of furnishing 24 hours nursing care within the facility, patient meals, laundry and linen
services, and housekeeping. Plant operation and maintenance cost would be recorded on line 3.
For a hospice that does not maintain its own inpatient beds, but furnishes inpatient general care
through a contractual arrangement with another facility, record contracted/purchased costs on
Worksheet K-3. Do not include any costs associated with providing direct patient care. These
costs are recorded in the visiting services section.
40-260
Rev. 2
12-10
FORM CMS-2552-10
4057 (Cont.)
Line 8--Inpatient - Respite Care--This cost center includes costs applicable to patients who
receive this level of care on an intermittent, nonroutine and occasional basis. The costs included
on this line are those direct costs of furnishing routine and ancillary services associated with
inpatient respite care for which other provisions are not made on this worksheet. Costs incurred
by the hospice in furnishing direct patient care services to patients receiving inpatient respite care
either directly by the hospice or under a contractual arrangement in an inpatient facility are to be
included in visiting service costs section.
For a hospice that maintains its own inpatient beds, these costs include (but are not limited to)
the costs of furnishing 24 hours nursing care within the facility, patient meals, laundry and linen
services and housekeeping. Plant operation and maintenance costs would be recorded on line 3.
For A hospice that does not maintain its own inpatient beds, but furnishes inpatient respite care
through a contractual arrangement with another facility, record contracted/purchased costs on
Worksheet K-3. Do not include any costs associated with providing direct patient care. These
costs are recorded in the visiting service costs section.
Line 9--Physician Services--In addition to the palliation and management of terminal illness and
related conditions, hospice physician services also include meeting the general medical needs of
the patients to the extent that these needs are not met by the attending physician. The amount
entered on this line includes costs incurred by the hospice or amounts billed through the hospice
for physicians’ direct patient care services.
Line 10--Nursing Care--Generally, nursing services are provided as specified in the plan of care
by or under the supervision of a registered nurse at the patient’s residence.
Line 11--Nursing Care-Continuous Home Care--Enter the continuous home care portion of costs
for nursing services provided by a registered nurse, licensed practical nurse, or licensed
vocational nurse as specified in the plan of care by or under the supervision of a registered nurse
at the patient’s residence.
Line 12--Physical Therapy--Physical therapy is the provision of physical or corrective treatment
of bodily or mental conditions by the use of physical, chemical, and other properties of heat,
light, water, electricity, sound massage, and therapeutic exercise by or under the direction of a
registered physical therapist as prescribed by a physician. Therapy and speech-language
pathology services may be provided for purposes of symptom control or to enable the individual
to maintain activities of daily living and basic functional skills.
Line 13--Occupational Therapy--Occupational therapy is the application of purposeful goaloriented activity in the evaluation, diagnostic, for the persons whose function is impaired by
physical illness or injury, emotional disorder, congenial or developmental disability, and to
maintain health. Therapy and speech-language pathology services may be provided for purposes
of symptom control or to enable the individual to maintain activities of daily living and basic
functional skills.
Line 14--Speech/Language Pathology--These are physician-prescribed services provided by or
under the direction of a qualified speech-language pathologist to those with functionally
impaired communications skills. This includes the evaluation and management of any existing
disorders of the communication process centering entirely, or in part, on the reception and
production of speech and language related to organic and/or nonorganic factors. Therapy and
speech-language pathology services may be provided for purposes of symptom control or to
enable the individual to maintain activities of daily living and basic functional skills.
Line 15--Medical Social Services--This cost center includes only direct expenses incurred in
providing Medical Social Services. Medical Social Services consist of counseling and
assessment activities, which contribute meaningfully to the treatment of a patient’s condition.
These services must be provided by a qualified social worker, under the direction of a physician.
Rev. 1
40-261
4057 (Cont.)
FORM CMS-2552-10
12-10
Lines 16 - 18--Counseling--Counseling Services must be available to both the terminally ill
individual and family members or other persons caring for the individual at home. Counseling,
including dietary counseling, may be provided both for the purpose of training the individual's
family or other care giver to provide care, and for the purpose of helping the individual and those
caring for him or her to adjust to the individual's approaching death. This includes dietary,
spiritual, and other counseling services provided while the individual is enrolled in the hospice.
Costs associated with the provision of such counseling are accumulated in the appropriate
counseling cost center. Costs associated with bereavement counseling are recorded on line 35.
Line 19--Home Health Aide And Homemaker--Enter the cost of home health aide and
homemaker services. Home health aide services are provided under the general supervision of a
registered professional nurse and may be provided by only individuals who have successfully
completed a home health aide training and competency evaluation program or competency
evaluation program as required in 42 CFR 484.36.
Home health aides may provide personal care services. Aides may also perform household
services to maintain a safe and sanitary environment in areas of the home used by the patient,
such as changing the bed or light cleaning and laundering essential to the comfort and cleanliness
of the patient.
Homemaker services may include assistance in personal care, maintenance of a safe and healthy
environment and services to enable the individual to carry out the plan of care.
Line 20--Home Health Aide and Homemaker-Continuous Home Care--Enter the continuous care
portion of cost for home health aide and/or homemaker services provided as specified in the plan
of care and under the supervision of a registered nurse.
Line 21--Other-- Enter on this line any other visiting cost which cannot be appropriately
identified in the services already listed.
Line 22--Drugs, Biological and Infusion Therapy--Only drugs as defined in §1861(t) of the Act
and which are used primarily for the relief of pain and symptom control related to the
individual's terminal illness are covered. The amount entered on this line includes costs incurred
for drugs or biologicals provided to the patients while at home. If a pharmacist dispenses
prescriptions and provides other services to patients while the patient is both at home and in an
inpatient unit, a reasonable allocation of the pharmacist cost must be made and reported
respectively on line 22 (drugs and Biologicals) and line 7 (Inpatient General Care) or line 8
(Inpatient Respite Care) of Worksheet K.
A hospice may, for example, use the number of prescriptions provided in each setting to make
that allocation, or may use any other method that results in a reasonable allocation of the
pharmacist’s cost in relation to the service rendered.
Infusion therapy may be used for palliative purposes if you determine that these services are
needed for palliation. For the purposes of a hospice, infusion therapy is considered to be the
therapeutic introduction of a fluid other than blood, such as saline solution, into a vein.
Line 23--Analgesics--Enter the cost of analgesics.
Line 24--Sedatives/Hypnotics--Enter the cost of sedatives/hypnotics.
Line 25--Other Specify--Specify the type and enter the cost of any other drugs which cannot be
appropriately identified in the drug cost center already listed.
40-262
Rev. 1
12-10
FORM CMS-2552-10
4058
Line 26--Durable Medical Equipment/Oxygen--Durable medical equipment as defined in 42
CFR 410.38 as well as other self-help and personal comfort items related to the palliation or
management of the patient’s terminal illness are covered. Equipment is provided by the hospice
for use in the patient’s home while he or she is under hospice care.
Line 27--Patient Transportation--Enter all of the cost of transportation except those costs
previously directly assigned in column 3. This cost is allocated during the cost finding process.
Line 28--Imaging Services--Enter the cost of imaging services including MRI.
Line 29--Labs and Diagnostics--Enter the cost of laboratory and diagnostic tests.
Line 30--Medical Supplies--The cost of medical supplies reported in this cost center are those
costs which are directly identifiable supplies furnished to individual patients.
These supplies are generally specified in the patient's plan of treatment and furnished under the
specific direction of the patient's physician.
Line 31--Outpatient Service--Use this line for any outpatient services costs not captured
elsewhere. This cost can include the cost of an emergency room department.
Lines 32 - 33--Radiation Therapy and Chemotherapy--Radiation, chemotherapy and other
modalities may be used for palliative purposes if you determine that these services are needed for
palliation. This determination is based on the patient’s condition and your care giving
philosophy.
Line 34--Other--Enter any additional costs involved in providing visiting services which has not
been provided for in the previous lines.
Lines 35 - 38--Hospice Non Reimbursable Service--Enter in the appropriate lines the applicable
costs. Bereavement program costs consists of counseling services provided to the individual’s
family after the individual’s death. In accordance with §1814 (i)(1)(A) of the Social security Act
bereavement counseling is a required hospice service, but it is not reimbursable.
Line 39--Total--Line 39 column 10, should agree with Worksheet A, line 116, column 7.
4058.
WORKSHEET K-1 - COMPENSATION ANALYSIS - SALARIES AND WAGES
Enter all salaries and wages for the hospice on this worksheet for the actual work performed
within the specific area or cost center in accordance with the column headings. For example, if
the administrator also performs visiting services which account for 25 percent of that person's
time, then enter 75 percent of the administrator's salary on line 6 (A&G) and 25 percent of the
administrator's salary enter on line 10 (nursing care).
The records necessary to determine the split in salary between two or more cost centers must be
maintained by the hospice and must adequately substantiate the method used to split the salary.
These records must be available for audit by the contractor and the contractor can accept or reject
the method used to determine the split in salary. When approval of a method has been requested
in writing and this approval has been received prior to the beginning of a cost reporting period,
the approved method remains in effect for the requested period and all subsequent periods until
you request in writing to change to another method or until the contractor determines that the
method is no longer valid due to changes in your operations.
Rev. 1
40-263
4058 (Cont.)
FORM CMS-2552-10
12-10
Definitions
Salary--This is gross salary paid to the employee before taxes and other items are withheld,
includes deferred compensation, overtime, incentive pay, and bonuses. (See CMS Pub. 15-1,
Chapter 21.)
Administrator (Column 1)-Possible Titles:
President, Chief Executive Officer
Duties: This position is the highest occupational level in the agency. This individual is the
chief management official in the agency. The administrator develops and guides the
organization by taking responsibility for planning, organizing, implementing, and evaluating.
The administrator is responsible for the application and implementation of established policies.
The administrator may act as a liaison among the governing body, the medical staff, and any
departments.
The administrator provides for personnel policies and practices that adequately support sound
patient care and maintains accurate and complete personnel records. The administrator
implements the control and effective utilization of the physical and financial resources of the
provider.
Director (Column 2)-Possible Titles:
Medical Director, Director of Nursing, or Executive Director
Duties: The medical director is responsible for helping to establish and assure that the quality
of medical care is appraised and maintained. This individual advises the chief executive officer
on medical and administrative problems and investigates and studies new developments in
medical practices and techniques.
The nursing director is responsible for establishing the objectives for the department of nursing.
This individual administers the department of nursing and directs and delegates management of
professional and ancillary nursing personnel.
Medical Social Worker (Column 3)--This individual is a person who has at least a bachelor’s
degree from a school accredited or approved by the council of social work education. These
services must be under the direction of a physician and must be provided by a qualified social
worker.
Supervisors (Column 4)--Employees in this classification are primarily involved in the direction,
supervision, and coordination of the hospice activities.
When a supervisor performs two or more functions, e.g., supervision of nurses and home health
aides, the salaries and wages must be split in proportion with the percent of the supervisor's time
spent in each cost center, provided the hospice maintains the proper records (continuous time
records) to support the split. If continuous time records are not maintained by the hospice, enter
the entire salary of the supervisor on line 6 (A&G) and allocate to all cost centers through
stepdown. However, if the supervisor's salary is all lumped in one cost center, e.g., nursing care,
and the supervisor's title coincides with this cost center, e.g., nursing supervisor, no adjustment is
required.
Total Therapists (Column 6)--Include in column 6, on the line indicated, the cost attributable to
the following services:
Physical therapy
Occupational therapy
Speech pathology
40-264
-
line 12
line 13
line 14
Rev. 1
12-10
FORM CMS-2552-10
4059
Therapy and speech-language pathology may be provided for purposes of symptom control or to
enable the individual to maintain activities of daily living and basic functional skill.
Physical therapy is the provision of physical or corrective treatment of bodily or mental
conditions by the use of physical, chemical, and other properties of heat, light, water, electricity,
sound, massage, and therapeutic exercise by or under the direction of a registered physical
therapist as prescribed by a physician.
Occupational therapy is the application of purposeful, goal-oriented activity in the evaluation,
diagnosis, and/or treatment of persons whose ability to work is impaired by physical illness or
injury, emotional disorder, congenital or developmental disability, or the aging process, in order
to achieve optimum functioning, to prevent disability, and to maintain health.
Speech-language pathology is the provision of services to persons with impaired functional
communications skills by or under the direction of a qualified speech-language pathologist as
prescribed by a physician. This includes the evaluation and management of any existing
disorders of the communication process centering entirely, or in part, on the reception and
production of speech and language related to organic and/or nonorganic factors.
Aides (Column 7)--Included in this classification are specially trained personnel employed for
providing personal care services to patients. These employees are subject to Federal wage and
hour laws. This function is performed by specially trained personnel who assist individuals in
carrying out physician instructions and established plans of care. The reason for the home health
aide services must be to provide hands-on, personal care services under the supervision of a
registered professional nurse.
Aides may provide personal care services and household services to maintain a safe and sanitary
environment in areas of the home used by the patient, such as changing the bed or light cleaning
and laundering essential to the comfort and cleanliness of the patient. Additional services
include, but are not limited to, assisting the patient with activities of daily living.
All Other (Column 8)--Employees in this classification are those not included in columns 1 - 7.
Included in this classification are dietary, spiritual, and other counselors. Counseling Services
must be available to both the terminally ill individual and the family members or other persons
caring for the individual at home. Counseling, including dietary counseling, may be provided
both for the purpose of training the individual's family or other care giver to provide care, and for
the purpose of helping the individual and those caring for him or her to adjust to the individual's
approaching death. This includes dietary, spiritual and other counseling services provided while
the individual is enrolled in the hospice.
Total (Column 9)--Add the amounts of each cost center, columns 1 through 8, and enter the total
in column 9. Transfer these totals to Worksheet K, column 1, lines as applicable. To facilitate
transferring amounts from Worksheet K-1 to Worksheet K, the same cost centers with
corresponding line numbers are listed on both worksheets. Not all of the cost centers are
applicable to all agencies. Therefore, use only those cost centers applicable to your hospice.
4059.
WORKSHEET K-2 - COMPENSATION ANALYSIS – EMPLOYEE BENEFITS
(PAYROLL RELATED)
Enter all payroll-related employee benefits for the hospice on this worksheet. See CMS Pub. 151, Chapter 20, for a definition of fringe benefits. Use the same basis as that used for reporting
salaries and wages on Worksheet K-1. Therefore, using the same example as given for
Worksheet K-1, enter
Rev. 1
40-265
12-10
FORM CMS-2552-10
4060
75 percent of the administrator's payroll-related fringe benefits on line 6 (A&G) and enter 25
percent of the administrator's payroll-related fringe benefits on line 10 (nursing care). Payrollrelated employee benefits must be reported in the cost center in which the applicable employee's
compensation is reported.
This assignment can be performed on an actual basis or the following basis:
•
FICA - actual expense by cost center;
•
Pension and retirement and health insurance (nonunion) (gross salaries of participating
individuals by cost center);
•
Union health and welfare (gross salaries of participating union members by cost center);
and
•
All other payroll-related benefits (gross salaries by cost center). Include non payrollrelated employee benefits in the A&G cost center, e.g., cost for personal education,
recreation activities, and day care.
Add the amounts of each cost center, columns 1 through 8, and enter the total in column 9.
Transfer these totals to Worksheet K, column 2, corresponding lines. To facilitate transferring
amounts from Worksheet K-2 to Worksheet K, the same cost centers with corresponding line
numbers are listed on both worksheets.
4060.
WORKSHEET K-3 - HOSPICE COMPENSATION ANALYSIS - CONTRACTED
SERVICES/PURCHASED SERVICES.
The hospice may contract with another entity for the provision of non-core hospice services.
However, nursing care, medical social services and counseling are core hospice services and
must routinely be provided directly by hospice employees. Supplemental services may be
contracted in order to meet unusual staffing needs that cannot be anticipated and that occur so
infrequently it would not be practical to hire additional staff to fill these needs. You may also
contract to obtain physician specialty services. If contracting is used for any services, maintain
professional, financial and administrative responsibility for the services and assure that all staff
meet the regulatory qualification requirements.
Enter on this worksheet all contracted and/or purchased services for the hospice. Enter the
contracted/purchased cost on the appropriate cost center line within the column heading which
best describes the type of services purchased. Costs associated with contracting for general
inpatient or respite care would be recorded on this worksheet. For example, where physical
therapy services are purchased, enter the contract cost of the therapist in column 6, line 12. If a
contracted/purchased service covers more than one cost center, then the amount applicable to
each cost center is included on each affected cost center line. Add the amounts of each cost
center, columns 1 through 8, and enter the total in column 9. Transfer these totals to Worksheet
K, column 4, corresponding lines. To facilitate transferring amounts from Worksheet K-3 to
Worksheet K, the same cost centers with corresponding line numbers are listed on both
worksheets.
40-266
Rev. 1
12-10
4061.
FORM CMS-2552-10
4061
WORKSHEET K-4, PART I - COST ALLOCATION - GENERAL SERVICE
COSTS AND, PART II - COST ALLOCATION - STATISTICAL BASIS
Worksheet K-4 provides for the allocation of the expenses of each general service cost center to
those cost centers, which receive the services. The cost centers serviced by the general service
cost centers include all cost centers within the provider organization, i.e., other general service
cost centers, reimbursable cost centers, nonreimbursable cost centers. Obtain the total direct
expenses from Worksheet K, column 10. To facilitate transferring amounts from Worksheet K
to Worksheet K-4, Part I, the same cost centers with corresponding line numbers (lines 3 through
39) are listed on both worksheets.
Worksheet K-4, Part II, provides for the proration of the statistical data needed to equitably
allocate the expenses of the general service cost centers on Worksheet K-4, Part I.
To facilitate the allocation process, the general format of Worksheets K-4, Parts I & II are
identical. The column and line numbers for each general service cost center are identical on the
two worksheets. In addition, the line numbers for each general, reimbursable, nonreimbursable,
and special purpose cost centers are identical on the two worksheets. The cost centers and line
numbers are also consistent with Worksheets K, K-1, K-2, and K-3.
The statistical bases shown at the top of each column on Worksheet K-4, Part II are the
recommended bases of allocation of the cost centers indicated. If a different basis of allocation
is used, the provider must indicate the basis of allocation actually used at the top of the column.
Most cost centers are allocated on different statistical bases. However, for those cost centers
where the basis is the same (e.g., square feet), the total statistical base over which the costs are to
be allocated will differ because of the prior elimination of cost centers that have been closed.
Close the general service cost centers in accordance with 42 CFR 413.24(d)(1) which states, in
part, that the cost of nonrevenue-producing cost centers serving the greatest number of other
centers, while receiving benefits from the least number of centers, is apportioned first. This is
clarified in CMS Pub. 15-1, §2306.1, which further clarify the order of allocation for stepdown
purposes. Consequently, first close those cost centers that render the most services to and
receive the least services from other cost centers. The cost centers are listed in this sequence
from left to right on the worksheet. However, the circumstances of an agency may be such that a
more accurate result is obtained by allocating to certain cost centers in a sequence different from
that followed on these worksheets.
NOTE: A change in order of allocation and/or allocation statistics is appropriate for the current
fiscal year cost if received by the contractor, in writing, within 90 days prior to the end
of that fiscal year. The contractor has 60 days to make a decision or the change is
automatically accepted. The change must be shown to more accurately allocate the
overhead or, if the allocation is accurate, it should be changed due to simplification of
maintaining the statistics. If a change in statistics is made, the provider must maintain
both sets of statistics until an approval is made. If both sets are not maintained and the
request is denied, the provider reverts back to the previously approved methodology.
The provider must include with the request all supporting documentation and a
thorough explanation of why the alternative approach should be used. (See CMS Pub.
15-1, §2313.)
If the amount of any cost center on Worksheet K, column 10, has a credit balance, show this
amount as a credit balance on Worksheet K-4, Part I, column 0. Allocate the costs from the
applicable overhead cost centers in the normal manner to the cost center showing a credit
balance. After
Rev. 1
40-267
4061 (Cont.)
FORM CMS-2552-10
12-10
receiving costs from the applicable overhead cost centers, if a general service cost center has a
credit balance at the point it is allocated, do not allocate the general service cost center. Rather,
enter the credit balance on the first line of the column and on line 39. This enables column 6,
line 39, to crossfoot to columns 0 and 5A, line 39. After receiving costs from the applicable
overhead cost centers, if a revenue producing cost center has a credit balance on Worksheet K-4,
Part I, column 6, do not carry forward a credit balance to any worksheet.
On Worksheet K-4, Part II, enter on the first line in the column of the cost center the total
statistics applicable to the cost center being allocated (e.g., in column 1, capital-related cost buildings and fixtures, enter on line 1 the total square feet of the building on which depreciation
was taken). Use accumulated cost for allocating administrative and general expenses.
Such statistical base does not include any statistics related to services furnished under
arrangements except where both Medicare and non-Medicare costs of arranged-for services are
recorded in your records.
For all cost centers (below the cost center being allocated) to which the service rendered is being
allocated, enter that portion of the total statistical base applicable to each.
The total sum of the statistical base applied to each cost center receiving the services rendered
must equal the total statistics entered on the first line.
Enter on Worksheet K-4, Part II, line 39, the total expenses of the cost center to be allocated.
Obtain this amount from Worksheet K-4, Part I from the same column and line number of the
same column. In the case of capital-related costs - buildings and fixtures, this amount is on
Worksheet K-4, Part I, column 1, line 1.
Divide the amount entered on line 39 by the total statistical base entered in the same column on
the first line. Enter the resulting unit cost multiplier on line 40. Round the unit cost multiplier to
six decimal places.
Multiply the unit cost multiplier by that portion of the total statistical base applicable to each cost
center receiving the services rendered. Enter the result of each computation on Worksheet K-4,
Part I in the corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving costs, the total
expenses (line 39) of all of the cost centers receiving the allocation on Worksheet K-4, Part I,
must equal the amount entered on the first line of the cost center being allocated.
The preceding procedures must be performed for each general service cost center. Each cost
center must be completed on Worksheets K-4, Part I & II before proceeding to the next cost
center.
After all the costs of the general service cost centers have been allocated on Worksheet K-4, Part
I, enter in column 7 the sum of the expenses on lines 7 through 38. The total expenses entered in
column 7, line 39, must equal the total expenses entered in column 0, line 39.
Column Descriptions
Column 1--Depreciation on buildings and fixtures and expenses pertaining to buildings and
fixtures such as insurance, interest, rent, and real estate taxes are combined in this cost center to
facilitate cost allocation.
40-268
Rev. 1
10-12
FORM CMS-2552-10
4061 (Cont.)
Allocate all expenses to the cost centers on the basis of square footage of the space occupied.
The square footage may be weighted if the person who occupies a certain area of space spends
their time in more than one function. For example, if a person spends 10 percent of time in one
function, 20 percent in another function, and 70 percent in still another function, the square
footage may be weighted according to the percentages of 10 percent, 20 percent, and 70 percent
to the applicable functions.
Column 2--Allocate all expenses (e.g., interest, and personal property tax) for movable
equipment to the appropriate cost centers on the basis of dollar value.
Column 4--The cost of vehicles owned or rented by the agency and all other transportation costs
which were not directly assigned to another cost center on Worksheet K, column 3, is included in
this cost center. Allocate this expense to the cost centers to which it applies on the basis of miles
applicable to each cost center.
This basis of allocation is not mandatory and a provider may use weighted trips rather than actual
miles as a basis of allocation for transportation costs, which are not directly assigned. However,
a hospice must request the use of the alternative method in accordance with CMS Pub. 15-1,
§2313. The hospice must maintain adequate records to substantiate the use of this allocation.
Column 6--The A&G expenses are allocated on the basis of accumulated costs after
reclassifications and adjustments.
Therefore, obtain the amounts to be entered on Worksheet K-4, Part II, column 6, from
Worksheet K-4, Part I, columns 0 through 5.
A negative cost center balance in the statistics for allocating A&G expenses causes an improper
distribution of this overhead cost center. Negative balances are excluded from the allocation
statistics when A&G expenses are allocated on the basis of accumulated cost.
A&G costs applicable to contracted services may be excluded from the total cost (Worksheet K4, Part I, column 0) for purposes of determining the basis of allocation (Worksheet K-4, Part II,
column 5) of the A&G costs. This procedure may be followed when the hospice contracts for
services to be performed for the hospice and the contract identifies the A&G costs applicable to
the purchased services
The contracted A&G costs must be added back to the applicable cost center after allocation of
the hospice A&G cost before the reimbursable costs are transferred to Worksheet K-5. A
separate worksheet must be included to display the breakout of the contracted A&G costs from
the applicable cost centers before allocation and the adding back of these costs after allocation.
Contractor approval does not have to be secured in order to use the above described method of
cost finding for A&G.
Worksheet K-4, Part II, Column 6A--Enter the costs attributable to the difference between the
total accumulated cost reported on Worksheet K-4, Part I, column 5A, line 39 and the
accumulated cost reported on Worksheet K-4, Part II, column 6, line 6. Enter any amounts
reported on Worksheet K-4, Part I, column 5A for (1) any service provided under arrangements
to program patients only that is not grossed up and (2) negative balances. Including these costs
in the statistics for allocating administrative and general expenses causes an improper
distribution of overhead.
In addition, report on line 6 the administrative and general costs reported on Worksheet K-4, Part
I, column 6, line 6 since these costs are not included on Worksheet K-4, Part II, column 6 as an
accumulated cost statistic.
Rev. 3
40-269
4062.2
FORM CMS-2552-10
10-12
The accumulated cost center line number must match the reconciliation column number. Include
in the column number the alpha character "A", i.e., if the accumulated cost center for A&G is
line 6 (A&G), the reconciliation column designation must be 6A.
Worksheet K-4, Part II, Column 6--The administrative and general expenses are allocated on the
basis of accumulated costs. Therefore, enter the amount from Worksheet K-4, Part I, column
5A.
4062.
WORKSHEET K-5 - ALLOCATION OF GENERAL SERVICE COSTS TO
HOSPICE COST CENTERS
This worksheet distributes the hospital’s overhead to the specific cost centers of the hospice.
4062.1 Part I - Allocation of General Service Costs to Hospice Cost Centers.--Worksheet K-5,
Part I, provides for the allocation of the expenses of each general service cost center of the
hospital to those cost centers which receive the services.
Obtain the direct total expenses (column 0, lines 2 through 33) from Worksheet K-4 Part I, lines
7 through 38. The amounts on columns 0 through 23 and column 25, line 34 must agree with the
corresponding amounts on Worksheet B, Part I, columns 0 through 23 and column 25, line 116.
Complete the amounts entered on lines 1 through 33, columns 1 through 23 and column 25 in
accordance with the instructions in §4062.2.
NOTE: Worksheet B, Part I established the method used to reimburse direct graduate medical
education cost (i.e., reasonable cost or the per resident amount). Therefore, this
worksheet must follow that method. If Worksheet B, Part I, column 25, excluded the
costs of interns and residents, column 25 on this worksheet must also exclude these
costs.
In column 24, enter the total of columns 4A through 23.
In column 27, for lines 2 through 33, multiply the amount in column 26 by the unit cost
multiplier on line 35, and enter the result in this column. The total of the amounts on lines 2
through 33 must equal the amount in column 26, line 1.
In column 28, enter on lines 2 through 33 the sum of columns 26 and 27. The total on line 34
equals the total in column 26, line 34.
4062.2 Part II - Allocation of General Service Costs to Hospice Cost Centers - Statistical
Basis.--Worksheet K-5, Part II, provides for the proration of the statistical data needed to
equitably allocate the expenses of the hospital’s general service cost centers on Worksheet K-5,
Part I. To facilitate the allocation process, the general format of Worksheet K-5, Parts I and II, is
identical.
The statistical basis shown at the top of each column on Worksheet K-5, Part II, is the
recommended basis of allocation of the cost center indicated and must be consistent with the
statistical basis utilized on Worksheet B, Part I.
Lines 1 - 33--On Worksheet K-5, Part II, for all cost centers to which the general service cost
center is being allocated, enter that portion of the total statistical base applicable to each.
Line 34--Enter the total of lines 1 through 33 for each column. The total in each column must be
the same as shown for the corresponding column on Worksheet B-1, line 116.
40-270
Rev. 3
08-11
FORM CMS-2552-10
Line 35--Enter the total expenses for the cost center allocated.
Worksheet B, Part I, columns as indicated, line 116.
4063
Obtain this amount from
Line 36--Enter the unit cost multiplier which is obtained by dividing the cost entered on line 35
by the total statistic entered in the same column on line 34. Round the unit cost multiplier to six
decimal places.
Multiply the unit cost multiplier by that portion of the total statistic applicable to each cost center
receiving the services. Enter the result of each computation on Worksheet K-5, Part I, in the
corresponding column and line.
After the unit cost multiplier has been applied to all the cost centers receiving the services, the
total cost (Part I, line 34) must equal the total cost on line 34, Part II.
Perform the preceding procedures for each general service cost center.
4062.3 Part III - Computation of the Total Hospice Shared Costs.--This worksheet provides
for the shared therapy, drugs, or medical supplies from the hospital to the hospice.
Column Description
Column 1--Where applicable, enter in column 1 the cost to charge ratio from Worksheet C, Part I
column 9, lines as indicated.
Column 2--Where hospital departments provides services to the hospice, enter on the appropriate
lines the charges, from the provider’s records, applicable to the hospital-based hospice.
Column 3--Multiply the amount in column 2 by the ratios in column 1 and enter the result in
column 3.
Line 11--Sum of column 3 lines 1 through 10.
4063.
WORKSHEET K-6 - CALCUALTION HOSPICE OF PER DIEM COST
Worksheet K-6 calculates the average cost per day for a hospice patient. It is only an average
and should not be misconstrued as the absolute.
Line 1--Transfer the total cost from Worksheet K-5, Part I, column 27, line 34 less column 27,
line 33, plus Worksheet K-5, Part III, column 3 line 11. This line reflects the true cost including
shared cost and excluding any non-hospice related activity.
Line 2--Enter the total unduplicated days from Worksheet S-9, column 6, line 5.
Line 3--Calculate the aggregate cost per day by dividing the total cost from line 1 by the total
number of days from line 2.
Line 4--Enter the unduplicated Medicare days from Worksheet S-9, column 1, line 5.
Line 5--Calculate the aggregate Medicare cost by multiplying the average cost from column 4,
line 3 by the number of unduplicated Medicare days on column 1, line 4 to arrive at the average
Medicare cost.
Line 6--Enter the unduplicated Medicaid days from Worksheet S-9, column 2, line 5.
Rev. 2
40-271
4063 (Cont.)
FORM CMS-2552-10
08-11
Line 7--Calculate the aggregate Medicaid cost by multiplying the average cost from line 3 by the
number of unduplicated Medicaid days on line 6 to arrive at the average Medicaid cost.
Line 8--Enter the unduplicated SNF days from Worksheet S-9, column 3, line 5.
Line 9--Calculate the aggregate SNF cost by multiplying the average cost from line 3 by the
number of unduplicated SNF days on line 8 to arrive at the average SNF cost.
Line 10--Enter the unduplicated NF days from Worksheet S-9, column 4, line 5.
Line 11--Calculate the aggregate NF cost by multiplying the average cost from line 3 by the
number of unduplicated NF days on line 10 to arrive at the average NF cost.
Line 12--Enter the unduplicated Other days from Worksheet S-9, column 5, line 5.
Line 13--Enter the Aggregate cost for other days by multiplying the average cost from line 3 by
the number of unduplicated Other days on line 12 to arrive at the average other cost.
40-272
Rev. 2
10-12
4064.
FORM CMS-2552-10
4064
WORKSHEET L - CALCULATION OF CAPITAL PAYMENT
Worksheet L, Parts I through III, calculate program settlement for PPS inpatient hospital capitalrelated costs in accordance with the final rule for payment of capital-related costs on a
prospective payment system pursuant to 42 CFR 412, Subpart M. (See the August 30, 1991
Federal Register.) Only provider components paid under IPPS complete this worksheet.
Worksheet L consists of the following three parts:
Part I - Fully Prospective Method
Part II - Payment Under Reasonable Cost
Part III - Computation of Exception Payments
COMPLETE EITHER PART I OR PART II, OR PARTS I AND III.
At the top of the worksheet, indicate by checking the applicable boxes the health care program,
provider component, and the IPPS capital payment method for which the worksheet is prepared.
4064.1 Part I - Fully Prospective Method.--This part computes settlement under the fully
prospective method only, as defined in 42 CFR 412.340. Use the fully prospective method for
IPPS capital settlement when the hospital's base year hospital-specific rate is below the adjusted
Federal rate and for IPPS hospitals with cost reporting periods beginning after the capital PPS
transition.
Line Descriptions
Line 1--Enter the amount of the Federal rate portion of the capital DRG payments for other than
outlier during the period.
Line 2--Enter the amount of the Federal rate portion of the capital outlier payments made for PPS
discharges during the period. (See 42 CFR 412.312(c).)
Indirect Medical Education Adjustment
Lines 3 - 6
Line 3--Enter the result of dividing the sum of total patient days (Worksheet S-3, Part I, column
8, lines 14 and 30) by the number of days in the cost reporting period (365 or 366 in case of leap
year). Do not include statistics associated with an excluded unit (subprovider).
NOTE: Reduce total patient days by nursery days (Worksheet S-3, Part I, column 8, line 13),
and swing bed days (Worksheet S-3, Part I, column 8, lines 5 and 6).
Line 4--Obtain the intern and resident amount from Worksheet E, Part A, line 18 plus line 25.
Line 5--Enter the result of the following calculation: {e.2822 x line 4/line 3}-1 where e = 2.71828. (See
42 CFR 412.322(a)(3) for limitation of the percentage of I&Rs to average daily census. Line 4
divided by line 3 cannot exceed 1.5.
Line 6--Multiply line 5 by line 1.
Rev. 3
40-273
4064.2
FORM CMS-2552-10
10-12
Capital Disproportionate Share Adjustment
Lines 7 - 11
Enter the amount of the Federal rate portion of the additional capital payment amounts relating to
the disproportionate share adjustment. Complete these lines if you answered yes to line 45 on
Worksheet S-2, Part I.
(See 42 CFR 412.312(b)(3).)
For hospitals qualifying for
disproportionate share in accordance with 42 CFR 412.106(c)(2) (Pickle amendment hospitals),
do not complete lines 7 through 9, and enter 11.89 percent on line 10.
Line 7--Enter the percentage of SSI recipient patient days (from your contractor or your records)
to Medicare Part A patient days. This amount agrees with the amount reported on Worksheet E,
Part A, line 30.
Line 8--Enter the percentage resulting from the calculation of Medicaid patient days (Worksheet
S-2, Part I, columns 1 through 6, line 24) to total days reported on Worksheet S-3, Part I, column
8, line 14, plus column 8, line 32 minus the sum of lines 5 and 6, plus employee discount days
reported on Worksheet S-3, Part I, column 8, line 30. This amount must agree with the amount
reported on Worksheet E, Part A, line 31.
Line 9--Add lines 7 and 8, and enter the result.
Line 10--Enter the percentage that results from the following calculation: (e.2025 x line 9)-1 where e
equals 2.71828. If Worksheet S-2, Part I, line 22, column 2 is “Y” (Pickle amendment hospital),
enter 11.89 percent.
Line 11--Multiply line 10 by line 1 and enter the result.
Line 12--Enter the sum of lines 1, 2, 6 and 11. For title XVIII, transfer this amount to Worksheet
E, Part A, line 50.
4064.2 Part II - Payment Under Reasonable Cost.--This part computes capital settlement under
reasonable cost principles subject to the reduction pursuant to 42 CFR 412.324(b). Use the
reasonable cost method for capital settlement determinations for new providers under 42 CFR
412.324(b) for the first two years or for titles V or XIX determinations, if applicable. This part
may also be completed for cost reporting periods beginning on or after October 1, 2002, for the
first two years for new providers under 42 CFR 412.304(c)(2)(i) (response to Worksheet S-2,
Part I, line 47, column 1 is “Y” and column 2 is “N”).
Line Descriptions
Line 1--Enter the amount of program inpatient routine service capital costs. This amount is the
sum of the program inpatient routine capital costs from the appropriate Worksheet D, Part I,
column 7, sum of the amounts on lines 30 through 35 and 43 for the hospital (lines 40 through 42
as applicable for the subprovider).
Line 2--Enter the amount of program inpatient ancillary capital costs. This amount is the sum of
the amounts of program inpatient ancillary capital costs from the appropriate Worksheet D, Part
II, column 5, line 200.
Line 3--Enter the sum of lines 1 and 2.
Line 4--Enter a reduction factor of 85 percent.
Line 5--Multiply line 3 by line 4. For title XVIII, transfer the amount to Worksheet E, Part A,
line 50.
40-274
Rev. 3
10-12
FORM CMS-2552-10
4064.3
4064.3 Part III - Computation of Exception Payments.--This part computes minimum payment
levels by class of provider eligible for additional exception payment for extraordinary
circumstances pursuant to 42 CFR 412.312(e). Complete this part only if the provider
component completed Part I of this worksheet. Complete this part only if the provider qualifies
for the exception payment for extraordinary circumstances pursuant to 42 CFR 412.348(f) (the
facility indicates “Y” to question 46 on Worksheet S-2, Part I).
Line 1--Enter the amount of program inpatient routine service and ancillary service capital costs.
This amount is the sum of the program inpatient routine service capital costs from the
appropriate Worksheet D, Part I, column 7, sum of lines 30 through 35 and 43 for the hospital,
lines 40 through 42, as applicable for the subprovider, and program inpatient ancillary service
capital costs from Worksheet D, Part II, column 5, line 200.
Line 2--Enter program inpatient capital costs for extraordinary circumstances as provided by
42 CFR 412.348(f), if applicable, from Worksheet L-1, sum of Part II, column 7, sum of lines 30
through 35 and 43 for the hospital; lines 40 through 42, as applicable for the subproviders; and
Part III, column 5, line 200.
Line 3--Enter line 1 less line 2.
Line 4--Enter the appropriate minimum payment level percentage: The minimum payment
levels for portions of cost reporting periods beginning on or after October 1, 2001 are:
•
•
•
SCHs (located in either an urban or a rural area) - 90 percent;
Urban hospitals with at least 100 beds and a disproportionate patient percentage of at
least 20.2 percent - 80 percent; and
All other hospitals - 70 percent.
For providers that qualify for an exception payment for extraordinary circumstances pursuant to
42 CFR 412.348(f) in conjunction with 412.312(e) the appropriate minimum payment level is 70
percent.
The minimum payment levels will be revised, if necessary, to keep total payments under the
exceptions process at no more than 10 percent of capital prospective payments.
If you were an SCH during a portion of the cost reporting period, compute the minimum
payment level percentage by dividing the number of days in your cost reporting period for which
you were not an SCH (70 percent factor applicable) by the total number of days in the cost
reporting period. Multiply that ratio by 70 percent. Divide the number of days in your cost
reporting period for which you were an SCH (90 percent factor applicable) by the total number
of days in the cost reporting period. Multiply that ratio by 90 percent. Add the amounts from
steps 1 and 2 to compute the capital cost minimum payment level percentage. Display exception
percentage in decimal format, e.g., 70 percent is displayed as .70 or 0.70.
Line 5--Enter the product of line 3 multiplied by line 4.
Line 6--Hospitals that did not qualify as sole community providers during the cost reporting
period enter a reduction factor of 85 percent. SCHs enter 100 percent. If you were a sole
community hospital during a portion of the cost reporting period, compute the capital cost
reduction percentage by dividing the number of days in your cost reporting period for which you
were not a sole community hospital (reduction factor applicable) by the total number of days in
the cost reporting period. Multiply that ratio by 15 percent and subtract the amount from 100.
Enter the resulting extraordinary circumstance percentage adjustment in decimal format, e.g., 85
percent is displayed as .85 or 0.85.
Rev. 3
40-275
4064.3 (Cont.)
FORM CMS-2552-10
10-12
Line 7--Enter the product of line 2 multiplied by line 6.
Line 8--Enter the sum of lines 5 and 7.
Line 9--Enter the amount from Part I, line 12, if applicable.
Line 10--Enter line 8 less line 9.
Lines 11 - 14--A hospital is entitled to an additional payment if its capital payments for the cost
reporting period is less than the applicable minimum payment level. The additional payment
equals the difference between the applicable minimum payment level and the capital payments
that the hospital would otherwise receive. This additional payment amount is reduced for any
amounts by which the hospital’s cumulative payments exceed its cumulative minimum payment
levels. The offsetting amounts will be determined based on the amounts by which the hospital’s
cumulative payments exceed its cumulative minimum payment levels in the lesser of the
preceding 10-year period or the period of time under which the hospital is subject to the
prospective payment system for capital related costs.
A positive amount on line 10 represents the amount of capital payments under the minimum
payment level in the current year. This amount must be offset for the amount by which the
hospital’s cumulative payments exceed its cumulative minimum payment levels in prior years, as
reported on line 11. If the net amount on line 12 remains a positive amount, this amount
represents the current year’s additional payment for capital payments under the minimum
payment level. Report this amount on line 13. If the net amount on line 12 is a negative amount,
this amount represents the reduced amount by which the accumulated capital payment amounts
exceeded the accumulated minimum payment levels. In this case, no additional payment is made
in the current year. Transfer the amount on line 12 to line 14, and carry it forward to the
following cost reporting period.
A negative amount on line 10 represents the amount of capital payments over the minimum
payment level in the current year. Add any carry forward of prior years’ amounts of the
hospital’s cumulative payments in excess of cumulative minimum payment levels, as reported on
line 11, to the current year excess on line 12. The net amount on line 12 represents the total
amount by which the accumulated capital payment amounts exceeded the accumulated minimum
payment levels. No additional payment is made in the current year. Transfer the amount on line
12 to line 14, and carry it forward to the subsequent cost reporting period.
Line 11--The offsetting amounts will be determined based on the amounts by which the
hospital’s cumulative payments exceed its cumulative minimum payment levels in the lesser of
the preceding 10-year period or the period of time under which the hospital is subject to the
prospective payment system for capital related costs. Enter the appropriate offset amount as
computed pursuant to 42 CFR 412.312(e)(3).
Line 12--Enter the sum of lines 10 and 11.
Line 13--If the amount on line 12 is positive, enter the amount on this line.
Line 14--If the amount on line 12 is negative, enter the amount on this line.
Complete lines 15 through 17 only when line 12 is a positive amount.
Line 15--Enter the current years allowable operating and capital payments calculated from
Worksheet E, Part A, line 47, plus the capital payments reported on line 9 above, minus 75
percent of the current year’s operating disproportionate share payment amount reported on
Worksheet E, Part A, line 34.
40-276
Rev. 3
10-12
FORM CMS-2552-10
4065.1
Line 16--Current years operating and capital costs from Worksheet D-1, line 49 minus the sum of
D, Part III, lines 30 through 35, column 9 (PPS subproviders use lines 40 through 42, as
applicable, column 9), and D, Part IV, column 11, line 200.
Line 17--Enter on this line the current year’s exception offset amount. This is computed as line
15 minus line 16. If this amount is negative, enter zero on this line. If the amount on line 13 is
greater than line 17, transfer the amount on line 13, less any reported amount on line 17, to
Worksheet E, Part A, line 51.
4065.
WORKSHEET L-1 - ALLOCATION OF ALLOWABLE CAPITAL COSTS FOR
EXTRAORDINARY CIRCUMSTANCES
This worksheet provides for the determination of direct and indirect capital-related costs
associated with capital expenditures for extraordinary circumstances, allocated to inpatient
operating costs. Only complete this worksheet for providers that qualify for an additional
payment for extraordinary circumstances under 42 CFR 412.348(f) (the facility indicates “Y” to
question 46 on worksheet S-2, Part I).
4065.1 Part I - Allocation of Allowable Capital Costs for Extraordinary Circumstances.--Use
this part in conjunction with Worksheet B-l. The format and allocation process employed is
similar to that used on Worksheets B, Part I and B-1. Any cost center subscripted lines and/or
columns added to Worksheet B, Part I, are also added to this worksheet in the same sequence.
Column 0--Assign capital expenditures relating to extraordinary costs to specific cost centers on
this worksheet, column 0. Enter on the appropriate lines those capital-related expenditure
amounts relating to extraordinary costs which were directly assigned on Worksheet B, Part II.
Enter on lines 3 and 4, as applicable, the remaining capital expenditure amounts relating to
extraordinary costs which have not been directly assigned.
Columns 1 through 23--Transfer amounts on the top lines of columns 1 and 2 from column 0,
line as applicable. For example, transfer line 1, column 0 to line 1, column 1. For all other
columns, the top line represents the cross total amount.
For each column, enter on line 203 of this worksheet, Part I, the total statistics of the cost center
being allocated. Obtain the individual statistics from Worksheet B-1 from the same column and
line number used to allocate cost on this worksheet. (For example, obtain the amount of capitalrelated costs - buildings and fixtures from Worksheet B-1, column 1, line 1.)
Divide the amount entered on line 203 by the total capital expenses entered in the same column
on the first line. Enter the resulting unit cost multiplier on line 204. Round the unit cost
multiplier to six decimal places.
Multiply the unit cost multiplier by that portion of the total statistics applicable to each cost
center receiving the services. The applicable cost center statistics are reported on Worksheet B1. Enter the result of each computation on this worksheet in the corresponding column and line.
(See §4000.1 for rounding standards.)
After the unit cost multiplier has been applied to all the cost centers receiving the services
rendered, the total cost (line 197) of all the cost centers receiving the allocation on this worksheet
must equal the amount entered on the first line. Perform the preceding procedures for each
general service cost center. Complete the column for one cost center before proceeding to the
column for the next cost center.
Rev. 3
40-277
4065.2
FORM CMS-2552-10
10-12
After the capital-related costs of all the general service cost centers have been allocated, enter in
column 24 the sum of columns 2A through 23 for lines 30 through 196. (See §4020 for
exception regarding negative cost centers.)
When an adjustment is required to capital costs for extraordinary circumstances after cost
allocation, show the amount applicable to each cost center in column 25. Submit a supporting
schedule showing the computation of the adjustment.
Transfer From Worksheet:
L-1, Part I, Column 26
To Worksheet L-1, Part II
Line 30 - Adults and Pediatrics
Column l, line 30 for the hospital
Lines 31 through 35 - Intensive
Care Type Inpatient Hospital
Units
Column 1, lines 31 through 35
Lines 40 through 42, as
applicable - Subprovider
Column l, lines 40 through 42, as applicable
Line 43 - Nursery
Column 1, line 43 for titles V and XIX
To Worksheet L-1, Part III
Lines 50 through 76 - Ancillary
Services
Column l, lines 50 through 76
Lines 88 through 91 and 93 Outpatient Service Cost
Column l, lines 88 through 91 and 93
Subscripts of line 92 - Distinct
Part Observation Bed Units
Column 1, subscripts of line 92
Lines 88, 89, 94, 97, and 98
Column l, lines 88, 89, 94, 97, and 98
4065.2 Part II - Computation of Program Inpatient Routine Service Capital Costs for
Extraordinary Circumstances.--This part computes the amount of capital costs for extraordinary
circumstances applicable to hospital inpatient routine service costs. Complete only one
Worksheet L-1, Part II for each title. Report hospital and subprovider information on the same
worksheet, lines as appropriate.
Column 1--Enter on each line the capital costs for extraordinary circumstances as appropriate.
Obtain this amount from Worksheet L-1, Part I, column 26.
Column 2--Compute the amount of the swing bed adjustment. If you have a swing bed
agreement or have elected the swing bed optional method of reimbursement, determine the
amount for the cost center in which the swing beds are located by multiplying the amount in
column 1 by the ratio of the amount entered on Worksheet D-1, line 26 to the amount entered on
Worksheet D-1, line 21.
Column 3--Enter column 1 minus column 2.
Column 4--Enter on each line the total patient days, excluding swing bed days, by cost center
from the corresponding lines of Worksheet D, Part I, column 4.
40-278
Rev. 3
08-11
FORM CMS-2552-10
4065.3
Column 5--Divide the cost of each cost center in column 3 by the total patient days in column 4
for each line to determine the per diem cost capital cost for extraordinary circumstances. Enter
the resultant per diem cost in column 5.
Column 6--Enter the program inpatient days for the corresponding cost centers from Worksheet
D, Part I, column 6.
Column 7--Multiply the per diem in column 5 by the inpatient program days in column 6 to
determine the program’s share of capital costs for extraordinary circumstances applicable to
inpatient routine services, as applicable, and enter the result.
4065.3 Part III - Computation of Program Inpatient Ancillary Service Capital Costs For
Extraordinary Circumstances.--This part computes the program inpatient ancillary capital costs
for extraordinary circumstances for titles V, XVIII, Part A, and XIX. Complete a separate copy
of this part for the hospital and each subprovider for titles V, XVIII, Part A, and XIX, as
applicable. In this case, enter the subprovider component number in addition to showing the
provider number.
Make no entries on this worksheet for any costs centers with a negative balance on Worksheet B,
Part I, column 26.
Column 1--Enter on each line the capital-related costs for each cost center as appropriate. Obtain
this amount from Worksheet L-1, Part I, column 26.
NOTE: Compute capital costs for extraordinary circumstances relating to non-distinct
observation bed units. To compute extraordinary circumstances relating to nondistinct observation bed units, develop a ratio of total observation bed costs to total
general routine costs. Compute this ratio, rounded to six decimal places, by dividing
the amount from Worksheet L-1, Part I, column 26, line 30 by the amount on
Worksheet D-1, line 37. Then multiply this ratio by the general routine capital costs
for extraordinary circumstances from Supplemental Worksheet L-1, Part I, column 26,
line 30 to obtain the capital costs for extraordinary circumstances relating to nondistinct observation bed units for line 92, column 1. Transfer distinct part observation
bed unit costs from Worksheet L-1, Part I, the appropriate subscript of column 26, line
92.
Column 2--Enter on each line the charges applicable to each cost center as shown on Worksheet
C, Part I, column 6.
Column 3--Divide the cost of each cost center in column 1 by the charges in column 2 for each
line to determine the cost/charge ratio. Round the ratios to six decimal places, e.g., round
.0321514 to 032151. Enter the resultant departmental ratios in column 3.
Column 4--Enter on each line the appropriate titles V, XVIII, Part A, or XIX inpatient charges.
Transfer these charges from the corresponding lines of Worksheet D, Part II, column 4.
Column 5--Multiply the ratio in column 3 by the charges in column 4 to determine the program’s
share of capital costs for extraordinary circumstances applicable to titles V, XVIII, Part A, or
XIX inpatient ancillary services, as appropriate.
Rev. 2
40-279
4066
4066.
FORM CMS-2552-10
08-11
WORKSHEET M-1 - ANALYSIS OF PROVIDER-BASED RURAL HEALTH
CLINIC/FEDERALLY QUALIFIED HEALTH CENTER COSTS
Use this worksheet only if you operate a certified rural health clinic (RHC) or federally qualified
health center (FQHC). Use only those cost centers that represent services for which the facility
is certified. If you have more than one provider-based RHC and/or FQHC, complete separate
worksheets for each RHC and FQHC facility, unless the facility has received prior contractor
approval to file a consolidated cost report (see CMS Pub. 100-4, chapter 9, §30).
This worksheet is for the recording of direct RHC and FQHC costs from your accounting books
and records to arrive at the identifiable agency cost. This data is required by 42 CFR 413.20.
The worksheet also provides for the necessary reclassifications and adjustments to certain
accounts prior to the cost finding calculations.
Column Descriptions
Columns 1 through 3--The expenses listed in these columns must be in accordance with your
accounting books and records. If the cost elements of a cost center are maintained separately on
your books, a reconciliation of costs per the accounting books and records to those on this
worksheet must be maintained by you and are subject to review by your contractor.
Enter on the appropriate lines in columns 1 through 3 the total expenses incurred during the
reporting period. Detail the expenses as Salaries (column 1) and Other (column 2). The sum of
columns 1 and 2 must equal column 3.
Column 4--Enter any reclassifications among the cost center expenses listed in column 3 which
are needed to effect proper cost allocation. This column need not be completed by all providers,
but is completed only to the extent reclassifications are needed and appropriate in the particular
circumstances. See §4014 for examples of reclassifications that may be needed. Submit with the
cost report copies of any work papers used to compute the reclassifications reported in this
column.
The net total of the entries in column 4 must equal zero on line 30 if no reclassifications were
reported on worksheet A, column 4, of the appropriate line 88 and/or 89.
Column 5--Add column 4 to column 3, and extend the net balances to column 5. The total of
column 5 must equal the total of column 3 on line 30, if no reclassifications were reported on
worksheet A, column 4, of the appropriate line 88 and/or 89.
Column 6--In accordance with 42 CFR 413.9(c)(3), enter on the appropriate lines the amounts of
any adjustments to expenses required under the Medicare principles of reimbursement. (See
§4016.) Submit with the cost report copies of any work papers used to compute the adjustments
reported in this column.
NOTE: The allowable cost of the services furnished by National Health Service Corp (NHSC)
personnel may be included in your facility's costs. Obtain this amount from your
contractor, and include this as an adjustment to the appropriate lines on column 6.
Column 7--Adjust the amounts in column 5 by the amounts in column 6, and extend the net
balance to column 7. The total facility costs on line 32 must equal the net expenses for cost
allocation on Worksheet A for the RHC/FQHC cost center.
Line Descriptions
Lines 1 through 9--Enter the costs of your health care staff.
40-280
Rev. 2
08-11
FORM CMS-2552-10
4066 (Cont.)
Line 10--Enter the sum of the amounts on lines 1 through 9.
Line 11--Enter the cost of physician medical services furnished under agreement.
Line 12--Enter the expenses of physician supervisory services furnished under agreement.
Line 14--Enter the sum of the amounts on lines 11 through 13.
Lines 15 through 20--Enter the expenses of other health care costs.
Line 20--If you answered yes on Worksheet S-8, line 15 report on this line the amount of
reimbursable graduate medical education costs from Worksheet B, Part I, sum of columns 21 and
22, lines 88 (RHC) and/or 89 (FQHC), as applicable. To claim GME the RHC/FQHC must have
provided a "substantial amount" toward the cost of the intern and residents.
Line 21--Enter the sum of the amounts on lines 15 through 20.
Line 22--Enter the sum of the amounts on lines 10, 14, and 21. Reduce that result by the amount
reported on line 20 if you are entitled to claim GME costs on line 20. Transfer this amount to
Worksheet M-2, line 10.
Lines 23 through 27--Enter the expenses applicable to services that are not reimbursable under
the RHC/FQHC benefit.
Line 27--If you have incurred non-allowable costs associated with graduated medical education,
report on line 26 the non-allowable costs.
Line 28--Enter the sum of the amounts on lines 23 through 27. Transfer the total amount in
column 5 to Worksheet M-2, line 11.
Line 29--Enter the overhead expenses directly costed to the facility. These expenses may
include rent, insurance, interest on mortgage or loans, utilities, depreciation of buildings and
fixtures, depreciation of equipment, housekeeping and maintenance expenses, and property
taxes. Submit with the cost report supporting documentation to detail and compute the facility
costs reported on this line.
Line 30--Enter the expenses related to the administration and management of the RHC/FQHC
that are directly costed to the facility. These expenses may include office salaries, depreciation
of office equipment, office supplies, legal fees, accounting fees, insurance, telephone service,
fringe benefits, and payroll taxes. Submit with the cost report supporting documentation to detail
and compute the administrative costs reported on this line.
Line 31--Enter the sum of the amounts on lines 29 and 30. Transfer the total amount in column 5
to Worksheet M-2, line 14.
Line 32--Enter the sum of the amounts on lines 22, 28, and 31. Do not include the amount
reported on line 20 for GME. This is the total facility cost. This amount should agree with the
amount reported for RHC and FQHC on Worksheet A, column 7 reduced by any amounts
claimed on line 20 above.
Rev. 2
40-281
4067
4067.
FORM CMS-2552-10
08-11
WORKSHEET M-2 - ALLOCATION OF OVERHEAD TO RHC/FQHC SERVICES
Use this worksheet only if you operate a certified provider-based RHC or FQHC as part of your
complex. If you have more than one provider-based RHC and/or FQHC, complete a separate
worksheet for each RHC and FQHC facility.
Visits and Productivity.--Worksheet M-2 summarizes the number of facility visits furnished by
the health care staff and calculates the number of visits to be used in the rate determination.
Lines 1 through 9 list the types of practitioners (positions) for whom facility visits must be
counted and reported.
Column descriptions
Column 1--Record the number of all full time equivalent (FTE) personnel in each of the
applicable staff positions in the facility’s practice. (See CMS IOM 100-04, chapter 9, §40.3 for a
definition of FTEs).
Column 2--Record the total visits actually furnished to all patients by all personnel in each of the
applicable staff positions in the reporting period. Count visits in accordance with instructions in
42 CFR 405.2463(a) defining a visit.
Column 3--Productivity standards established by CMS are applied as a guideline that reflects the
total combined services of the staff. Apply a level of 4200 visits for each physician and a level
of 2100 visits for each nonphysician practitioner. You are not subject to the productivity
standards if you answered “Yes” to question 12 of Worksheet S-8. If so, then enter the revised
standards established by you and your contractor.
Column 4--For lines 1 through 3, enter the product of column 1 and column 3. This is the
minimum number of facility visits the personnel in each staff position are expected to furnish.
Column 5--On line 4, enter the greater of the subtotal of the actual visits in column 2 or the
minimum visits in column 4.
Contractors have the authority to waive the productivity guideline in cases where you have
demonstrated reasonable justification for not meeting the standard. In such cases, the contractor
will substitute your actual visits if an exception is granted.
On lines 5 through 7 and 9, enter the actual number of visits for each type of position.
Line descriptions
Line 1--Enter the number of FTEs and total visits furnished to facility patients by staff
physicians working at the facility on a regular ongoing basis. Also include on this line, physician
data (FTEs and visits) for services furnished to facility patients by staff physicians working
under contractual agreement with you on a regular ongoing basis in the RHC facility. These
physicians are subject to productivity standards. (See 42 CFR 491.8.)
Line 8--Enter the total of lines 4 through 7 (and subscripts).
Line 9--Enter the number of visits furnished to facility patients by physicians under agreement
with you who do not furnish services to patients on a regular ongoing basis in the RHC facility.
Physicians services under agreements with you are (1) all medical services performed at your site
by a nonstaff physician who is not the owner or an employee of the facility, and (2) medical
services performed at a location other than your site by such a physician for which the physician
is compensated by you. While all physician services at your site are included in RHC/FQHC
services,
40-282
Rev. 2
10-12
FORM CMS-2552-10
4068
physician services furnished in other locations by physicians who are not on your full time staff
are paid to you only if your agreement with the physician provides for compensation for such
services.
Determination of Total Allowable Cost Applicable To RHC/FQHC Services.--Lines 10 through
18 determine the amount of the overhead costs incurred by both the parent provider and the
facility which apply to RHC or FQHC services.
Line 10--Enter the cost of health care services from Worksheet M-1, column 7, line 22.
Line 11--Enter the total nonreimbursable costs from Worksheet M-1, column 7, line 28.
Line 12--Enter the sum of lines 10 and 11 for the cost of all services (excluding overhead).
Line 13--Enter the percentage of RHC or FQHC services. This percentage is determined by
dividing the amount on line 10 (the cost of health care services) by the amount on line 12 (the
cost of all services, excluding overhead).
Line 14--Enter the total facility overhead costs incurred from Worksheet M-1, column 7, line 31.
Line 15--Enter the overhead costs incurred by the parent provider allocated to the RHC/FQHC.
This amount is the difference between the total costs after cost allocation on Worksheet B, Part I,
column 26 and Worksheet B, Part I, column 0. If GME costs are claimed on line 20 of
Worksheet M-1, do not include the GME costs allocated to the RHC/FQHC in columns 21 and
22 of Worksheet B, Part I.
Line 16--Enter the sum of lines 14 and 15 to determine the total overhead costs related to the
RHC/FQHC.
Line 17--If you are claiming allowable GME cost (line 20 of Worksheet M-1 completed), divide
the total intern and resident visits reported on Worksheet S-8, line 15, column 5 by the total visits
for the facility (sum of lines 8 and 9, column 5 above), multiply the result by line 16 above, and
enter that amount. If you are not claiming GME enter -0-.
Line 18--Subtract the amount on line 17 from line 16 and enter the result.
Line 19--Enter the overhead amount applicable to RHC/FQHC services. It is determined by
multiplying the amount on line 13 (the ratio of RHC/FQHC services to total services) by the
amount on line 18 (total overhead costs).
Line 20--Enter the total allowable cost of RHC/FQHC services. It is the sum of line 10 (cost of
RHC/FQHC health care services) and line 19 (overhead costs applicable to RHC/FQHC
services).
4068.
WORKSHEET M-3 - CALCULATION OF REIMBURSEMENT SETTLEMENT
FOR RHC/FQHC SERVICES
This worksheet applies to title XVIII only and provides for the reimbursement calculation. Use
this worksheet to determine the interim all inclusive rate of payment and the total program
payment due you for the reporting period for each RHC or FQHC being reported.
Determination of Rate For RHC/FQHC Services.--Worksheet M-3 calculates the cost per visit
for RHC/FQHC services and applies the screening guideline established by CMS on your health
care staff productivity.
Line descriptions
Line 1--Enter the total allowable cost from Worksheet M-2, line 20.
Rev. 3
40-283
4068 (Cont.)
FORM CMS-2552-10
10-12
Line 2--Report vaccine costs on this line from Worksheet M-4.
Line 3--Subtract the amount on line 2 from the amount on line 1 and enter the result.
Line 4--Enter the greater of the minimum or actual visits by the health care staff from
Worksheet M-2, column 5, line 8.
Line 5--Enter the visits made by physicians under agreement from Worksheet M-2, column 5,
line 9.
Line 6--Enter the total adjusted visits (sum of lines 4 and 5).
Line 7--Enter the adjusted cost per visit. This is determined by dividing the amount on line 3 by
the visits on line 6.
For services rendered from January 1, 2010, through December 31, 2013, the maximum rate per
visit entered on line 8 and the outpatient mental health treatment service limitation applied on
line 14 both correspond to the same time period (partial calendar year). Consequently, both are
entered in the same column and no further subscripting of the columns is necessary.
Lines 8 and 9--The limits are updated every January 1. However, the possibility exists that limits
may also be updated other than on January 1. Complete columns 1, 2 and 3, if applicable (add a
column 3 for lines 8-14 if the cost reporting overlaps 3 limit update periods) of lines 8 and 9 to
identify costs and visits affected by different payment limits for a cost reporting period that
overlaps January 1. If only one payment limit is applicable during the cost reporting period
(calendar year reporting period), complete column 2 only.
Line 8--Enter the per visit payment limit. Obtain this amount from CMS Pub. 27, §505 or from
your contractor.
NOTE: If you are based in a small rural hospital with less than 50 beds (the bed count is based
on the same calculation used on Worksheet E, Part A, line 4), in accordance with 42
CFR §412.105(b), do not apply the per visit payment limit. Transfer the adjusted cost
per visit (line 7) to line 9, columns 1 and/or 2.
NOTE: RHCs that are based in a small urban hospital with less than 50 beds (as calculated
above) will also be exempt from the per visit limit.
For RHCs based in small urban hospitals transfer the adjusted cost per visit (line 7) to line 9,
column 1 and/or 2.
Line 9--Enter the lesser of the amount on line 7 or line 8.
Calculation of Settlement.--Complete lines 10 through 29 to determine the total program
payment due you for covered RHC/FQHC services furnished to program beneficiaries during the
reporting period. Complete columns 1 and 2 of lines 10 through 14 to identify costs and visits
affected by different payment limits during a cost reporting period.
Line descriptions
Line 10--Enter the number of program covered visits excluding visits subject to the outpatient
mental health services limitation from your contractor records.
Line 11--Enter the subtotal of program cost. This cost is determined by multiplying the rate per
visit on line 9 by the number of visits on line 10 (the total number of covered program
beneficiary visits for RHC/FQHC services during the reporting period).
40-284
Rev. 3
10-12
FORM CMS-2552-10
4068 (Cont.)
Line 12--Enter the number of program covered visits subject to the outpatient mental health
services limitation from your contractor records.
Line 13--Enter the program covered cost for outpatient mental health services by multiplying the
rate per visit on line 9 by the number of visits on line 12.
Line 14--Enter the limit adjustment. In accordance with MIPPA 2008, section 102, the
outpatient mental health treatment service limitation applies as follows: For services rendered
through December 31, 2009, the limitation is 62.50 percent; services from January 1, 2010,
through December 31, 2011, the limitation is 68.75 percent; services from January 1, 2012,
through December 31, 2012, the limitation is 75 percent; services from January 1, 2013 through
December 31, 2013, the limitation is 81.25 percent; and services on or after January 1, 2014, the
limitation is 100 percent. This is computed by multiplying the amount on line 13 by the
corresponding outpatient mental health treatment service limit percentage. This limit applies
only to therapeutic services, not initial diagnostic services.
NOTE: Section 4104 of ACA eliminates coinsurance and deductible for preventive services,
effective for dates of service on or after January 1, 2011. RHCs and FQHCs must provide
detailed HCPCS coding for preventive services to ensure coinsurance and deductible are not
applied. Providers must maintain this documentation to apply the appropriate reductions on
lines 16.03 and 16.04.
Line 15--Enter the amount of GME pass through costs determined by dividing the program
intern and resident visits reported on Worksheet S-8, line 15 by the total visits reported on
Worksheet S-8, line 15, column 5. Multiply that result by the allowable GME costs equal to the
sum of Worksheet M-1, column 7, line 20 and Worksheet M-2, line 17. For cost reporting
periods that overlap January 1, 2011 prorate the result using a ratio of days prior to and on or
after January 1, 2011 for each column. For cost reporting periods beginning on or after
January 1, 2011, do not use column 1 and enter the result in column 2.
Line 16--For cost reporting periods that overlap January 1, 2011, enter in column 1 the sum of
lines 11, 14, and 15, column 1 and in column 2, the sum of lines 11, 14, and 15, column 2. For
cost reporting periods beginning on or after January 1, 2011, do not use column 1 and enter the
total program cost in column 2. This is equal to the sum of the amounts in columns 1 and 2,
respectively (and 3 if applicable), lines 11, 14, and 15.
Line 16.01--Enter the total program charges from the contractor’s records (PS&R). For cost
reporting periods that overlap January 1, 2011, do not complete column 1 and enter total
program charges for services rendered on or after January 1, 2011 in column 2. For cost
reporting periods beginning on or after January 1, 2011, enter total program charges in column 2.
Line 16.02--Enter the total program preventive charges from the provider’s records. For cost
reporting periods that overlap January 1, 2011, do not complete column 1 and enter total
program preventive charges for services rendered on or after January 1, 2011 in column 2. For
cost reporting periods beginning on or after January 1, 2011, enter total program preventive
charges in column 2.
Line 16.03--Enter the total program preventive costs. For cost reporting periods that overlap
January 1, 2011, do not complete column 1 and enter the total program preventive costs ((line
16.02 divided by line 16.01) times line 16) for services rendered on or after January 1, 2011, in
column 2. For cost reporting periods beginning on or after January 1, 2011, enter the total
program preventive costs ((line 16.02 divided by line 16.01) times line 16, column 2.
Line 16.04.--Enter the total program non-preventive costs. For cost reporting periods that
overlap January 1, 2011, do not complete column 1 and enter the total program non- preventive
costs ((line 16 minus lines 16.03 and 18) times .80) for services rendered on or after January 1,
2011, in column
2. For cost reporting periods beginning on or after January 1, 2011, enter the total program nonRev. 3
40-285
4068 (Cont.)
FORM CMS-2552-10
10-12
preventive costs ((line 16, column 2, minus lines 16.03 and 18, column 2) times .80) in column 2.
Line 16.05--Enter the total program costs. For cost reporting periods that overlap January 1,
2011, enter total program costs (line 16 times .80) for services rendered prior to January 1, 2011
in column 1, and enter the sum of lines 16.03 and 16.04, in column 2. For cost reporting periods
beginning on or after January 1, 2011, enter the sum of lines 16.03 and 16.04, in column 2.
Line 17--Enter the primary payer amounts from your records.
Line 18--Enter the amount credited to the RHC's program patients to satisfy their deductible
liabilities on the visits on lines 10 and 12 as recorded by the contractor from clinic bills
processed during the reporting period. RHCs determine this amount from the interim payment
lists provided by the contractor. FQHCs enter zero on this line as deductibles do not apply.
Line 19--Enter the coinsurance amount applicable to the RHC or FQHC for program patient
visits on lines 10 and 12 as recorded by the contractor from clinic bills processed during the
reporting period. This line captures data for informational and statistical purposes only. This
line does not impact the settlement calculation.
Line 20--Enter the net program costs, excluding vaccines. For cost reporting periods that
overlap January 1, 2011, enter the result of subtracting the amount on line 17 from the amount
on line 16.05, columns 1 and 2. For cost reporting beginning on or after January 1, 2011, enter
the result of subtracting the amount on line 17 from the amount on line 16.05, column 2.
Line 21--Enter the amount from Worksheet M-4, line 16.
Line 22--Enter the total allowable Medicare cost, sum of the amounts on lines 20 and 21.
Line 23--Enter your total allowable bad debts, net of recoveries, from your records. If recoveries
exceed the current year’s bad debts, line 23 will be negative.
Line 24--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is
reported for statistical purposes only. This amount must also be reported on line 23.
Line 25--Enter any other adjustment. For example, if you change the recording of vacation pay
from the cash basis to the accrual basis (see Pub. 15-1, §2146.4), enter the adjustment. Specify
the adjustment in the space provided.
Line 26--This is the sum of lines 22 and 23 plus or minus line 25.
Line 27--Enter the total interim payments from Worksheet M-5 made to you for covered services
furnished to program beneficiaries during the reporting period (from contractor records).
Line 28--For final settlement, report on line 28 the amount on line 5.99 of Worksheet M-5.
Line 29--Enter the total amount due to/from the program (line 26 minus line 27 and 28).
Transfer this amount to Worksheet S, Part III, column 3, line 10 and/or 11 as applicable.
Line 30--Enter the program reimbursement effect of protested items. The reimbursement effect
of the nonallowable items is estimated by applying a reasonable methodology which closely
approximates the actual effect of the item as if it had been determined through the normal
costfinding process. (See CMS Pub. 15-2, §115.2.) A schedule showing the supporting details
and computations must be attached.
40-285.1
Rev. 3
4069
4069.
FORM CMS-2552-10
08-11
WORKSHEET M-4 - COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA
VACCINE COST
The cost and administration of pneumococcal and influenza vaccine to Medicare beneficiaries
are 100 percent reimbursable by Medicare. This worksheet provides for the computation of the
cost of these vaccines. Additionally, only use this worksheet for vaccines rendered to patients
who, at the time of receiving the vaccine(s), were not inpatients or outpatients of the parent
provider. If a patient simultaneously received vaccine(s) with any Medicare covered services as
an inpatient or outpatient, those vaccine costs are reimbursed through the parent provider and
cannot be claimed by the RHC and FQHC.
To accommodate vaccines other than the seasonal influenza vaccines covered by Medicare,
subscript column 2 (add column 2.01 and 2.02, if necessary). The data entered in all columns (1,
2, and applicable subscripts) for lines 4, 11, and 13 are mutually exclusive. That is, the vaccine
costs, the total number of vaccines administered, and the total number of Medicare covered
vaccines shall only be represented one time in the appropriate column.
Line 1--Enter the health care staff cost from Worksheet M-1, column 7, line 10.
Line 2--Enter the ratio of the estimated percentage of time involved in administering
pneumococcal and influenza vaccine injections to the total health care staff time. Do not include
physician service under agreement time in this calculation.
Line 3--Multiply the amount on line 1 by the amount on line 2 and enter the result.
Line 4--Enter the cost of the pneumococcal and influenza vaccine medical supplies from your
records.
Line 5--Enter the sum of lines 3 and 4.
Line 6--Enter the amount from Worksheet M-1, column 7, line 22. This is your total direct cost
of the facility.
Line 7--Enter the amount from Worksheet M-2, line 16.
Line 8--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9--Multiply the amount on line 7 by the amount on line 8 and enter the result.
Line 10--Enter the sum of the amounts on lines 5 and 9.
Line 11--Enter the total number of pneumococcal and influenza vaccine injections from your
records.
Line 12--Enter the cost per pneumococcal and influenza vaccine injections by dividing the
amount on line 10 by the number on line 11.
Line 13--Enter the number of program pneumococcal and influenza vaccine injections from your
records or the PS&R.
Line 14--Enter the program cost for vaccine injections by multiplying the amount on line 12 by
the amount on line 13.
Line 15--Enter the total cost of pneumococcal and influenza vaccines and their administration by
entering the sum of the amount in column 1, line 10 and the amount in column 2 (and applicable
subscripts), line 10.
40-286
Rev. 2
10-12
FORM CMS-2552-10
4070
Transfer this amount to Worksheet M-3, line 2.
Line 16--Enter the Medicare cost of pneumococcal and influenza vaccines and their
administration costs. This is equal to the sum of the amount in column 1, line 14 plus column 2
(and applicable subscripts), line 14.
Transfer the result to Worksheet M-3, line 21.
4070.
WORKSHEET M-5 - ANALYSIS OF PAYMENTS TO HOSPITAL-BASED
RHC/FQHC SERVICES RENDERED TO PROGRAM BENEFICIARIES
Complete this worksheet for Medicare interim payments only. If you have more than one
hospital-based RHC/FQHC, complete a separate worksheet for each facility.
Complete the identifying information on lines 1 through 4. The remainder of the worksheet is
completed by your contractor.
Line Descriptions
Line 1--Enter the total program interim payments paid to the RHC/FQHC. The amount entered
reflects the sum of all interim payments paid on individual bills (net of adjustment bills) for
services rendered in this cost reporting period. The amount entered includes amounts withheld
from the component's interim payments due to an offset against overpayments to the component
applicable to prior cost reporting periods. It does not include any retroactive lump sum
adjustment amounts based on a subsequent revision of the interim rate, or tentative or net
settlement amounts, nor does it include interim payments payable.
Line 2--Enter the total program interim payments payable on individual bills. Since the cost in
the cost report is on an accrual basis, this line represents the amount of services rendered in the
cost reporting period, but not paid as of the end of the cost reporting period. It does not include
payments reported on line 1.
Line 3--Enter the amount of each retroactive lump sum adjustment and the applicable date.
Line 4--Transfer the total interim payments to the title XVIII Worksheet M-3, line 27.
DO NOT COMPLETE THE REMAINDER OF WORKSHEET M-5. LINES 5 THROUGH 7
ARE FOR CONTRACTOR USE ONLY.
Line 5--List separately each tentative settlement payment after desk review together with the
date of payment. If the cost report is reopened after the NPR has been issued, report all
settlement payments prior to the current reopening settlement on line 5.
Line 6--Enter the net settlement amount (balance due to the provider or balance due to the
program) for the NPR, or, if this settlement is after a reopening of the NPR, for this reopening.
NOTE: On lines 3, 5, and 6, when an amount is due from the provider to the 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.
Line 7--Enter the sum of the amounts on lines 4, 5.99, and 6 in column 2. The amount in column
2 must equal the amount on Worksheet M-3, line 26.
Line 8--Enter the contractor name, the contractor number and NPR date in columns 0, 1 and 2,
respectively.
Rev. 3
40-287
12-10
FORM CMS-2552-10
4090
EXHIBIT 1 - Form CMS-2552-10 Worksheets
The following is a listing of the Form CMS-2552-10 worksheets and the page number location.
Changes to worksheets are indicated by redline on this and the subsequent page for this
transmittal. Where only the page number changes, no redlining is indicated.
Worksheets
Page(s)
Wkst. S, Parts I, II & III
Wkst. S-2, Part I
Wkst. S-2, Part II
Wkst. S-3, Part I
Wkst. S-3, Parts II & III
Wkst. S-3, Part IV
Wkst. S-3, Part V
Wkst. S-4
Wkst. S-5
Wkst. S-6
Wkst. S-7
Wkst. S-8
Wkst. S-9
Wkst. S-10
Wkst. A
Wkst. A-6
Wkst. A-7, Parts I - III
Wkst. A-8
Wkst. A-8-1
Wkst. A-8-2
Wkst. A-8-3, Parts I-VI
Wkst. B, Part I
Wkst. B, Part II
Wkst. B-1
Wkst. B-2
Wkst. C, Part I
Wkst. C, Part II
Wkst. D, Part I
Wkst. D, Part II
Wkst. D, Part III
Wkst. D, Part IV
Wkst. D, Parts V
Wkst. D-1, Part I
Wkst. D-1, Part II
Wkst. D-1, Parts III & IV
Wkst. D-2, Parts I-III
Wkst. D-3
Wkst. D-4, Part I
Wkst. D-4, Part II
Wkst. D-4, Part III
Wkst. D-5, Part I
Wkst. D-5, Part II
Wkst. E, Part A
Wkst. E, Part B
Wkst. E-1, Part I
Wkst. E-1, Part II
Wkst. E-2
40-503
40-504 - 40-507
40-508 - 40-509
40-510 - 40-511
40-512 - 40-513
40-514
40-515
40-516
40-517
40-518
40-519 - 40-520
40-521
40-522
40-523
40-524 - 40-526
40-527
40-528
40-529
40-530
40-531
40-532 - 40-534
40-535 - 40-543
40-544 - 40-552
40-553 - 40-561
40-562
40-563 - 40-564
40-565 - 40-566
40-567
40-568
40-569
40-570 - 40-571
40-572
40-573
40-574
40-575
40-576 - 40-577
40-578
40-579
40-580
40-581
40-582
40-583
40-584 - 40-585
40-586 - 40-587
40-588
40-589
40-590
Rev. 1
40-501
4090 (Cont.)
FORM CMS-2552-10
12-10
Worksheets (Cont.)
Page(s)
Wkst. E-3, Part I
Wkst. E-3, Part II
Wkst. E-3, Part III
Wkst. E-3, Part IV
Wkst. E-3, Part V
Wkst. E-3, Part VI
Wkst. E-3, Part VII
Wkst. E-4
Wkst. G
Wkst. G-1
Wkst. G-2, Parts I & II
Wkst. G-3
Wkst. H
Wkst. H-1, Part I
Wkst. H-1, Part II
Wkst. H-2, Part I
Wkst. H-2, Part II
Wkst. H-3, Parts I-III
Wkst. H-4
Wkst. H-5
Wkst. I-1
Wkst. I-2
Wkst. I-3
Wkst. I-4
Wkst. I-5
Wkst. J-1, Part I
Wkst. J-1, Part II
Wkst. J-2, Part I
Wkst. J-2, Part II
Wkst. J-3
Wkst. J-4
Wkst. K
Wkst. K-1
Wkst. K-2
Wkst. K-3
Wkst. K-4, Part I
Wkst. K-4, Part II
Wkst. K-5, Part I
Wkst. K-5, Part II
Wkst. K-5, Part III
Wkst. K-6
Wkst. L
Wkst. L-1, Part I
Wkst. L-1, Part II
Wkst. L-1, Part III
Wkst. M-1
Wkst. M-2
Wkst. M-3
Wkst. M-4
Wkst. M-5
40-591
40-592
40-593
40-594
40-595
40-596
40-597
40-598 - 40-599
40-600 - 40-601
40-602
40-603
40-604
40-605
40-606
40-607
40-608 - 40-610
40-611 - 40-613
40-614
40-615
40-616
40-617
40-618
40-619
40-620
40-621
40-622 - 40-624
40-625 - 40-627
40-628
40-629
40-630
40-631
40-632
40-633
40-634
40-635
40-636
40-637
40-638 - 40-640
40-641 - 40-643
40-644
40-645
40-646
40-647 - 40-655
40-656
40-657 - 40-658
40-659
40-660
40-661
40-662
40-663
40-502
Rev. 1
| File Type | application/pdf |
| Author | CMS |
| File Modified | 2013-05-10 |
| File Created | 2012-11-07 |