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FORM CMS 2552-10
4095
EXHIBIT 2 - ELECTRONIC REPORTING SPECIFICATIONS FOR
FORM CMS 2552-10 TABLE OF CONTENTS
Topic
Page(s)
Table 1:
Record Specifications
40-703 - 40-714
Table 2:
Worksheet Indicators
40-715 - 40-724
Table 3:
List of Data Elements with Worksheet,
Line, and Column Designations
40-725 -40-771
Table 3A:
Worksheets Requiring No Input
40-772
Table 3B:
Tables to Worksheet S-2
40-772
Table 3C:
Lines Which Cannot Be Subscripted
Table 3D:
Permissible Payment Mechanisms
40-775
Table 3E:
Line Numbering for Special Care Units
40-775
Table 4:
Numbering Convention for Multiple
Components
40-776
40-773 - 40-774
Table 5:
Cost Center Coding
40-777 - 40-781
Table 6:
Edits, Levels I & II
40-782 - 40-811
Rev. 1
40-701
08-11
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
4095 (Cont.)
Table 1 specifies the standard record format to be used for electronic reporting. Each electronic
cost report submission (file ) has four types of records. The first group (type 1 records) contains
information for identifying, processing, and resolving problems. The text used throughout the
cost report for variable line labels (e.g., Worksheet A) and variable column headers (Worksheet B-1)
are included in the type 2 records. Refer to Table 5 for cost center coding. The data, detailed
in Table 3, is identified as type 3 records. The encryption coding at the end of the file,
records 1, 1.01, and 1.02 are type 4 records.
The medium for transferring cost reports submitted electronically to fiscal intermediaries is 3½" diskettes,
Compact Diskettes, or Flash Drive. The file must be in IBM format. The character set must be ASCII.
Providers should seek approval from their fiscal intermediaries regarding the method of submission to
insure that the method of transmission is acceptable.
The following are requirements for all records:
1. All alpha characters must be in upper case.
2. For micro systems, the end of record indicator must be a carriage return and line feed, in that
sequence.
3. No record may exceed 60 characters.
Below is an example of a set of type 1 records with a narrative description of their meaning.
1
2
3
4
5
6
123456789012345678901234567890123456789012345678901234567890
1
1 010123201012120111201A09P005201125820100121
1
4
.00000
14:30
Record #1:
Records #4-6:
Rev. 2
This is a cost report file submitted by CCN 010123 for the period from
May 1, 2010 (2010121) through April 30, 2011 (2011120). It is filed on the Form
CMS-2552-10. It is prepared with vendor number A09's PC based system, version
number 5. Position 38 changes with each new test case and/or reapproval and is alpha.
Positions 39 and 40 will remain constant for approvals issued after the first test case.
This file is prepared by the hospital on September 15, 2011 (2011258). The electronic cost
report specification, dated May 1, 2010 (2010121), is used to prepare this file.
The hospital was subject to an inpatient capital reduction of 0.0%.
40-703
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
08-11
FILE NAMING CONVENTION
Name each cost report ECR file in the following manner:
ECNNNNNN.YYLC, where
1. EC (Electronic Cost Report) is constant;
2. NNNNNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from
hospitals with two or more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed.
Name each cost report PI file in the following manner:
PINNNNNN.YYLC, where
1. PI (Print Image) is constant;
2. NNNNNN is the 6 digit CMS Certification Number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from
hospitals with two or more cost reporting periods ending in the same calendar year.
5. C is the number of times this original cost report is being filed.
RECORD NAME: Type 1 Records - Record Number 1
Size
Usage
Loc.
1. Record Type
1
X
1
2. For Future use
10
9
2-11
3. Space
1
X
12
4. Record Number
1
X
13
5. Spaces
3
X
14-16
6. Hospital CCN
Number
6
9
17-22
Field must have 6 numeric characters
7. Fiscal Year
Ending
Beginning
DateDate
7
9
23-29
YYYYDDD - Julian date; first day
covered by this cost report
8. Fiscal Year
Ending Date
7
9
30-36
YYYYDDD - Julian date; last day
covered by this cost report
9. MCR Version
1
9
37
40-704
Remarks
Constant "1"
Alpha numeric
Constant "1"
Constant "1" (for Form
CMS 2552-10)
Rev. 2
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
4095 (Cont.)
RECORD NAME: Type 1 Records - Record Number 1 (Continued)
Size
Usage
Loc.
Remarks
10. Vendor Code
3
X
38-40
11. Vendor Equipment
1
X
41
12. Version Number
3
X
42-44
Version of extract software, e.g.,
001=1st , 002=2nd, etc. or 101=1st,
102=2nd. The version number must
be incremented by 1 with each
recompile and release to client(s).
13. Creation Date
7
9
45-51
YYYYDDD - Julian date; date on which
the file was created (extracted from
the cost report)
14. ECR Spec. Date
7
9
52-58
YYYYDDD - Julian date; date of
electronic cost report specifications
used in producing each file. Valid
for cost reporting periods ending on
or after (06/30/2012) 2012182,
Prior approval(s) 2010121,
for cost reporting periods beginning on
or after (05/01/2010),
To be supplied upon approval. Refer
to page 40-703.
P = PC; M = Main Frame
RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size
Usage
Loc.
1. Record Type
1
9
1
2. Spaces
10
X
2-11
3. Record Number
Remarks
Constant "1"
#2 - Reserved for future use.
#3 - Vendor information; optional
record for use by vendors. Left
justified in positions 21-60.
#4 - The time that the cost report is
created. This is represented in
military time as alpha numeric. Use
position 21-25 . Example 2:30PM
is expressed as 14:30.
#5 to #99 - Reserved for future use.
Rev. 3
40-705
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
10-12
RECORD NAME: Type 1 Records - Record Numbers 2 - 99 (Continued)
Size
Usage
Loc.
Remarks
4. Spaces
7
X
14-20
Spaces (Optional)
5. ID Information
40
X
21-60
Left justified to position 21.
RECORD NAME: Type 2 Records for Labels
Size
Usage
Loc.
1. Record Type
1
9
1
2. Worksheet Indicator
7
X
2-8
3. Spaces
2
X
9-10
4. Line Number
3
9
11-13
Numeric
5. Subline Number
2
9
14-15
Numeric
6. Column Number
3
X
16-18
Alphanumeric
7. Subcolumn Number
2
9
19-20
Numeric
8. Cost Center Code
5
9
21-25
Numeric. Refer to Table 5 for
appropriate cost center code.
9. Labels/Headings
a. Line Labels
36
X
26 -60
10
X
21-30
Alphanumeric, left justified
36
X
21-57
Worksheet I-1 basis
b. Column Headings
Statistical
b. Col.Basis
Headings
& Code
c. Line Statistics
40-706
Remarks
Constant "2"
Alphanumeric. Refer to Table 2.
Rev. 3
08-11
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
4095 (Cont.)
RECORD NAME: Type 2 Records for Labels (Continued)
The type 2 records contain text which appears on the printed cost report. Of these, there are
three groups: (1) Worksheet A cost center names (labels); (2) column headings for stepdown entries;
and (3) other text appearing in various places throughout the cost report. The standard cost center
labels are listed below.
A Worksheet A cost center label must be furnished for every cost center with cost or charge data
anywhere in the cost report. The line and subline numbers for each label must be the same as the
line and subline numbers of the corresponding cost center on Worksheet A. The columns and
subcolumn numbers are always set to zero.
Column headings for the General Service cost centers on Worksheets B-1, B, Parts I, and II,
and Worksheet J-1, Part II (lines 1-3) are supplied once, consisting of one to three records.
The statistical basis shown on Worksheet B-1 is also reported. The statistical basis consists
of one or two records (lines 4 and 5). Statistical basis code is supplied only to Worksheet B-1
columns and is recorded as line 5 and only for capital cost centers, columns 1-2 and subscripts
as applicable. The statistical code must agree with the statistical basis indicated on lines 4 and 5,
i.e., code 1 = square footage, code 2 = dollar value, and code 3 = all others. Refer to Table 2
for the special worksheet identifier to be used with column headings and statistical basis and to
Table 3 for line and column references. See below for statistical basis line labels for Worksheet
I-1. These line labels are required records in the file. (See 9c above for record placement.)
Rev. 2
40-707
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
08-11
Use the following type 2 cost center descriptions for all Worksheet A standard cost center lines.
Line
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
19
20
21
22
23
30
31
32
33
34
40
41
42
43
44
45
46
50
51
52
53
54
55
56
57
58
59
Description
CAP REL COSTS-BLDG & FIXT
CAP REL COSTS-MVBLE EQUIP
OTHER CAP REL COSTS
EMPLOYEE BENEFITS
ADMINISTRATIVE & GENERAL
MAINTENANCE & REPAIRS
OPERATION OF PLANT
LAUNDRY & LINEN SERVICE
HOUSEKEEPING
DIETARY
CAFETERIA
MAINTENANCE OF PERSONNEL
NURSING ADMINISTRATION
CENTRAL SERVICES & SUPPLY
PHARMACY
MEDICAL RECORDS & LIBRARY
SOCIAL SERVICE
NONPHYSICIAN ANESTHETISTS
NURSING SCHOOL
I&R SERVICES-SALARY & FRINGES APPRVD
I&R SERVICES-OTHER PRGM COSTS APPRVD
PARAMED ED PRGM-(SPECIFY)
ADULTS & PEDIATRICS
INTENSIVE CARE UNIT
CORONARY CARE UNIT
BURN INTENSIVE CARE UNIT
SURGICAL INTENSIVE CARE UNIT
SUBPROVIDER - IPF
SUBPROVIDER - IRF
SUBPROVIDER
NURSERY
SKILLED NURSING FACILITY
NURSING FACILITY
OTHER LONG TERM CARE
OPERATING ROOM
RECOVERY ROOM
DELIVERY ROOM & LABOR ROOM
ANESTHESIOLOGY
RADIOLOGY-DIAGNOSTIC
RADIOLOGY-THERAPEUTIC
RADIOISOTOPE
CT SCAN
MRI
CARDIAC CATHETERIZATION
40-708
Line
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
88
89
90
91
92
94
95
96
97
100
101
105
106
107
108
109
110
111
113
114
115
116
190
191
192
193
Description
LABORATORY
PBP CLINICAL LAB SERVICES-PRGM ONLY
WHOLE BLOOD & PACKED RED BLOOD CELLS
BLOOD STORING, PROCESSING & TRANS.
INTRAVENOUS THERAPY
RESPIRATORY THERAPY
PHYSICAL THERAPY
OCCUPATIONAL THERAPY
SPEECH PATHOLOGY
ELECTROCARDIOLOGY
ELECTROENCEPHALOGRAPHY
MEDICAL SUPPLIES CHARGED TO PATIENTS
IMPL. DEV. CHARGED TO PATIENTS
DRUGS CHARGED TO PATIENTS
RENAL DIALYSIS
ASC (NON-DISTINCT PART)
RURAL HEALTH CLINIC
FEDERALLY QUALIFIED HEALTH CENTER
CLINIC
EMERGENCY
OBSERVATION BEDS (NON-DISTINCT PART)
HOME PROGRAM DIALYSIS
AMBULANCE SERVICES
DURABLE MEDICAL EQUIP-RENTED
DURABLE MEDICAL EQUIP-SOLD
I&R SERVICES-NOT APPRVD PRGM
HOME HEALTH AGENCY
KIDNEY ACQUISITION
HEART ACQUISITION
LIVER ACQUISITION
LUNG ACQUISITION
PANCREAS ACQUISITION
INTESTINAL ACQUISITION
ISLET ACQUISITION
INTEREST EXPENSE
UTILIZATION REVIEW-SNF
AMBULATORY SURGICAL CENTER (D.P.)
HOSPICE
GIFT, FLOWER, COFFEE SHOP & CANTEEN
RESEARCH
PHYSICIANS' PRIVATE OFFICES
NONPAID WORKERS
Rev. 2
08-11
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
4095 (Cont.)
Type 2 records for Worksheet B-1, columns 1-23, lines 1-5 and line 6 (for columns 1-2
only (capital cost center columns)) are listed below. The numbers running vertical to line 1
descriptions are the general service cost center line designations.
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
19
20
21
22
23
LINE
3
1
2
CAP
CAP
EMPLOYEE
ADMINISMAINOPERATION
LAUNDRY
HOUSEDIETARY
CAFETERIA
MAINNURSING
CENTRAL
PHARMACY
MEDICAL
SOCIAL
NONPHYSIC.
NURSING
I&R
I&R
PARAMED
BLDGS &
MOVABLE
BENEFITS
TRATIVE &
TENANCE &
OF PLANT
& LINEN
KEEPING
FIXTURES
EQUIPMENT
TENANCE &
ADMINISSERVICES &
PERSONNEL
TRATION
SUPPLY
RECORDS &
SERVICE
ANESTHET.
SCHOOL
SALARY &
PROGRAM
EDUCATION
LIBRARY
GENERAL
REPAIRS
SERVICE
FRINGES
COSTS
4
SQUARE
DOLLAR
GROSS
ACCUM.
SQUARE
SQUARE
POUNDS OF
HOURS OF
MEALS
MEALS
NUMBER
DIRECT
COSTED
COSTED
TIME
TIME
ASSIGNED
ASSIGNED
ASSIGNED
ASSIGNED
ASSIGNED
5
6
FEET
VALUE
SALARIES
COST
FEET
FEET
LAUNDRY
SERVICE
SERVED
SERVED
HOUSED
NRSING HRS
REQUIS.
REQUIS.
SPENT
SPENT
TIME
TIME
TIME
TIME
TIME
1
2
Type 2 records for Worksheet H-1, Part II, columns 1-5, lines 1-5 are listed below. The numbers
running vertical to line 1 descriptions are the general service cost center line designations.
1
1
2
3
4
5
CAPITAL
CAPITAL
PLANT
TRANSADMINIS-
2
LINE
3
4
BLDGS &
MOVABLE
OPER. &
PORTATTRATIVE &
FIXTURES
EQUIPMENT
MAINT.
ION
GENERAL
SQUARE
DOLLAR
SQUARE
MILEAGE
ACCUM.
5
FEET
VALUE
FEET
COST
Type 2 records for Worksheet I-1, column 2 statistical basis labels for lines 1-8, 10-16, 18-22, 24-26,
and 28-30 with subscripts as appropriate for line 30 are listed below.
Line
Description
1 HOURS OF SERVICE
2 HOURS OF SERVICE
Rev. 1
Line Description
16 ACCUMULATED COST
18 SQUARE FEET
40-709
4095 (Cont.)
3
4
5
6
7
8
10
11
12
13
14
15
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
HOURS OF SERVICE
HOURS OF SERVICE
HOURS OF SERVICE
HOURS OF SERVICE
ACCUMULATED COST
ACCUMULATED COST
SALARY
SQUARE FEET
PERCENTAGE OF TIME
PERCENTAGE OF TIME
REQUISITIONS
REQUISITIONS
19
20
21
22
24
25
26
28
29
30
08-11
PERCENTAGE OF TIME
SALARY
ACCUMULATED COST
SQUARE FEET
REQUISITIONS
REQUISITIONS
ACCUMULATED COST
CHARGES
CHARGES
CHARGES
Type 2 records for Worksheet K-4, columns 1-6, lines 1-5 are listed below. The numbers
running vertical to line 1 descriptions are the general service cost center line designations.
1
1
2
3
4
5
6
CAPITAL
CAPITAL
PLANT
TRANSVOLUNT.
ADMINIS-
2
LINE
3
4
BLDGS &
MOVABLE
OPER. &
PORTATSERVICES
TRATIVE &
FIXTURES
EQUIPMENT
MAINT.
ION
COORDI.
GENERAL
SQUARE
DOLLAR
SQUARE
MILEAGE
HOURS OF
ACCUM.
5
FEET
VALUE
FEET
SERVICE
COST
Examples of type 2 records are below. Either zeros or spaces may be used in the line, subline,
column, and subcolumn number fields (positions 11-20). Spaces are preferred. (See
first two lines of the example.)* Refer to Table 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
*
*
2A000000
1
0100CAP REL COSTS-BLDS & FIXT
2A000000000000101000000101CAP REL COSTS-WEST WING
2A000000
2
0200CAP REL COSTS-MVBLE EQUIP
2A000000
5
0500ADMINISTRATIVE AND GENERAL
2A000000
21
2100I&R SERVICES-SALARY & FRINGES APPRVD
2A000000
21 1
2101I&R SALARY-SURGERY
Examples of column headings for Worksheets B-1, B, Parts I, and II, and Worksheet
J-1, Part II (lines 1-3), statistical bases used in cost allocation on Worksheet B-1,
Worksheet J-1, Part II (lines 4 and 5), and statistical codes used for Worksheet B-1
40-710
Rev. 2
08-11
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
4095 (Cont.)
(line 6) are displayed below. Also below are examples of Worksheets H-1, Part II (4th
character indicates the 1st HHA) and Worksheet I-1 for both renal and home program.
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
1
2
3
4
5
6
1
1
1
1
1
1
CAP
BLDGS &
FIXTURES
SQUARE
FEET
1
2B10000*
2H11002*
2H11002*
2I1D000*
2I1D000*
2I1H000*
1
1
1
1
12
7
1
1
1
2
2
2
CAP
CAPITAL
BLDG &
HRS OF SERVICE
PERCENTAGE OF TIME
ACCUMULATED COST
Worksheet H-1, Part II records share the same size constraints as the Worksheet
B-1 records. Worksheet I-1 may not exceed 36 characters.
RECORD NAME: Type 3 Records for Nonlabel Data
Size
Usage
Loc.
1. Record Type
1
9
1
2. Worksheet Indicator
7
X
2-8
3. Spaces
2
X
9-10
4. Line Number
3
9
11-13
Numeric
5. Subline Number
2
9
14-15
Numeric
6. Column Number
3
X
16-18
Alphanumeric
7. Subcolumn Number
2
9
19-20
Numeric
8. Field Data
a. Alpha Data
36
X
21-56
Left justified. (Y or N for yes/no
answers; dates must use mm/dd/yyyy
format - slashes, no hyphens).
Refer to Table 6 for additional
requirements for alpha data.
4
X
57-60
Spaces (optional).
Rev. 2
Remarks
Constant "3"
Numeric. Refer to Table 2.
40-711
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
08-11
RECORD NAME: Type 3 Records for Nonlabel Data (Continued)
b. Numeric Data
Size
Usage
Loc.
Remarks
16
9
21-36
Right justified. May contain
embedded decimal point. Leading
zeros are suppressed; trailing zeros
to the right of the decimal point
are not. (See example below.)
Positive values are presumed; no "+"
signs are allowed. Use leading
minus to specify negative values.
Express percentages as decimal
equivalents, i.e., 8.75% is expressed
as .087500. All records with zero
values are dropped. Refer to Table
6 for additional requirements
regarding numeric data.
A sample of type 3 records and a number line for reference are below.
123456789
3A000000
3A000000
3A000000
3A000000
3A000000
3A000000
3A000000
3A000000
3A000000
3A000000
3C000001
3C000001
4
21
21
62
1
1
2
21
21
62
62
62
5 8
3
6
1
1
1
1
2
2
2
2
2
2
1
1
32961
1336393
185599
17750
1014775
1767922
14596
768441
2746235
4982
22476
18021
1
1
1
1
1
The line numbers are numeric. In several places throughout the cost report (see list below), the line
numbers themselves are data. The placement of the line and subline numbers as data must be uniform.
40-712
Rev. 2
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
4095 (Cont.)
Worksheet A-6, columns 3, 7, and 10
Worksheet A-8, columns 4 and 5
Worksheet A-8-1, Part A, column 1
Worksheet A-8-2, column 1
Worksheet B-2, column 3
Examples of records (*) with a Worksheet A line number as data and a number line
for reference are below.
*
*
*
123456789
1
3
1
8
2
1
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
3A6000G 0
13
13
13
13
13
13
14
14
14
14
15
16
0
1
3
4
6
7
0
1
3
4
0
0
TO SPREAD INTEREST EXPENSE
G
1
221409
87
225321
BETWEEN CAPITAL-RELATED COST
G
401
3912
BUILDING & FIXTURES AND
ADMINISTRATIVE AND GENERAL
Note
RECORD NAME: TYPE "3" RECORDS
123456789
1
3
1
8
2
1
*
3A800000
3A800000
3A800000
3A800000
37
37
37
37
0
1
2
4
PBP ADJUSTMENT - EMERGENCY ROOM
A
-250935
61
*
3A800000
3A800000
3A800000
3A800000
37
37
37
1
0
2
4
1
PBP ADJUSTMENT - HEART ACQUISITION
-114525
85
41
Rev. 3
40-713
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 1 - RECORD SPECIFICATIONS
10-12
RECORD NAME: TYPE 3 RECORDS (Continued)
*
*
*
3A810000
3A810000
3A810000
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3A820010
3
4
5
3
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
3
4
5
3
4
4
4
4
4
4
4
4
4
1
1
1
1
1
2
3
4
5
6
7
12
14
1
2
3
4
5
6
7
12
14
CAT SCANS
13352
11122
4101
4101
DR. B
126292
94719
31573
124900
741
6860
12000
4101
DR. C
189439
142079
47360
124900
333
5750
18900
RECORD NAME: TYPE 4 RECORDS
File Encryption and Date and Time Stamp
This type 4 record consist of 4 records: 1, 1.01, and 1.02 These records are
created at the point in which the ECR file has been completed and saved to
disk or compact disk to ensure the integrity of the file.
40-714
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
4095 (Cont.)
This table contains the worksheet indicators that are used for electronic cost reporting.
A worksheet indicator is provided only for those worksheets from which data are to be provided.
The worksheet indicator consists of seven characters in positions 2-8 of the record identifier. The
first two characters of the worksheet indicator (positions 2 and 3 of the record identifier) always show
the worksheet. The third character of the worksheet indicator (position 4 of the record identifier)
is used in several ways. First, it may be used to identify worksheets for multiple hospital-based
components, such as subprovider, or to identify various types of hospital services such as kidney,
heart, lung, or liver acquisitions. Alternatively, it may be used as part of the worksheet, e.g., A81.
The fourth character of the worksheet indicator (position 5 of the record identifier) represents the type
of provider, by using the keys below. Except for Worksheet A-6 (to handle multiple worksheets)
and Worksheet I-4 (to handle multiple payment rates), the fifth and sixth characters of the worksheet
indicator (positions 6 and 7 of the record identifier) identify worksheets required by a Federal
program (18 = Title XVIII, 05 = Title V, or 19 = Title XIX) or worksheet required for the facility
(00 = Universal). The seventh character of the worksheet indicator (position 8 of the record identifier)
represents the worksheet part.
Provider Type - Fourth Digit of the Worksheet Identifier
Universal.................................0 (Zero)
Hospital..........................................
A
IPF…….………………………
B
IRF…….………………………
C
Subprovider (Other)...................................
D
SNF.................................................
E
Swing Bed SNF...........................................
F
NF...................................................
G
Swing Bed NF.......................................
H
CMHC...........................................
I
ICF/MR...........................................
J
CORF……………..…......… K
OPT………………...………. L
OSP…………..…………..... M
OOT……………..………..... N
FQHC..................................................
Q
RHC..................................................
R
Rev. 3
40-715
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
10-12
Worksheets Which Apply to the Hospital Complex
Worksheet
S, Part I
S, Part III
S-2, Part I
S-2, Part II
S-3, Part I
S-3, Part II
S-3, Part III
S-3, Part IV
S-3, Part V
S-4
S-5
S-6
S-7
S-8
S-9
S-10
A
A-6
A-7, Part I
A-7, Part II
A-7, Part III
A-8
A-8-1
A-8-2
A-8-3
B-1 (For use in column headings)
B, Part I
B, Part II
B-1
B-2
C, Part I
40-716
Worksheet
Indicator
S000001
S000003
S200001
S200002
S300001
S300002
S300003
S300004
S300005
S410000 (a)
S500000
S61?000 (a) (b)
S700000
S81?000 (m)
S910000 (a)
S100000
A000000
A600?A 0 (f)
A700001
A700002
A700003
A800000
A810000
A820010 (c)
A83P000 (d) (l)
A83R000 (d) (l)
A83O000 (d) (l)
A83S000 (d) (l)
B10000*
B000001
B000002
B100000
B200010 (c)
C000001
Rev. 3
08-11
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
4095 (Cont.)
Worksheets Which Vary by Program (Continued)
Worksheet
Rev. 2
Title V
Title XVIII
Title XIX
C, Part II
Hospital
C000052
*
C000192
D, Part III:
Hospital
D00A053
D00A183
D00A193
D, Part IV:
Hospital
IPF
IRF
Subprovider (Other)
SNF
NF
ICF/MR
D00A054
D00B054
D00C054
D01D054 (e)
D00E054
D00G054
D00J054
D00A184
D00B184
D00C184
D01D184 (e)
D00E184
*
*
D00A194
D00B194
D00C194
D01D194 (e)
D00E194
D00G194
D00J194
D, Part V:
Hospital
IPF
IRF
Subprovider (Other)
SNF
Swing Bed SNF
NF
Swing Bed NF
ICF/MR
D00A055
D00B055
D00C055
D01D055 (e)
D00E055
D00F055
D00G055
D00H055
D00J055
D00A185
D00B185
D00C185
D01D185 (e)
D00E185
D00F185
*
*
*
D00A195
D00B195
D00C195
D01D195 (e)
D00E195
D00F195
D00G195
D00H195
D00J195
D-1, Parts I through IV: (d)
Hospital
D10A051
IPF
D10B051
IRF
D10C051
Subprovider (Other) D11D051 (e)
SNF
D10E051
NF
D10G051
ICF/MR
D10J051
D10A181
D10B181
D10C181
D11D181 (e)
D10E181
*
*
D10A191
D10B191
D10C191
D11D191 (e)
D10E191
D10G191
D10J191
40-717
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
08-11
Worksheets Which Apply to the Hospital Complex
Worksheet
Worksheet
Indicator
D-2, Parts I & II (d)
D200000
Worksheet Which Varies by Program
Worksheet
Title V
D-3:
Hospital
IPF
IRF
Subprovider (Other)
SNF
Swing Bed SNF
NF
Swing Bed NF
ICF/MR
D30A050
D30B050
D30C050
D31D050 (e)
D30E050
D30F050
D30G050
D30H050
D30J050
Title XVIII
Title XIX
D30A180
D30B1800
D30C180
D31D180 (e)
D30E180
D30F180
*
*
*
D30A190
D30B190
D30C190
D31D190 (e)
D30E190
D30F190
D30G190
D30H190
D30J190
Worksheets Which Apply to the Hospital Complex
Worksheet
Worksheet
Indicator
D-4, Part I, II and IV: (d)
D4K0000 (h)
D4H0000 (h)
D4L0000 (h)
D4P0000 (h)
D4N0000 (h)
D4I0000 (h)
D4S0000 (h)
D4O0000 (h)
D-5, Part I:
D5H0001 (i)
D5M0001 (i)
Worksheet Which Varies by Component
D-5, Part II:
Hospital
IPF
IRF
Subprovider (Other)
40-718
D50A002
D50B002
D50C002
D51D002 (e)
Rev. 2
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
4095 (Cont.)
Worksheets Which Vary by Component and/or Program
Worksheet
Title XVIII
Title XIX
E, Part A:
Hospital
Subprovider
*
*
E00A18A
E01D18A (e)
*
*
E, Part B:
Hospital
IPF
IRF
Subprovider
SNF
*
*
*
*
*
E00A18B
E00B18B
E00C18B
E01D18B (e)
E00E18B
*
*
*
*
*
E-1, Part I:
Hospital
IPF
IRF
Subprovider
SNF
Swing Bed SNF
*
*
*
*
*
*
E10A181
E10 B181
E10C181
E11D181 (e)
E10E181
E10F181
*
*
*
*
*
*
E-1, Part II:
Hospital
*
E10A182
*
E20F050
E20H050
E20F180
*
E20F190
E20H190
E-2:
Swing Bed SNF
Swing Bed NF
Rev. 3
Title V
E-3, Part I:
Hospital
Subprovider (Other)
*
*
E30A181
E31D181 (e)
*
*
E-3, Part II:
Hospital
IPF
*
*
E30A182
E30 B182
*
*
E-3, Part III:
Hospital
IRF
*
*
E30A183
E30 C183
*
*
40-719
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
10-12
Worksheets Which Vary by Component and/or Program (Continued)
Worksheet
Title V
Title XVIII
Title XIX
E-3, Part IV:
Hospital
Subprovider (Other)
*
*
E30A184
E31D184 (e)
*
*
E-3, Part V:
Hospital (CAH)
*
E30A185
*
E-3, Part VI:
SNF
*
E30E186
*
NOTE:
Refer to Table 3 for instructions on the reporting of data for hospital-based
SNF reimbursed prospectively under title XVIII.
E-3, Part VII:
Hospital
NF
ICF/MR
E30A057
E30G057
E30J057
*
*
*
E30A197
E30G197
E30J197
E-4:
Hospital
E40A050
E40A180
E40A190
Worksheets Which Apply to the Hospital Complex
Worksheet
Indicator
Worksheet
G
G-1
G-2, Parts I & II (d)
G-3
H
H-1, Part I
H-1, Part II
H-2, Part I
H-2, Part II
G000000
G100000
G200000
G300000
H010000
H110001
H110002
H210001
H210002
(a)
(a)
(a)
(a)
(a)
Worksheet Which Varies by Program
Worksheet
40-720
Title V
Title XVIII
Title XIX
H-3, Part I
H310051 (a)
H310181 (a)
H310191 (a)
H-3, Part II
H310052 (a)
H310182 (a)
H310192 (a)
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
4095 (Cont.)
Worksheet Which Varies by Program
Worksheet
Title V
Title XVIII
Title XIX
H-4, Part I
H410051 (a)
H410181 (a)
H410191 (a)
H-4, Part II
H410052 (a)
H410182 (a)
H410192 (a)
Worksheets Which Apply to the Hospital Complex (Continued)
Worksheet
H-5
I-1
I-2
I-3
I-4
I-5
J-1, Part I
J-1, Part II
J-2
J-4
K
K-1
K-2
K-3
K-4, Part I
K-4, Part II
K-5, Part I
K-5, Part II
K-5, Part III
L-1, Part I
M-1
M-2
Rev. 3
Worksheet
Indicator
H510000
I1D0000
I1H0000
I2D0000
I2H0000
I3D0000
I3H0000
I4D0010
I4H0010
I500000
J11I001
J11I002
J21I000
J41I 000
K010000
K110000
K210000
K310000
K410001
K410002
K510001
K510002
K510003
L100001
M11?000
M21?000
(a)
(j)
(j)
(j)
(j)
(j)
(j)
(j, k)
(j, k)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(a)
(m)
(m)
40-721
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
Worksheet Which Varies by Component and/or Program
Worksheet
40-722
Title V
Title XVIII
10-12
`
Title XIX
J-3
J31I050 (b)
J31I180 (b)
J31I190
(b)
L, Part I:
Hospital
Subprovider
L00A051
L01D051 (e)
L00A181
L01D181 (e)
L00A191
L01D191 (e)
L, Part II:
Hospital
Subprovider
L00A052
L01D052 (e)
L00A182
L01D182 (e)
L00A192
L01D192 (e)
L-1, Part II:
Universal (0)
L100052
L100182
L100192
M-3
M-4
M-5
M31?050 (m)
M41?050 (m)
*
M31?180 (m)
M41?180 (m)
M51?180 (m)
M31?190 (m)
M41?190 (m)
*
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
4095 (Cont.)
FOOTNOTES:
(a)
Multiple Hospital-Based HHAs, CMHCs, and Hospices
The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0
to accommodate multiple hospital-based HHAs and CMHCs, and 1 through 5 for
hospital-based Hospices. If there is only one of the components, the default is 1. This
affects the H, J, and K series worksheets including Worksheets S-4, S-6, and S-9.
For CMHCs the fourth character of the worksheet indicator (position 5 of the record)
is I.
(b)
Multiple Outpatient Rehabilitation Providers
The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0
to accommodate multiple providers. If there is only one outpatient provider type, the
default is 1. The fourth character of the worksheet indicator (position 5 of the record)
indicates the outpatient rehabilitation provider as listed below. These affects
Worksheet S-6.
I = CMHC
K = CORF
L = OPT
M = OOT
N = OSP
(c)
Multiple Worksheets for Reclassification and Adjustments Before and After Stepdown
The fifth and sixth digits of the worksheet indicator (positions 6 and 7 of the record) are
numeric from 01-99 to accommodate reports with more lines on Worksheets A-8-2,
and/or B-2. For reports which do not need additional worksheets, the default is 01.
For reports which do need additional worksheets, the first page of each worksheet is
numbered 01. The number for each additional page of each worksheet is incremented by 1.
(d)
Worksheets With Multiple Parts Using Identical Worksheet Indicator
Although this worksheet has several parts, the lines are numbered sequentially. This
worksheet identifier is used with all lines from this worksheet regardless of the worksheet
part. This differs from the Table 3 presentation which still identifies each worksheet and
part as they appear on the printed cost report. This affects Worksheets A-8-3, D-1, D-2,
D-4, G-2, H-5, and J-2.
(e)
Multiple Subproviders
The third digit of the worksheet indicator (position 4 of the record) is a numeric from 1 to 0
to accommodate facilities with two or more subproviders. If there is only one subprovider,
the default is 1. This affects Worksheets D, Parts III-V; D-1; D-3; D-5, Part II; E, Parts A
and B; E-1; E-3, Parts I-V ; and L, Parts I and II.
(f)
Worksheet A-6
For Worksheet A-6, include in the worksheet identifier the reclassification code as the 5th
and 6th digits (6th and 7th in the ECR file). For example, 3A600 0A 0 or 3A600 0B 0,
3A600 0C 0, …3A600 AA 0, 3A600 AB 0, 3A600 AC 0, … 3A600 ZZ 0
(g)
To be used at a later date.
Rev. 3
40-723
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 2 - WORKSHEET INDICATORS
10-12
FOOTNOTES (Continued):
(h)
Worksheet D-4
The third digit of the worksheet indicator (position 4 of the record) must be K for kidney
acquisitions, an H for heart acquisitions, an L for liver acquisitions, an N for pancreas
acquisitions, a P for lung acquisitions, I for intestine, S for islet, or O for other.
(i)
Worksheet D-5, Part I
The third digit of the worksheet indicator (position 4 of the record) must be either an H for
hospital staff data or an M for medical staff data.
(j)
Renal Dialysis
The third digit of the worksheet indicator (position 4 of the record) must contain either a D for
renal dialysis department or an H for home program dialysis. This applies to Worksheets
I-1, I-2, I-3, and I-4.
(k)
Multiple ESRD Payment Rates
The sixth digit of the worksheet indicator (position 7 of the record) is a numeric from 1 to 9 to
accommodate two or more payment rates in effect during one cost reporting period. If there is
only a single payment rate, the default is 1. This applies only to Worksheet I-4.
(l)
Multiple Worksheet A-8-3
This worksheet is used for either physical or respiratory therapy services furnished by
outsider suppliers. The fourth digit of the worksheet indicator (position 5 of the record) is an
alpha character of either P for physical therapy, R for respiratory therapy services, O for
Occupational therapy or S for Speech Pathology.
(m)
Multiple Health Clinic Providers
The third digit of the worksheet indicator (position 4 of the record) is numeric from 1 to 0
to accommodate multiple providers. To accommodate providers 11 - 25, use alpha
characters A through O. If there is only one health clinic provider type, the default is 1.
The fourth character of the worksheet indicator (position 5 of the record) indicates the
health clinic provider. Q indicates Federally Qualified Health Center, and R indicates
Rural Health Clinic.
40-724
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
INTRODUCTION
This table identifies those data elements necessary to calculate a hospital cost report. It also identifies
some figures from a completed cost report. These calculated fields (e.g., Worksheet B, column 26) are
needed to verify the mathematical accuracy of the raw data elements and to isolate differences between
the file submitted by the hospital complex and the report produced by the fiscal intermediary. Where an
adjustment is made, that record must be present in the electronic data file. For explanations of the
adjustment required, refer to the cost report instructions.
Table 3 "Usage" column is used to specify the format of each data item as follows:
9 Numeric, greater than or equal to zero.
-9 Numeric, may be either greater than or less than zero.
9(x).9(y) Numeric, greater than zero, with x or fewer significant
digits to the left of the decimal point, a decimal point,
and exactly y digits to the right of the decimal point.
X Character.
Consistency in line numbering (and column numbering for general service cost centers) for each cost
center is essential. The sequence of some cost centers does change among worksheets. The special care
units are the most likely to cause errors. Table 3E provides an example with a chart of special care unit
line numbers for reference. Refer to Table 4 for line and column numbering conventions for use with
complexes which have more components than appear on the preprinted FORM CMS 2552-10.
Table 3 refers to the data elements needed from a standard cost report. When a standard line is subscripted,
the subscripted lines must be numbered sequentially with the first subline number displayed as "01" or "1"
in field locations 14-15. It is unacceptable to format in series of 10, 20, or skip subline numbers (i.e., 01,
03, except for skipping subline numbers for prior year cost center(s) deleted in the current period or initially
created cost center(s) no longer in existence after cost finding). Exceptions are specified in this manual.
For "Other (specify)" lines, i.e. Worksheets S-4, S-6, S-8, settlement series and any other non cost center
lines, all subscripted lines should be in sequence and consecutively numbered beginning with subscripted
subline "01". Automated systems should reorder these numbers where the provider skips or deletes a line
number in the series.
Drop all records with zero values from the file. Any record absent from a file is treated as if it were zero.
All numeric values are presumed positive. Leading minus signs may only appear in data with values
less than zero which are specified in Table 3 with a usage of "-9".
Italic script within this table denotes adjustments which are not displayed in the print image or hard copy
of the cost report, but are contained in the ECR file. Examples of these type entries are Worksheets D-2,
Part I; D, Part III; and D, Part IV.
Rev. 3
40-725
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S
Part I: Cost report Status
Provider Use Only
Electronically filed cost report
Manually submitted cost report
If this is an amended report enter the number of times the
provider resubmitted this cost report
Medicare Utilization: enter "F" for full, or "L" for low,
1
2
1
1
1
1
X
X
3
4
1
1
1
1
9
X
5
6
7
8
9
10
11
1
2
2
2
2
3
3
1
10
5
1
1
10
1
X
X
X
X
X
X
X
12
3
1
9
1-12
1-5, 7, 9
1-5, 7, 9-12
1
1-12
13-199
200
1
2
3
4
5
1-3, 5
1-5
11
11
11
11
11
11
11
-9
-9
-9
-9
-9
-9
-9
1
1
2
2
2
2
1
2
1
2
3
4
36
9
36
2
10
36
X
X
X
X
X
X
3-19
3-10, 12-19
3-10, 12-19
3-6
3-10, 12-19
3-10, 12-13, 15-17
3-7, 9, 12-13, 15-17
3-10, 12-13, 15-17
1
2
3
4
5
6
7
8
36
6
5
1
10
1
1
1
X
X
X
9
X
X
X
X
Contractor Use Only
Cost Report Status
Enter the cost report status code:1 for as submitted,
2 for settled without audit, 3 settled with audit, 4 reopened,
or 5 amended
Date received (mm/dd/yyyy)
Contractor Number:
Initial report for this Provider CCN
Final report for this Provider CCN
Notice of Program Reimbursement (NPR) date(mm/dd/yyyy)
Enter Contractor's vendor code (ADR)
If line 4, column 1 is 4: Enter the number of times
the cost report was reopened = 0-9
Part III:
Balances due provider or program:
Title V
Title XVIII, Part A
Title XVIII, Part B
HIT
Title XIX
Providers as assigned
In total
WORKSHEET S-2, Part I
Hospital and Hospital Health Care Complex Address:
For the hospital only:
Street
P.O. Box
City
State
Zip Code
County
Hospital and Hospital-Based Component Identification:
Component name
CMS Certification number (xxxxxx)
CBSA number (xxxxx)
Type of hospital/subprovider (See Table 3B.)
Certification date (mm/dd/yyyy)
Title V payment system (See Table 3D.)
Title XVIII payment system (See Table 3D.)
Title XIX payment system (See Table 3D.)
40-726
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2 Part I (Continued)
Cost reporting period beginning date (mm/dd/yyyy)
Cost reporting period ending date (mm/dd/yyyy)
Type of control (See Table 3B.)
Does this facility qualify for and receive disproportionate share hospital
payment in accordance with 42 CFR §412.106, or low income payment
in accordance with 42 CFR §412.624 (e)(2)?
Enter "Y" for yes, "N" for no.
Is this facility subject to 42 CFR §412.06 (c )(2)
(Pickle amendment hospital)?
Enter in column 2 "Y" for yes or "N" for no.
Which method is used to determine labor and delivery Medicaid days on
lines 24 and/or 25 of this wkst? In column 1, enter 1 if date of admission,
2 if it is based on census days, or 3 if it is based on 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.
If line 22 is "yes" enter the in state Medicaid paid days in col. 1
If line 22 is "yes" enter the in state Medicaid eligible days in
col. 2.
If line 22 is "yes" enter out of state Medicaid paid days in col. 3.
If line 22 is "yes" enter out of state Medicaid eligible days in
col. 4.
If line 22 is "yes" enter Medicaid HMO days in col. 5
If line 22 is "yes" enter Other Medicaid days in col. 6
If line 22 is "yes" and this provider is an IRF
enter the in state Medicaid paid days in col. 1
If line 22 is "yes" and this provider is an IRF
enter the in-state Medicaid eligible days in col. 2.
If line 22 is "yes" and this provider is an IRF
enter out of state Medicaid paid days in col. 3.
If line 22 is "yes" and this provider is an IRF
enter out of state Medicaid eligible days in col. 4.
If line 22 is "yes" and this provider is an IRF
enter Medicaid HMO days in col. 5.
If line 22 is "yes" and this provider is an IRF
enter Other Medicaid days in col. 6.
For standard Geographic classification (not wage), what is your
status at the beginning of the cost reporting period.
Enter (1) for urban and (2) for rural.
For standard Geographic classification (not wage), what is your
status at the end of the cost reporting period.
Enter (1) for urban and (2) for rural.
If this is a sole community hospital (SCH), enter number of
periods.
Beginning date SCH status applies in this period (mm/dd/yyyy)
Ending date SCH status applies in this period (mm/dd/yyyy)
If this is a Medicare dependent hospital (MDH), enter number of
periods.
Beginning date MDH status applies in this period (mm/dd/yyyy)
Ending date MDH status applies in this period (mm/dd/yyyy)
Prospective Payment System (PPS)-Capital
Does your facility qualify and receive Capital payment for
disproportionate share in accordance with 42CFR412.320?
Enter "Y" for yes and "N" for no.
Rev. 3
20
20
21
1
2
1
10
10
2
X
X
9
22
1
1
X
22
2
1
X
23
1
1
9
23
24
2
1
1
9
X
9
24
24
2
3
9
9
9
9
24
24
24
4
5
6
9
9
9
9
9
9
25
1
9
9
25
2
9
9
25
3
9
9
25
4
9
9
25
5
9
9
25
6
9
9
26
1
1
9
27
1
1
9
35
36
36
1
1
2
1
10
10
9
X
X
37
38
38
1
1
2
1
10
10
9
X
X
45
1-3
1
X
40-727
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2, Part I (Continued)
Is this facility eligible for the special exceptions payment pursuant to
42 CFR §412.348(g)? Enter "Y" for yes and "N" for no,
If yes, complete Worksheet L, Part III and L-1, Parts I through III.
Is this a new hospital under 42 CFR 412.300 PPS capital?
Enter "Y" for yes or "N" for no.
Are you electing full federal capital payment?
Enter "Y" for yes or "N" for no.
Teaching Hospitals
Is this a hospital involved in training residents in approved GME programs?
Enter "Y" for yes or "N" for no.
If line 56 is yes, is this the first cost reporting period during which
residents in approved GME programs trained at this facility?
Enter "Y" for yes or "N" for no in column 1.
If column 1 is "Y" did residents start training in the first month
of this cost reporting period? Enter "Y" for yes or "N" for no in column 2.
If column 2 is "Y", complete Worksheet E-4.
If column 2 is "N", complete Worksheet D, Part III & IV and
D-2, Part II, if applicable.
If line 56 is yes, did this facility elect cost reimbursement for
physicians' services as defined in CMS Pub. 15-1, section 2148?
Are you claiming costs on line 100 of Worksheet A? If "Y",
complete Worksheet D-2, Part I.
Are you claiming nursing school and/or allied health costs for a program
that meets the provider-operated criteria under §413.85?
Enter "Y" for yes or "N" for no (see instructions)
Did your facility receive additional FTE slots under section 5503?
Enter "Y" for yes or "N" for no in col. 1. If "Y", effective for
portions of cost reporting periods beginning on or after July, 2011
enter the average number of primary care FTE residents for IME in
column 2,
enter direct GME in column 3, from the hospital's 3 most recent cost
reports ending and submitted before March 23, 2010. (see inst.)
46
1-3
1
X
47
1-3
1
X
48
1-3
1
X
56
1
1
X
57
1
1
X
57
2
1
X
58
1
1
X
59
1
1
X
60
1
1
X
61
1
1
X
61
2
9
9(6).99
61
3
9
9(6).99
62
1
9
9(6).99
62.01
1
9
9(6).99
63
1
1
X
64
1
9
9(6).99
64
65
65
65
65
2
1
2
3
4
9
36
10
9
9
9(6).99
X
X
9(6).99
9(6).99
ACA Provisions Affecting the Health Resources and Services Administration (HRSA)
Enter the number of FTE residents that your hospital trained in this cost
reporting period for which your hospital received
HRSA PCRE funding.
Enter the number of FTE residents that rotated from a Teaching Health
Center (THC) into your hospital during in this cost reporting
period of HRSA THC program. (see instructions)
Teaching Hospitals that Claim Residents in Non-Provider Settings
Has your facility trained residents in non-provider settings
during this cost reporting period? Enter "Y" for yes
or "N" for no. If yes, complete lines 64-67). (see instructions)
If line 63 is yes, or your facility trained residents in the base year period,
enter the number of unweigted non-primary care resident FTEs in all
non-provider settings
If line 63 is yes, or your facility trained residents in the base year period,
enter the number of unweigted non-primary care
residents FTEs for the hospital.
Enter Program name in column 1.(Subscript line 65 as necessary)
Enter Program code in column 2.
Enter the unweighted primary care FTE for nonprovider sites in column 3.
Enter the unweighted primary care FTE for the hospital in column 4.
40-728
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2 Part I (Continued)
If line 63 is yes, enter the number of unweighted non-primary care
resident FTEs for the current year. Enter "Y" for yes or "N" for no.
If line 63 is yes, enter the number of unweighted non-primary care resident
FTEs by specialty for the current year.
Enter Program name in column 1.(Subscript line 65 as necessary)
Enter Program code in column 2.
Enter the unweighted primary care FTE for nonprovider sites in column 3.
Enter the unweighted primary care FTE for the hospital in column 4.
Inpatient Psychiatric Facility PPS
Are you an Inpatient Psychiatric Facility (IPF), or do you
contain an IPF subprovider? (Y/N)
If line 70 column 1 is Y, does the facility have a teaching program
in the most recent cost report filed on or
before November 15, 2004? (Y/N)
Is the facility training residents in a new teaching program in
accordance with 42 CFR Sec. 412.424 (d)(1)(iii)(2)? (Y/N)
If column 2 is Y, enter 1, 2 or 3 respectively in column 3. If the
current cost reporting period covers the beginning of the fourth
year enter 4 in column 3, or in the subsequent academic year
of the new teaching program in existence, enter 5.
Inpatient Rehabilitation Facility PPS
Are you an Inpatient Rehabilitation Facility (IRF), or do you
contain an IRF subprovider? (Y/N)
If line 75 column 1 is Y, does the facility have a teaching program
in the most recent cost reporting period ending on or
before November 15, 2004? (Y/N)
Is the facility training residents in a new teaching program in
accordance with 42 CFR Sec. 412.424 (d)(1)(iii)(2)? (Y/N)
If column 2 is Y, enter 1, 2 or 3 respectively in column 3. If the
current cost reporting period covers the beginning of the fourth
year enter 4 in column 3, or in the subsequent academic year
of the new teaching program in existence, enter 5.
Long Term Care Hospital PPS
Are you a Long Term Care Hospital (LTCH)? (Y/N)
TEFRA Providers
Is this a new hospital under 42 CFR 413.40(f)(1)(i) TEFRA?
(Y/N)
Have you established a new Other subprovider (excluded unit)
under 42 CFR 413.40(f)(1)(i)? (Y/N)
Title V and XIX Inpatient Services
Do you have title V and XIX inpatient hospital services?
Is this hospital reimbursed for title V and XIX through the
cost report either in full or in part? (Y/N)
Are title XIX NF patients occupying title XVIII SNF beds
(dual certification)? (see instructions)
Enter "Y" for yes, and "N" for no in the applicable column.
Do you operate an ICF\MR facility for purposes
of title V and XIX? (Y/N)
Does Title V and/or Title XIX reduce Capital Cost? (Y/N)
If line 94 is "Y", by what percentage?
Does Title V and/or Title XIX reduce Operating Cost? (Y/N)
If line 96 is "Y", by what percentage?
Does this hospital qualify as a Critical Access Hospital (CAH)?
(Y/N)
Rev. 3
66
1
9
9(6).99
66
67
67
67
67
2
1
2
3
4
9
36
10
9
9
9(6).99
X
X
9(6).99
9(6).99
70
1
1
X
71
1
1
X
71
2
1
X
71
3
1
9
75
1
1
X
76
1
1
X
76
2
1
X
76
3
1
9
80
1
1
X
85
1
1
X
86
1
1
X
90
1-2
1
X
91
1-2
1
X
92
2
1
X
93
94
95
96
97
105
1-2
1-2
1-2
1-2
1-2
1
1
1
9
1
9
1
X
X
9.9(4)
X
9.9(4)
X
40-729
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2, Part I (Continued)
Rural Providers
If this facility qualifies as an CAH, has it elected the
all-inclusive method of payment for outpatient services? (Y/N)
If this facility qualifies as a CAH, is it eligible for cost
reimbursement for I &R training programs? (Y/N)
If this facility is a CAH, do I&Rs in an approved medical education
program train in the CAH's excluded IPF and/or IRF unit? (Y/N)
Is this a rural hospital qualifying for an exception to the
CRNA fee schedule? See 42 CFR 412.113(c). (Y/N)
If this hospital qualifies as a CAH or a cost provider, are therapy services
provided by outside supplier? Enter "Y" for yes, or "N" for no,
for the type of therapy as follows:
physical therapy in column 1, occupational therapy in column 2,
speech therapy in column 3 and respiratory therapy in column 4.
106
1
1
X
107
1
1
X
107
2
1
X
108
1
1
X
109
1-4
1
X
1
1
X
X
9
1
1
9.9(2)
X
X
1
9
11
9
1
X
11
11
9
9
1
X
1
X
1
X
Miscellaneous Cost Reporting Information
Is this an all-inclusive provider?
115
1
If yes, enter the method used (A, B, or E only)
115
2
If column 2 is "E", enter in column 3 either "93" percent for short term
hospital or "98" percent for long term care (includes psychiatric,
rehabilitation and long term hospitals
providers) based on the definition in CMS 15-1 §2208.1.
115
3
Are you classified as a referral center? (Y/N)
116
1
Are you legally-required to carry malpractice insurance? (Y/N)
117
1
Is the malpractice a claims-made or occurrence policy?
If the policy is claims made enter 1. If the policy is occurrence, enter 2.
118
1
List malpractice premiums in column 1, paid losses in column 2,
118.01
1-3
and self-insurance in column 3.
Are malpractice premiums and paid losses reported in other than the
Administrative and General cost center? (Y/N) If yes, submit
supporting schedule listing cost centers and amounts.
118.02
1
What is the liability limit for the malpractice insurance policy?
Enter in column 1 the monetary limit per lawsuit.
119
1
Enter in column 2 the monetary limit per policy year.
119
2
NOTE: Questions 119, columns 1 and 2 are eliminated and replaced with questions 118.01 and 118.02.
Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless
ACA Section 3121?(Y/N)
120
1
Is this a rural hospital with <100 beds which qualifies for the Outpatient Hold
Harmless provision in PPACA §3221?. (Y/N)
120
2
Did this facility incur and report costs for implantable devices
charged to patients. Enter "Y" for yes or "N" for no.
121
1
Transplant Center Information
Does this facility operate a transplant center? (Y/N)
If this is a Medicare certified kidney transplant center,
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is a Medicare certified heart transplant center,
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is a Medicare certified liver transplant center,
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is a Medicare certified lung transplant center,
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is a Medicare certified pancreas transplant
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
40-730
125
1
1
X
126
1-2
10
X
127
1-2
10
X
128
1-2
10
X
129
1-2
10
X
130
1-2
10
X
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2 Part I (Continued)
If this is a Medicare certified intestinal transplant
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is a Medicare certified islet transplant
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is a Medicare certified other transplant
enter the certification date (mm/dd/yyyy) and
the termination date if applicable (mm/dd/yyyy).
If this is an organ procurement organization (OPO),
enter the OPO number and
the termination date if applicable (mm/dd/yyyy).
131
1-2
10
X
132
1-2
10
X
133
1-2
10
X
134
134
1
2
6
10
X
X
140
140
141
141
141
142
142
143
143
143
1
2
1
2
3
1
2
1
2
3
1
6
36
36
5
36
9
36
2
10
X
X
X
X
X
X
X
X
X
X
144
1
1
X
145
1
1
X
146
146
147
148
149
1
2
1
1
1
1
10
1
1
1
X
X
X
X
X
If LCC applies, enter "Y" for each component and type of service. Enter
"N" if not exempt. (See 42 CFR 413.13.)
Hospital
Subprovider - IPF
Subprovider - IRF
SNF
HHA
Outpatient Rehab. Providers
155
156
157
159
160
161
1-4
3&4
3&4
3&4
1-4
2-4
1
1
1
1
1
1
X
X
X
X
X
X
Is this facility part of a Multicampus hospital that has one or more
campuses in different CBSAs? Enter "Y" for yes and "N" for no.
If line 165 is yes, enter the name in col. 0.
If line 165 is yes, enter County in column 1.
If line 165 is yes, enter State in col. 2.
If line 165 is yes, enter Zip code in col. 3.
If line 165 is yes, enter CBSA in col. 4.
If line 165 is yes, enter FTE count /campus in col. 5. (see inst.)
165
166
166
166
166
166
166
1
0
1
2
3
4
5
1
36
36
2
10
5
1
X
X
X
X
X
X
9(6).99
167
1
1
X
168
1
11
9
169
1
9
9.9(2)
Are there any related organization or home office costs as defined in
CMS Pub. 15-I, chapter 10?
If yes, enter home office chain number, if applicable.
Name
Contractor's Name
Contractor's Number
Street
P.O. Box
City
State
Zip Code
Are provider based physicians' costs included in Worksheet A?
(Y/N)
If you are claiming cost for renal services on Worksheet A,
are they inpatient services only? (Y/N)
Have you changed your cost allocation methodology from
the previously filed cost report? See CMS Pub. 15-II,
section 3617. (Y/N)
If yes, enter the approval date (mm/dd/yyyy).
Was there a change in the statistical basis? (Y/N)
Was there a change in the order of allocation? (Y/N)
Was the change to the simplified cost finding method? (Y/N)
Is this provider a meaningful user under §1886 (n)? (Y/N).
If this provider is a CAH, line 105 is "Y" and is a meaningful user,
line 167 is "Y" enter the reasonable cost incurred for the purchase
of certified HIT Technology
If this provider is a meaningful user (line 167 is "Y") and is not a
CAH (line 105 is "N"), enter the transition factor. (see instructions)
Rev. 3
40-731
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2, Part II
COMPLETED BY ALL HOSPITALS, PROVIDERS AND OPERATIONS
For all column 1 responses enter in column 1 "Y" for Yes and "N" for No.
For all the dates responses the format will be (mm/dd/yyyy)
Provider Organization and Operation
Has the Provider changed ownership? (Y/N) (see instructions)
If column 1 is yes, enter the date of change in column 2 (mm/dd/yyyy)
Has the provider terminated participation in the Medicare
Program? (Y/N)
If column 1 is yes, enter in column 2 the date of
termination.(mm/dd/yyyy)
If column 1 is yes, enter in column 3 "V" for voluntary
and "I" for involuntary.
Is the provider involved in business transactions, including management
contracts, with individuals or entities (e.g. chain home office, 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? (Y/N) (see instructions)
Financial Data Report
Were the financial statements prepared by a Certified Public
Accountant? (Y/N)
If col. 1 is "Y", enter in col. 2 A, C, or R (see instructions)
Submit complete copies or enter date available (mm/dd/yyyy)
(see instructions)
Are the cost report total expenses and total revenues different
from those on the filed financial statements? (Y/N) (see inst.)
Approved Educational Activities
Are costs claimed for Nursing School? (Y/N)
If column 1 is "Y", is the provider is the legal operator
of the program? (Y/N)
Are costs claimed for Allied Health Programs? (Y/N)
Were nursing school and/or allied health programs
approved and/or renewed during the cost reporting period? (Y/N)
Are costs claimed for Intern-Resident programs claimed on the
current cost report? (Y/N)
Was an Intern-Resident program initiated or renewed in the
the current cost reporting period?(Y/N)
Are GME costs directly assigned to cost centers other than I/R
in an Approved Teaching Program on Worksheet A? (Y/N)
Bad debt
Is the provider seeking reimbursement for bad debts? (Y/N)
If "Y", see instructions.
If line 12 is "Y", did the provider's bad debt collection policy change
during this cost reporting period? (Y/N) If "Y", submit copy.
If line 12 is "Y", are patient deductibles and/or co-payments
waived? (Y/N) If "Y", see instructions.
Bed Compliment
Did total beds available change from the prior cost reporting
period? (Y/N) If "Y", see instructions.
40-732
1
1
1
2
1
10
X
X
2
1
1
X
2
2
10
X
2
3
1
X
3
1
1
X
4
4
1
2
1
1
X
X
4
3
10
X
5
1
1
X
6
1
1
X
6
7
2
1
1
1
X
X
8
1
1
X
9
1
1
X
10
1
1
X
11
1
1
X
12
1
1
X
13
1
1
X
14
1
1
X
15
1
1
X
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
FIELD
SIZE
USAGE
1&3
1
X
2&4
10
X
1&3
1
X
2&4
10
X
1&3
1
X
1&3
1
X
0
36
X
1&3
1
X
1&3
1
X
22
1
1
X
23
1
1
X
24
1
1
X
25
1
1
X
26
1
1
X
27
1
1
X
LINE(S)
WORKSHEET S-2, Part II (Continued)
PS&R Data
Was the cost report prepared using the PS&R only? (Y/N)
16
If line 16, either col. 1 or 3 is "Y" enter the paid through date
for the PS&R in cols. 2 & 4 (mm/dd/yyyy).(see instructions.)
16
Was the cost report prepared using the PS&R for totals and the
provider's record for allocations? (Y/N)
17
If line 17 , either cols. 1 or 3 is "Y" enter the paid through date
in cols. 2 & 4. (see instructions)
17
If line 16 or 17 is "Y", were adjustments made to PS&R data for
additional claims that have been billed but are not
included on the PS&R to file this cost report? (Y/N)
If "Y" (see instructions)
18
If line 16 or 17 is "Y", were adjustments made to PS&R Report data
for other PS&R information?(Y/N) (Y/N) If "Y" (see instructions)
19
If line 16 or 17 is "Y", were adjustments made to PS&R data
for other? Describe
20
If line 16 or 17 is "Y", were adjustments made to PS&R data
for other? (Y/N)
20
Was the cost report prepared only using the provider's records?(Y/N)
If "Y" (see instructions)
21
COLUMN(S)
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY
Capital Related Cost
Have assets been relifed for Medicare purposes? (Y/N)
If "Y", see instructions.
Have changes occurred in the Medicare depreciation expense due
to appraisals made during the cost reporting period? (Y/N)
If "Y", see instructions.
Were new leases and/or amendments to existing leases entered into
during this cost reporting period? (Y/N) If "Y", see instructions
Have there been new capitalized leases entered into during
the cost reporting period? If "Y" see instructions.
Were assets subject to Sec. 2314 of DEFRA acquired during the
cost reporting period? (Y/N) If "Y", see instructions.
Has the provider's capitalization policy changed during the
cost reporting period? (Y/N) If "Y", see instructions.
Rev. 3
40-733
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-2, Part II (Continued)
Interest Expense
Were new loans, mortgage agreements or letters of credit entered
into during the cost reporting period? If "Y", see instructions.
Did the provider have a funded depreciation account and/or bond
funds (Debt Service Reserve Fund) treated as funded depreciation
account? (Y/N) If "Y" see instructions
Has existing debt been replaced prior to its scheduled maturity
with new debt? (Y/N) If "Y" see instructions.
Has debt been recalled before scheduled maturity without issuance
of new debt? Y/N) If "Y" see instructions.
Purchased Services
Have changes or new agreements occurred in patient care services
furnished through contractual arrangements with supplier
of services? (Y/N) If "Y" see instructions.
If line 32 is "Y", then were requirements of Se. 2135.2 applied
pertaining to competitive bidding? (Y/N) If "N" see instructions.
Provider-Based Physicians
Are services furnished at the provider facility under an arrangement
with provider-based physicians? (Y/N) If "Y" see instructions.
If line 34 is "Y", are there new agreements or amended existing
agreements with the provider-based physicians during the cost
reporting period? (Y/N) If "Y" (see instructions)
Home Office Costs
Are Home Office Costs claimed on the cost report? (Y/N)
If line 36 is "Y", has a home office cost statement been prepared
by the home office? (Y/N) If "Y" see instructions.
If line 36 "Y", is the fiscal year end of the home office different
from that of the provider? (Y/N)
If column 1 is yes, enter in column 2 the fiscal year end
of the home office(mm/dd/yyyy)
If line 36 is "Y", does the provider render services to other chain
components? (Y/N) If "Y" see instructions.
If line 36 is "Y", does the provider render services to the home
office? (Y/N) If "Y" see instructions.
Cost Report Preparer Contact Information
Enter the preparer's information:
Enter in column 1, first name
Enter in column 2, last name
Enter in column 3, title
Enter in column 1, employer
Enter in column 1, phone number
Enter in column 2, e-mail address
40-734
28
1
1
X
29
1
1
X
30
1
1
X
31
1
1
X
32
1
1
X
33
1
1
X
34
1
1
X
35
1
1
X
36
1
1
X
37
1
1
X
38
1
1
X
38
2
10
X
39
1
1
X
40
1
1
X
41
41
41
42
43
43
1
2
3
1
1
2
36
36
36
36
36
36
X
X
X
X
X
X
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEETS S-3, PART I
For hospital adults and pediatrics (excluding swing beds, et al), swing bed SNF, swing bed NF, adult and pediatrics in total, each
special care unit, the nursery, in total for the hospital, each subprovider, the hospital-based SNF, and in total for the facility, enter:
Worksheet A Line number
Number of beds
Bed days available
Numbers of hours for CAH patients
Title V inpatient days/visits
Title XVIII inpatient days/visits/trips
Title XIX inpatient days/visits/trips
Total inpatient days/visits
Total Interns & Residents
Employees on Payroll
Nonpaid workers
Title V discharges
Title XVIII discharges
Title XIX discharges
Total discharges
Rev. 3
1, 8-13,
16-26
1, 7-12, 14
16-21, 24, 27
1, 7-12, 14
16-21, 24
1, 7-12, 14
1, 6-20, 22, 25-26
1-5, 7-12, 14-19,
22, 24-26,
29, 33
1-20, 22
24-26, 28, 32
1, 5-22, 24-26
28 & 30-32
14, 16-27
14, 16-27
14, 16-27
1, 14, 16-18
1, 2, 14, 16-18
1, 14, 16-18
1, 14, 16-18 , 21
1
9
9
2
9
9
3
4
5
9
11
9
9
9(8).99
9
6
11
9
7
11
9
8
9
10
11
12
13
14
15
11
11
11
11
11
11
11
11
9
9(8).99
9(8).99
9(8).99
9
9
9
9
40-735
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
FIELD
SIZE
USAGE
1
2
3
5
11
11
11
11
9
9
-9
9(8).99
7
7
7
2
3
5
11
11
11
9
-9
9(8).99
1-23
24
25
25
1
1
0
1
11
11
36
11
-9
-9
X
-9
1
1
2-9, 11-18
2-9, 11-18
1
2
1
2
11
11
11
11
-9
-9
-9
-9
DESCRIPTION
LINE(S)
COLUMN(S)
WORKSHEET S-3, PART II
Worksheet A line reference
Reported salaries
Reclassification of salaries from Wkst. A-6
Paid hours related to salary in column 4
1, 7, 9
1-43
1-43
1-16, 26-43
WORKSHEET S-3, PART III
Total overhead:
Cost
Reclassification
Paid hours
Worksheet S-3, PART IV
Wage Related Costs
Core list
Total
Other than core related cost
Other than core related cost
Worksheet S-3, Part V
Contract Labor Cost
Total facility's contract labor cost
Total facility's benefit cost
Component specific contract labor cost
Component specific benefit cost
40-736
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-4
County
Home health aide hours
Titles as appropriate
Totals
Unduplicated census count
Titles as appropriate
Totals
Number of hours in a normal work week
Other (specify)
Number of full-time equivalent employees:
Staff
Contract staff and consultants
Total
How many CBSAs did you provide services to during
this cost reporting period?
List those CBSA code(s) serviced this period.
PPS Activity Data
Total
0
1
36
X
1
1
1-4
5
11
11
9
9
2
2
3
18
1-4
5
0
0
11
11
6
36
9(8).99
9(8).99
9(3).99
X
3-18
3-18
3-18
1
2
3
6
6
6
9(3).99
9(3).99
9(3).99
19
20
21-38
21-38
1
1
1-4
5
2
5
11
11
9
X
9
9
1
2
3
4
5
6
7
8
9
10
1-6
1-6
1-4
4&6
1-2
1-4
1-2
1-2
1-2
1-2
6
5
5
5
3
3
11
6
6
6
9
9(2).99
9(2).99
9(2).99
9
9
9
9(3).99
9(3).99
9(3).99
11
12
1
1
11
11
9
9
13
14
1
1
11
11
9
9
15
1
11
9
16
1
11
9
17
18
1
1
11
11
9
9
19
1
11
9
20
1
11
9
21
21
1
2
1
1
X
X
WORKSHEET S-5
Renal Dialysis Statistics
Number of patients in program at end of cost reporting period
Number of times per week patient receives dialysis
Average patient dialysis time including setup
CAPD/CCPD exchanges per day
Number of days in year dialysis furnished
Number of stations
Treatment capacity per day per station
Utilization (see instructions)
Average times dialyzers reused
Percentage of patients reusing dialyzers
Transplant Information
Number of patients on transplant list
Number of patients transplanted during fiscal year
EPOETIN (EPO)
Net costs of Epoetin furnished to all maintenance dialysis patients
by the provider
Epoetin amount from Wkst. A for Home Dialysis (see instructions)
Number of EPO units furnished relating to the renal dialysis
department
Number of EPO units furnished relating to the home dialysis
department
ARANESP
Net costs of Epoetin furnished to all maintenance dialysis patients
by the provider
ARANESP amount from Wkst. A for Home Dialysis (see instr.)
Number of ARANESP units furnished relating to the renal dialysis
department
Number of ARANESP units furnished relating to the home dialysis
department
Physician Payment Method (enter "X" if applicable)
MCP
Initial method
Rev. 3
40-737
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-6
Number of hours in a normal week
Other (specify)
Number of full-time equivalent employees on the payroll
Number of full-time equivalent contract personnel
Total
0
18
1-18
1-18
1-18
1
0
1
2
3
6
36
6
6
6
9(3).99
X
9(3).99
9(3).99
9(3).99
1
1
1
X
2
2
1
2
1
10
X
X
3-199
3-199
200
2&3
4
2-4
9
9
9
9
9
9
201
1
5
X
201
2
5
X
202
203
204
205
206
1
1
1
1
1
11
11
11
11
11
9
9
9
9
9
202
203
204
205
206
2
2
2
2
2
6
6
6
6
6
9(3).99
9(3).99
9(3).99
9(3).99
9(3).99
202
203
204
205
206
206
207
3
3
3
3
3
0
1
1
1
1
1
1
36
11
X
X
X
X
X
X
9
WORKSHEET S-7
If this facility contains a hospital-based SNF, are all patients under
managed care or there was no Medicare utilization,
enter "Y" and do not complete the rest of this worksheet.
Does this hospital have an agreement under either of sections 1883 or 1913
of the Act for swing beds?
If yes, enter the agreement date (mm/dd/yyyy).
Prospective Payment for SNF Statistical Data
Days (see instructions)
Total
Total
Enter in column 1 the SNF CBSA code or 5 character code
if Rural based facility, in effect at the beginning of the cost
reporting period.
Enter in column 2, the code in effect on or after October 1,
of the cost reporting period (if applicable).
Enter the amount of the expense for each of the following
categories to total SNF revenue from inpatient care service
Staffing
Recruitment
Retention of employees
Training
Other
Enter the percentage of total expenses for each of the following
categories to total SNF revenue from inpatient care service
Staffing
Recruitment
Retention of employees
Training
Other
Is the increased spending associated with direct patient care
and related spending reflects each of the categories? (Y/N)
Staffing
Recruitment
Retention of employees
Training
Other
Other (Specify)
Enter SNF revenue from inpatient care service
40-738
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-8
RHC/FQHC identification:
Street
City
State
Zip code
County
Designation (for FQHCs only) - "R" for rural or "U" for urban
Source of Federal Funds:
Amount of Federal Funds
Award Date (mm/dd/yyyy)
Other (specify)
Does this facility operate as other than an RHC or FQHC?
Indicate number of other operations.
Type of Operation
Facility hours of operations: from/to*
Have you received an approval for an exception to the
productivity standards?
Is this a consolidated cost report as defined in CMS Pub. 27,
section 508(D)?
Enter the number of providers included in this report.
Provider name
CCN number
Have you provided all or substantially all GME costs?
Enter "Y" for yes and "N" for no.
Number of program visits performed by Intern & Residents.
Total number of visits performed by Intern & Residents.
1
2
2
2
2
3
1
1
2
3
4
1
36
36
2
10
36
1
X
X
X
X
X
X
4-9
4-9
9
10
10
11
11
1
2
0
1
2
0
1-14
11
10
36
1
2
36
4
9
X
X
X
9
X
9
12
1
1
X
13
13
14
14
1
2
1
2
1
2
36
6
X
9
X
X
15
15
15
1
2, 3, 4
5
1
11
11
X
9
9
1
2
3
4
5
1-5
1-5
1-5
1-5
1-5
11
11
11
11
11
9
9
9
9
9
6
7
8
9
1-9
1-5
1&3
1-5
1-5
6
11
11
11
11
11
9
9(8).99
9(8).99
9
9
WORKSHEET S-9
Part I - Enrollment Days
Continuous Home Care
Routine Home Care
Inpatient Respite Care
General Inpatient Care
Total Hospice Days
Part II - Census Data
Number of Patients Receiving Hospice Care
Unduplicated Continuous Medicare Hours
Average Length of Stay (line 5/line 6)
Unduplicated Census Count
Total
Rev. 3
40-739
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET S-10
Uncompensated and indigent care cost computation
Cost to charge ratio
Net revenue from Medicaid
Did you receive DSH or supplemental payments from Medicaid?(Y/N)
If line 3 is "yes", does line 2 include all DSH or supplemental payments
from Medicaid?(Y/N)
If line 4 is "no", then enter DSH or supplemental payments
from Medicaid
Medicaid charges
Net revenue from stand-alone SCHIP
Stand-alone SCHIP charges
Net revenue from state or local indigent care program (see inst.)
Charges for patients covered under state or local indigent
care program (see instructions)
Private grants, donations, or endowment income restricted
to funding charity care (see instructions)
Government grants, appropriations or transfers for support
of hospital operations (see instructions)
Total unreimbursed cost for Medicaid , SCHIP and state and local indigent
care programs (sum of lines 8, 12 and 16)
Total initial obligation of patients approved for
charity care (at full charges) for the entire facility
Initial obligation of patients for charity care (at full charges) for §1886(d)
hospitals or CAHs
Partial payment by patients approved for charity care
Does the amount in line 19 column 2 include charges for
patient days beyond a length of stay limit imposed on
patients covered by Medicaid or other indigent care program?
If line 24 is "yes," charges for patient days beyond an indigent
care program's length of stay limit
Total bad debt expense for the entire hospital complex (see instructions)
Medicare bad debts for the entire hospital complex (see instructions)
40-740
1
2
3
1
1
1
6
11
1
9.9(6)
9
X
4
1
1
X
5
6
9
10
13
14
1
1
1
1
1
1
11
11
11
11
11
11
9
9
9
9
9
9
17
1
11
9
18
1
11
9
19
1
11
-9
20
1&2
11
9
21
22
1&2
1&2
11
11
9
9
24
1
1
X
25
26
27
1
1
1
11
11
11
9
9
9
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
FIELD
SIZE
USAGE
1
1
11
11
-9
9
2
2
11
11
-9
9
7
7
11
11
-9
9
1-499
0
36
X
1-499
1-499
1-499
1-499
1
3
4
5
2
6
11
11
X
9(3).99
9
9
1-499
1-499
1-499
1-499
500
7
8
9
10
4-5, 8-9
6
11
11
2
11
9(3).99
9
9
9
9
For land, land improvements, buildings and fixtures, building
improvements, fixed and movable equipment, and in total:
Parts I Analysis of changes in capital asset balances
Beginning balance
Purchases
Donations
Disposals and retirements
Fully depreciated assets
1-10
1-10
1-10
1-10
1-10
1
2
3
5
7
11
11
11
11
11
9
9
9
9
9
Part II - Reconciliation of capital cost centers from Worksheet A
Summary of capital depreciation, lease, interest, insurance,
taxes, and other capital-related costs
1-2
9-14
11
-9
1-2
1-2
1-3
1&2
4
5, 6 & 7
11
8
11
9
9.9(6)
9
1-2
9-14
11
-9
DESCRIPTION
LINE(S)
COLUMN(S)
WORKSHEET A
Direct salaries by department
4-23, 30-46, 50-60,
62-76, 88-91, 92.01 -101,
105-112, 114-117.
190-194
200
1-23, 30-46, 50-76,
88-91, 93-101,
105-117, 190-194
200
1, 2, 4-23, 30-46, 50-76,
88-91, 93-101,
105-112, 115-117,
190-194
200
Total direct salaries
Other direct costs by department
Total other direct costs
Net expenses for allocation by department
Total expenses for allocation
WORKSHEET A-6
For each expense reclassification:
Explanation
Increases:
Adjustment letter(s)
Worksheet A line number
Reclassification salary amount
Reclassification other amount
Decreases:
Worksheet A line number
Reclassification salary amount
Reclassification other amount
Worksheet A-7 column reference
Total
WORKSHEET A-7
Part III - Reconciliation of capital cost centers
Gross assets and capitalized leases
Ratio
Insurance, taxes, and other capital-related costs
Summary of capital
Depreciation, lease, interest, insurance,
taxes, and other capital-related costs
Rev. 3
40-741
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
FIELD
SIZE
USAGE
0
36
X
1
2
1
11
X
-9
4
6
9(3).99
5
2
9
COLUMN(S)
WORKSHEET A-8
Description of adjustment
Basis (A or B) *
32-49
1-9, 11, 13-22, 25-29,
32 -49
1-50
Amount *
Worksheet A line number +
3-9, 11, 13-22,
29, 32-49
1-22, 26-27, 29,
32-49
Worksheet A-7 column reference
* These include subscripts of lines 1-2 and 26-27 requiring records for columns 1 and 2. These subscripts should occur
based on Worksheet A layout.
+ Do not include preprinted lines, i.e. lines 1-2, 23-28 and 30-32 . Include only subscripts of those lines, if activated by an
entry in either of columns 1 or 2.
WORKSHEET A-8-1
Part A - For costs incurred and adjustments required as a
result of transactions with related organization(s):
Worksheet A line number
Expense item(s)
Amount allowable in reimbursable cost
Amount included in Worksheet A
Net Adjustment
Worksheet A-7, Part II, column reference
(9-14 only)
Total
Part B - For each related organization:
Type of interrelationship (A through G)
If type is G, description of relationship must be
included.
Name of individual or partnership with interest
in provider and related organization
Percent of ownership of provider
Name of related organization
Percent of ownership of related organization
Type of business
40-742
1-4
1-4
1-4
1-4
1-4
1
3
4
5
6
6
36
11
11
11
9(3).99
X
9
9
9
1-4
5
7
4-6
2
11
9
9
6-10
1
1
X
6-10
0
36
X
6-10
6-10
6-10
6-10
6-10
2
3
4
5
6
15
6
15
6
15
X
9(3).99
X
9(3).99
X
Rev. 3
08-11
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET A-8-2
By each cost center or physician:
Worksheet A line number
Physician identifier and aggregate only
Total physicians' remuneration
Physicians' remuneration professional component
Physicians' remuneration provider component
RCE amount
Number of physicians' hours - provider component
Cost of memberships and continuing education
Physician cost of malpractice insurance
In total for the facility (sum of lines 1-200):
Total physicians' remuneration
Physicians' remuneration professional component
Physicians' remuneration provider component
Number of physicians' hours - provider component
Cost of memberships and continuing education
Physician cost of malpractice insurance
Rev. 2
1-199
1-199
1-199
1
2
3
6
36
11
9(3).99
X
9
1-199
4
11
9
1-199
1-199
1-199
1-199
1-199
5
6
7
12
14
11
11
11
11
11
9
9
9
9
9
200
3
11
9
200
4
11
9
200
200
200
200
5
7
12
14
11
11
11
11
9
9
9
9
40-743
4095 (Cont.)
FORM CMS 2552-10
08-11
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET A-8-3
Total number of weeks worked during which outside supplies worked
Number of unduplicated days on which supervisor or therapist
was on provider site (see instructions)
Number of unduplicated days on which therapy assistant was on provider
site but neither supervisor nor therapist was on provider site (see
instructions)
Number of unduplicated offsite visits - supervisors or therapist
Number of unduplicated offsite visits - therapy assistants (include only visits
made by therapy assistant and on which supervisor and/or therapist was not
present during the visit(s)) (see instructions)
Standard travel expense rate
Optional travel expense rate per mile
Total hours worked by discipline
AHSEA by discipline
Number of travel hours by discipline
Number of miles driven by discipline
Travel allowance and expense - include only one
Travel allowance and expense - include only one
Overtime hours worked during period by discipline (see instructions)
Allocation of provider's standard work year for one full-time employee
times the percentages on line 50 (see instructions)
Equipment cost (see instructions)
Supplies (see instructions)
Total cost of outside supplier services (from your records)
Excess over limitation (line 64 minus line 63; if negative, enter zero)
40-744
1
1
11
9
3
1
11
9
4
5
1
1
11
11
9
9
6
7
8
9
10
12
13
33, 34, 35
44, 45, 46
47
1
1
1
1-5
1-5
1-3
1-3
1
1
1-4
11
5
3
11
5
11
11
11
11
11
9
99.99
.99
9(8).99
99.99
9
9
9
9
9(8).99
51
61
62
64
65
5
1
1
1
1
7
11
11
11
11
9(4).99
9
9
9
9
Rev. 2
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEETS B-1; B, PARTS I-II; H-5, PART I; J-1, PART II; and L-1, PART I HEADINGS*
Column heading (cost center name)
Statistical basis
1-2*
4, 5*
1-4, 5-23
1-4, 5-23
10
10
X
X
202
25
11
-9
30-46, 50-60, 62-76
88-91, 92.01 -101, 105-117
190-194 & 201
202
26
26
11
11
-9
9
WORKSHEET B, PART I
Total adjustments after cost finding
Costs after cost finding and post stepdown
adjustments by department
Total costs after cost finding and post stepdown adjustments
*
Refer to Table 1 for specifications and Table 2 for the worksheet identifier for column headings. There may be up to five
type 2 records (3 for cost center name and 2 for the statistical basis) for each column. However, for any column which has
less than five type 2 record entries, blank records or the word "blank" is not required to maximize each column record count.
WORKSHEET B, PART II
Directly assigned capital related costs by department
Total directly assigned capital related costs
Total adjustments after cost finding
Total capital related costs after cost finding
by department
Total capital related costs after cost finding in total
4-23, 30-46, 50-60
62-76, 88-91, 92.01 -101
105-117, 190-194
202
202
0
0
25
11
11
11
9
9
-9
30-46, 50-60, 62-76
88-91, 93-101
105-117, 190-194
202
26
26
11
11
-9
9
1
X
11
9
11
11
-9
9
WORKSHEET B-1
For each cost allocation using accumulated costs as the
statistic, include a record containing an X.
All cost allocation statistics
Reconciliation
Cost to be allocated
0
5-23
1-23, 30-46
50-60, 62-76,
88-91, 92.01 -101,105-117
190-194
1-23*
4-23, 30-46
50-76, 88-91,
93-101, 105-117
190-194
5A-23A
202
1-23+
*
In each column using accumulated costs as the statistical basis for allocating costs, identify each cost center which is
to receive no allocation with a negative 1 (-1) placed in the accumulated cost column. Providers may elect to indicate
total accumulated cost as a negative amount in the reconciliation column. However, there should never be entries in
both the reconciliation column and accumulated column simultaneously on the same line. For those cost centers which
are to receive partial allocation of costs, provide only the cost to be excluded from the statistic as a negative amount on
the appropriate line in the reconciliation column.
If line 5 is fragmented, line 5 must be deleted and subscripts of line 5 must be used.
+
Include any column which uses accumulated cost as it basis for allocation.
Rev. 3
40-745
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET B-2
For post stepdown adjustment:
Adjustment for EPO costs in Renal Dialysis
Worksheets B, Part indicator
Worksheet A line number
Amount of adjustment
1
1
1
1
1
2
3
4
36
1
6
11
X
9
9(3).99
-9
Adjustment for EPO costs for in Home Program
Worksheets B, Part indicator
Worksheet A line number
Amount of adjustment
2
2
2
2
1
2
3
4
36
1
6
11
X
9
9(3).99
-9
Adjustment for ARANESP costs in Renal Dialysis
Worksheets B, Part indicator
Worksheet A line number
Amount of adjustment
3
3
3
3
1
2
3
4
36
1
6
11
X
9
9(3).99
-9
Adjustment for ARANESP costs for in Home Program
Worksheets B, Part indicator
Worksheet A line number
Amount of adjustment
4
4
4
4
1
2
3
4
36
1
6
11
X
9
9(3).99
-9
Explanation
Worksheets B and L-1, Part numbers (1=B, Part I; 2=B,
Part II; and 3=L-1)
Worksheet A line number
Amount of adjustment
5-59
1
36
X
5-59
5-59
5-59
2
3
4
1
6
11
9
9(3).99
-9
1
1
6
6-7
6-7
11
11
11
11
11
9
9
9
9
9
4-5
11
-9
NOTE: On Worksheet B-2, if there are more than 59 lines needed, use multiple worksheets. (Refer to the
footnote to this worksheet in Table 2.)
WORKSHEET C, PART I
Observation bed cost (see instructions)
Total cost (line 200 minus line 201)
Total charges by department (inpatient)
Total charges by department (inpatient/outpatient)
Total charges (inpatient/outpatient)
92
202
30-46
50-101, 105-117
200
WORKSHEET C, PART II
Total capital and outpatient reductions
40-746
202
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
FIELD
SIZE
USAGE
1
1
2
2
3
3
9
11
11
11
11
11
11
11
-9
-9
-9
-9
-9
-9
-9
1
11
-9
2
11
-9
3
11
-9
4
1-4, 11&13
11
11
-9
-9
2
3
4
6
2-4 & 7
3-4 & 7
5-7
11
11
11
11
11
11
11
9
9
9
9
9
-9
9
COLUMN(S)
WORKSHEET D, PART III
Apportionment of inpatient routine service other pass
through costs
Where post stepdown adjustments affecting either nonphysician
anesthetists or direct medical education costs are made,
furnish only the net change for each cost center.
Nursing Services
Nursing Services change in total
Allied Health (Paramedical) Cost
Allied Health (Paramedical) change in total
Other Medical Educational Costs
Other Medical Educational change in total
Total inpatient program pass through cost
30-35, 40-45
200
30-35, 40-45
200
30-35, 40-45
200
200
WORKSHEET D, PART IV
Apportionment of inpatient ancillary service other pass through costs
Where post stepdown adjustments affecting either nonphysician
anesthetists or direct medical education costs are made,
furnish only the net change for each cost center.
Nonphysician anesthetist change by department
Nursing Services
Allied Health (Paramedical) Cost
Other Medical Education Cost
Total program pass through costs and charges
50-60 62-76, 88-93
94-98
50-60 62-76, 88-93
94-98
50-60 62-76, 88-93
94-98
50-60 62-76, 88-93
94-98
200
WORKSHEET D, PART V
Apportionment of medical and other health services costs
PPS Reimbursed Services (see instructions)
Cost reimbursed services subject to ded. and coins.(see inst.)
Cost reimbursed services not subject to ded. and coins.(see inst.)
Ambulance
Subtotal program charges
CRNA charges
Net program costs
50-98
50-98
50-98
95
200
201
202
NOTE: If Worksheet A, line 18 is subscripted and the provider qualifies for the exception as described in CMS Pub. 15-II, section 4010
for nonphysician anesthetist services, include the combined charges of those lines on Worksheet D, Part V, line 202, column 2.
Rev. 3
40-747
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET D-1
Part I - All Provider Components
Inpatient days (including private room days and swing-bed
days, excluding newborn)
Inpatient days (including private room days, excluding swing-bed
and newborn days)
Total private room days
Total semi-private room days
Swing-bed SNF type inpatient days through 12/31 *
Swing-bed SNF type inpatient days after 12/31 *
Swing-bed NF type inpatient days through 12/31 *
Swing-bed NF type inpatient days after 12/31 *
Inpatient days including private room days applicable to the
program (excluding swing-bed and newborn days)
Swing-bed SNF days through 12/31 (title XVIII) *
Swing-bed SNF days after 12/31 (title XVIII) *
Swing-bed NF days through 12/31 (titles V and XIX) *
Swing-bed NF days after 12/31 (titles V and XIX) *
Medically necessary private room program days
Medicare
Swing-bed
rates for:SNF services through 12/31
Swing-bed SNF services after 12/31
Non-Medicare
Swing-bed
ratesNF
for:
services through 12/31
Swing-bed NF services after 12/31
General inpatient routine service charges
Private room charges
Semi-private room charges
* Hospital or subprovider only
Part II - Hospital and Subproviders Only
Program overflow days by each special care unit for hospital and
subproviders only (This data is added to program routine days
from Worksheet S-3, Part I, line 1, columns 5-7, as
appropriate.) See CMS Pub. 15-II, section 4022
Total program inpatient costs
TEFRA target amount per discharge
Bonus payment (see instructions)
Lesser of lines 53/54 or 55 of 1996 cost report ending
period updated and compounded by the market basket.
Lesser of lines 53/54 or 55 of prior year cost report
updated by the market basket (see instructions)
If line 53/54 is less than the lower of lines 55, 58.01,
or 58.02 (see instructions).
Relief Payment (see instructions)
40-748
1
1
11
9
2
3
4
5
6
7
8
1
1
1
1
1
1
1
11
11
11
11
11
11
11
9
9
9
9
9
9
9
9
10
11
12
13
14
1
1
1
1
1
1
11
11
11
11
11
11
9
9
9
9
9
9
17
18
1
1
6
6
9(3).99
9(3).99
19
20
28
29
30
1
1
1
1
1
6
6
11
11
11
9(3).99
9(3).99
9
9
9
43-47
49
55
58
4
1
1
1
11
11
9
11
9
9
9(6).99
9
59
1
11
9(8).99
60
1
11
9(8).99
61
62
1
1
11
11
9
9
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET D-1 (Continued)
Part III - Skilled Nursing Facility, Nursing Facility and ICF/MR only
Aggregate charges to beneficiaries for excess costs
Inpatient routine service cost per diem limitation
Utilization review - physicians' compensation
Total program inpatient operating costs
79
81
85
86
1
1
1
1
11
6
11
11
9
9(3).99
9
9
87
89
1
1
11
11
9
9
Part IV - Computation of Observation Bed Cost Hospital only
Total observation bed days (see instructions)
Observation bed cost (title XVIII only)
Rev. 3
40-749
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET D-2
Part I:
Percent of assigned time of interns and residents
(not in approved programs)
Title XVIII, Part B inpatient days (Part A adjustment only) (1)
Title XVIII, Part A only charges (see note below)
Subtotal (sum of lines 2 through 8)
Subtotal (sum of lines 21 through 26)
Part II:
Title XVIII, Part B inpatient days
2-8, 10-19,
21-26
2-7, 10-13
21-26
9
27
1
6
6
8-10
8-10
6
11
11
11
11
9(3).99
-9
-9
-9
-9
29-30
32-36, 38-41
6
11
9
(1) Display only the Part A coverage days adjustment, negative amount, in the ECR record(s). See section 4026.1
for proper submission of reconciliation of these days.
Note: For Part A only charges, the amount reported is only the title XVIII Part B ancillary charges. This will be used to
reduce ancillary charges from Worksheet D-3, column 2 and Worksheet D, Part III, sum of columns 1-4 in order
to properly calculate the Part B ancillary charges.
WORKSHEET D-3
For each component under titles V, XVIII, and XIX, except
for SNFs under title XVIII:
Inpatient Part A ancillary charges by department
Total program charges (sum of lines 50-94 and 90-98)
Total program costs (sum of lines 50-76 and 90-98)
30-43, 50-76, 88-94,
96-98
200
200
2
2
3
11
11
11
9
9
9
1-6
1-6
8-40
1
3
2
11
11
11
9
9
9
49-54
3
11
9
57 & 58
3
11
9
59
62
63
66
68
69
3
2
2
1&3
1
1-4
11
11
11
11
11
11
9
9
9
9
9
-9
WORKSHEET D-4
Part I:
Inpatient routine service charges for organ acquisition
Medicare organ acquisition days
Part A inpatient ancillary organ acquisition charges
Part II:
Organ charges
Part III:
Provider charges for interns and residents services only where
the provider charges separately
Total charges applicable to costs in column 1 only where the
provider has a schedule of charges for the various
direct organ acquisition costs
Total usable organs
Medicare usable organs
Revenue for organs sold
Organ acquisition charges billed to Medicare under Part B
Net organ acquisition cost and charges
40-750
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET D-4 (Continued)
Part IV:
Statistics for living related kidney acquisitions, partial liver
& partial lung;
Organs excised at provider
Organs purchased from other transplant hospitals
Organs purchased from non-transplant hospitals
Organs purchased from OPOs
Organs transplanted
Organs sold to other hospitals
Organs sold to OPOs
Organs sold to transplant hospitals
Organs sold to military or VA hospitals
Organs sold outside the U.S.
Organs sent outside the U.S. (no revenue)
Organs used for research
Unusable or discarded organs
Statistics for cadaveric heart, liver, lung, kidney, pancreas or
intestine acquisition;
Organs excised at provider
Organs purchased from other transplant hospitals
Organs purchased from non-transplant hospitals
Organs purchased from OPOs
Organs transplanted
Organs sold to other hospitals
Organs sold to OPOs
Organs sold to transplant hospitals
Organs sold to military or VA hospitals
Organs sold outside the U.S.
Organs sent outside the U.S. (no revenue)
Organs used for research
Unusable or discarded organs
Revenue for hearts, livers, lungs, pancreas, intestine and kidneys
transplanted into non-Medicare patients;
Organs transplanted
Organs sold to other hospitals
Organs sold to OPOs
Organs sold to transplant hospitals
Organs sold to military or VA hospitals
Organs sold outside the U.S.
70
71
72
73
75
76
77
78
79
80
81
82
83
1
1
1
1
1
1
1
1
1
1
1
1
1
11
11
11
11
11
11
11
11
11
11
11
11
11
9
9
9
9
9
9
9
9
9
9
9
9
9
70
71
72
73
75
76
77
78
79
80
81
82
83
2
2
2
2
2
2
2
2
2
2
2
2
2
11
11
11
11
11
11
11
11
11
11
11
11
11
9
9
9
9
9
9
9
9
9
9
9
9
9
75
76
77
78
79
80
3
3
3
3
3
3
11
11
11
11
11
11
9
9
9
9
9
9
1-11
1-11
1-11
1-11
1-11
1-11
3
4
5
6
11
13
11
11
11
11
11
11
9
9
9
9
9
9
WORKSHEET D-5
Part I:
Physicians' remuneration - in total
Physicians' remuneration - professional component
RCE amount
Number of physicians' hours - professional component
Cost of memberships and continuing education
Cost of physician malpractice insurance
Rev. 3
40-751
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET D-5 (Continued)
Part II: - For the hospital and each subprovider:
Total inpatient days and outpatient visit days
Patient days (The same days and visit days are used for
both the hospital staff and medical staff costs.)
Title V inpatient days
Title V outpatient visit days
Title XVIII inpatient days (Part A)
Title XVIII outpatient visit days (Part B)
Title XIX inpatient days
Title XIX outpatient visit days
Total kidney acquisition days and outpatient visit days
Total liver acquisition days and outpatient visit days
Total heart acquisition days and outpatient visit days
Total lung acquisition days and outpatient visit days
Total pancreas acquisition days and outpatient visit days
Total intestinal acquisition days and outpatient visit days
Total islet acquisition days and outpatient visit days
Other Organ Acquisition
Other Organ Acquisition
2
1
11
9
4
5
6
7
8
9
10
11
12
13
14
15
16
17
17
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
11
11
11
11
11
11
11
11
11
11
11
11
11
36
11
9
9
9
9
9
9
9
9
9
9
9
9
9
X
9
1
2
2.01
3
4
1 & 1.01
1 & 1.01
1
1 & 1.01
1
11
11
11
11
9
9
9
9
9
9(6).99
5
6
1
1
9
9
9(6).99
9(6).99
7
1
9
9(6).99
7.01
1
9
9(6).99
8
1
9
-9(6).99
8.01
1
9
-9(6).99
8.02
10
11
12
13
1
1
1
1
1
9
9
9
9
4
-9(6).99
9(6).99
9(6).99
9(6).99
9.99
14
15
16
17
18
19
20
22
1
1
1
1
1
1
1
1 & 1.01
9
9
4
4
4
8
8
11
9(6).99
9(6).99
9.99
9.99
9.99
9.9(6)
9.9(6)
9
23
1
11
9(6).99
WORKSHEET E, PART A
For the hospital and subprovider(s)
DRG amounts - other than outlier payments
Outlier payments for discharges
Outlier reconciliation amount
Managed Care Simulated Payments
Bed days available divided by number of days in cost reporting period
Indirect Medical Education Adjustment
FTE count for allopathic and osteopathic before December 31, 1996
FTE count for allopathic and osteopathic add-on to cap for new programs
MMA §422 reduction amount to the IME cap as specified
under 42 CFR §412.105(f)(1)(iv)(B)(1)
ACA §5503 reduction amount to the IME cap as specified
under 42 CFR §412.105(f)(1)(iv)(B)(2)
Adjustment to FTE count for allopathic and osteopathic program
for affiliated programs (see instructions)
The amount of increase if the hospital was awarded FTE cap slots
under §5503 of the ACA. (see instructions)
The amount of increase if the hospital was awarded FTE cap slots
under §5503 of ACA (see instructions)
FTE count for allopathic and osteopathic in the current year
FTE count for residents in dental and podiatric programs.
Current year allowable FTE (see instructions)
Total allowable FTE for the prior year
Total allowable count for the penultimate year if that year ended
on or after 9/30/1997, otherwise enter zero
Sum of lines 12 through 14 divided by 3.
Adjustment for residents in initial years of the program
Adjustment for residents displaced by program or hospital closure
Adjusted rolling average FTE count
Current year resident to bed ratio (see instructions)
Prior year resident to bed ratio
IME Discharges occurring prior to 10/1 (see instructions)
Number of additional allopathic and osteopathic IME FTE
resident cap slots
40-752
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E, PART A (Continued)
Indirect medical education adjustment
IME payments adjustment. (see instructions)
IME Adjustment (see instructions)
Total IME payment (sum of lines 22 and 28)
Disproportionate share adjustment
SSI recipient patient days to Medicare Part A patient days
Percentage of Medicaid patient days to total days
Enter the sum of lines 30 and 31
Allowable disproportionate share percentage (see instructions)
Disproportionate share adjustment amount
Additional payment for high percentage of ESRD beneficiary discharges
Total Medicare discharges excluding discharges for DRGs 302,
316, 317, MS-DRG 683 and 684
Total ESRD Medicare discharges excluding DRGs 302, 316, and 317
ESRD Medicare discharges to total Medicare discharges
Total Medicare ESRD inpatient days excluding DRGs 302, 316,
and 317
Average weekly cost for dialysis treatments (see instructions)
Hospital specific payments (to be completed by SCH and MDH, small
rural hospitals only)
Nursing and Allied Health Managed Care
Special Add-on payment for new technologies
Net organ acquisition cost
Cost of teaching physicians
Routine service other pass through costs
Ancillary service other pass through costs
Primary payer payments (see instructions)
Deductibles billed to program beneficiaries
Coinsurance billed to program beneficiaries
Allowable bad debts (see instructions)
Adjusted reimbursable bad debts adjustment (see instructions)
Allowable bad debts for dual eligible
beneficiaries (see instructions)
Credits received from manufacturers for replaced devices applicable to
MS-DRG (see instructions)
Outlier payments reconciliation
Other adjustments (see instructions) (specify)
Other adjustments (see instructions) (specify)
Recovery of Accelerated depreciation
Low volume payment adjustment for Federal Fiscal year 2011
Low volume payment adjustment for Federal Fiscal year 2011
Protested amounts
To be completed by contractor
Operating outlier amount
Capital outlier amount
Operating outlier reconciliation amount
Capital outlier reconciliation amount
The rate used to calculate the Time Value of Money
Operating Time Value of Money
Capital Time Value of Money
27
28
29
1
1 & 1.01
1 & 1.01
11
11
11
9
9
9
30
31
32
33
34
1
1
1
1 & 1.01
1 & 1.01
11
9
9
9
11
9.9(4)
9.9(4)
9.9(4)
9.9(4)
9
40
41
42
1
1 & 1.01
1
11
11
9
9
9
9(6).99
43
45
1
1 & 1.01
11
9
9
9(6).99
48
53
54
55
56
57
58
60
62
63
64
65
1 & 1.01
1
1
1
1
1
1
1
1
1
1
1
11
11
11
11
11
11
11
11
11
11
11
11
9
9
9
9
9
9
9
9
9
9
-9
9
66
1
11
9
68
69
70
70
70.95
70.96
70.97
75
1
1
0
1
1
1
1
1
11
11
36
11
11
11
11
11
9
9
X
-9
-9
-9
-9
-9
90
91
92
93
94
95
96
1
1
1
1
1
1
1
11
11
11
11
11
11
11
-9
-9
-9
-9
9(8).9(2)
-9
-9
Column 1 can be subscripted for the following items: Transitional Corridor, Geographic Reclassification and SCH/MDH
elections. See CMS Pub. 15-2, chapter 40, section 4030 for the applicable lines.
Rev. 3
40-753
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E, PART B
For the hospital, each subprovider, and SNF (title XVIII only)
PPS payments
Outlier payment
Hospital specific payment to cost ratio
Transitional corridor payment (see instructions)
Ancillary service charges for physicians' professional
services (see note below)
Aggregate amount collected from beneficiaries
Amounts collectible
Interns and residents service charges
Teaching physicians charges
Deductibles and coinsurance (for nominal charge providers,
report deductibles only)
Coinsurance related to amount on line 25
Primary payer payments
Allowable Bad Debt (see instructions)
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
MSP-LCC reconciliation amount from PS&R
Other adjustments (see instructions) (specify)
Other adjustments (see instructions) (specify)
Recovery of Accelerated depreciation
Protested amounts
To be completed by contractor
Original outlier amount (see instructions)
Outlier reconciliation amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
Total (sum of lines 91 and 93)
3
4
5
8
1 & 1.01
1 & 1.01
1 & 1.01
1 & 1.01
11
11
5
11
9
9
9.9(3)
9
12
15
16
22
23
1
1
1
1
1
11
11
11
11
11
-9
9
9
9
9
25
26
31
34
1
1
1
1
11
11
11
11
9
9
9
-9
36
38
39
39
39.99
44
1
1
0
1
1
1
11
11
36
11
11
11
9
9
X
-9
-9
-9
90
91
92
93
94
1
1
1
1
1
11
11
-9
-9
9(8).9(2)
-9
-9
11
11
11
For ancillary service charges, the amount reported is the sum of (1) the program ancillary service charges attributable to
physicians' professional services included in total charges on Worksheet C, Part I, (2) program charges applicable to
excess cost of luxury items, and (3) your charges to beneficiaries for excess costs. This sum is used to reduce ancillary
service charges from Worksheet D-3 or Worksheet D, Part V in order to properly calculate the lower of cost or charges on
Worksheet E, Parts B, and Worksheet E-3, Parts V and VI.
Column 1 can be subscripted for the following items: Transitional Corridor, Geographic Reclassification and SCH/MDH
elections. See CMS Pub. 15-2, chapter 40, section 4030 for the applicable lines.
40-754
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E-1, Part I
For the hospital, each subprovider, SNF, and swing-bed SNF title XVIII only:
Total interim payments paid to provider
Interim payments payable
Date of each retroactive lump sum adjustment (mm/dd/yyyy)
Amount of each retroactive lump sum adjustment:
Program to provider
Provider to program
Enter the date of the tentative payment
From Program to Provider
Enter the amount of the tentative payment
From Program to Provider
Enter the date of the tentative payment
From Provider to Program
Enter the amount of the tentative payment
From Provider to Program
Enter name of the Contractor
Enter Contractor's number
Enter the date of Notice of Program
Reimbursement
1
2
3.01-3.98
2&4
2&4
1&3
11
11
10
9
9
X
3.01-3.49
3.50-3.98
2&4
2&4
11
11
9
9
5.01-5.03
1&3
10
X
5.01-5.03
2&4
11
-9
5.50-5.52
1&3
10
X
5.50-5.52
8
8
2&4
0
1
11
36
5
-9
X
X
8
2
10
X
1
2
3
4
5
6
1
1
1
1
1
1
11
11
11
11
11
11
9
9
9
9
9
9
7
8
30
31
32
1
1
1
1
1
11
11
11
11
11
9
-9
9
-9
9
1
5
1&2
2
11
11
9
9
7
1
11
9
9
1&2
11
9
11
1&2
11
9
13
16
16
1&2
0
1&2
11
36
11
9
X
-9
WORKSHEET E-1, Part II
Total hospital discharges as defined in AARA §4102 from
Worksheet S-3, Part I column 15, line 14
Medicare days from Wkst S-3, Part I, col.6 sum of lines 1, 8-12
Medicare HMO days from Wkst S-3, Part I, col. 6 of line 2
Total inpatient bed days from S-3, Part I col. 8 sum of lines 1, 8-12
Total hospital charges from Wkst C, Part I, col. 8 line 200
Total hospital charity care charges from Wkst S-10, col. 3 line 20
CAH only - The reasonable cost incurred for the purchase of
certified HIT technology Worksheet S-2, Part I line 168
Calculation of the HIT incentive payment (see instructions)
Interim payments
Initial/interim HIT payment adjustment (see instructions)
Balance due provider (line 8 minus line 30 and line 31)
WORKSHEET E-2
Inpatient routine services - swing bed-SNF
Title XVIII, Part B swing-bed days
Utilization review - physician compensation for SNF optional
method only
Amounts paid/payable under workmen's compensation or
other primary payers
Deductibles, excluding any billed for the professional
component of provider based physicians services
Coinsurance, excluding any billed for the professional
component of provider based physicians services
Other adjustments (see instruction) (specify)
Other adjustments (see instruction) (specify)
Rev. 3
40-755
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E-2 (Continued)
Reimbursable bad debts
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
Interim payments (titles V and XIX only)
Protested amounts
17
1&2
11
-9
18
20
23
1&2
1&2
1&2
11
11
11
9
9
-9
1
5
7
9
11
1
1
1
1
1
11
11
11
11
11
9
9
9
9
-9
13
16
16
17
17
17.99
19
22
1
0
1
0
1
1
1
1
11
36
11
36
11
11
11
11
9
X
9
X
9
-9
-9
-9
1
2
3
1
1
1
11
11
11
9
9
9
4
1
11
9(3).99
4.01-4.20
5
1
1
9
11
-9(6).99
9(3).99
6
1
11
9(3).99
7
1
11
9(3).99
8
13
17
19
21
23
1
1
1
1
1
1
11
11
11
11
11
11
9(3).99
9
9
9
9
-9
25
29
30
30
30.99
32
35
1
1
0
1
1
1
1
11
11
36
11
11
11
11
9
9
X
9
-9
-9
-9
50
51
52
53
1
1
1
1
11
11
11
11
-9
-9
-9
-9
WORKSHEET E-3, PART I
Inpatient hospital services
Primary payer payments
Deductibles - Part A
Coinsurance (see instructions)
Allowable bad debts (see instructions)
Allowable bad debts for dual eligible
beneficiaries (see instructions)
Other pass through cost (see instructions) (specify)
Other pass through cost (see instructions) (specify)
Other adjustment (see instructions) (specify)
Other adjustment (see instructions) (specify)
Recovery of Accelerated Depreciation
Interim payments
Protested amounts
WORKSHEET E-3, PART II
Net Federal IPF PPS Payments (excluding outlier, ECT, stop-loss,
and medical education payments)
Net IPF PPS Outlier Payments
Net IPF PPS ECT Payments
Unweighted intern and resident FTE count for latest cost report filed
on or before November 15, 2004
The amount of temporary increase if the IPF was awarded FTE cap slots
under §412.424(d)(1)(iii)(F)(1). (see instructions)
New Teaching program adjustment (see instructions)
Current year's unweighed FTE count of I&R other than FTE's in
the first 3 years of a "new teaching program".
Current year's unweighed I&R FTE count for residents within the
first 3 years of a "new teaching program".
Intern and resident count for IPF PPS medical education
adjustment (see instructions)
Nursing and Allied Health Managed Care payments
Primary payer payments
Deductibles - Part A
Coinsurance (see instructions)
Allowable bad debts (see instructions)
Allowable bad debts for dual eligible
beneficiaries (see instructions)
Outlier payments reconciliation
Other adjustment (see instructions) (specify)
Other adjustment (see instructions) (specify)
Recovery of Accelerated Depreciation
Interim payments
Protest amounts
To be completed by contractor
Original outlier amount from Worksheet E-3, Part II line 2
Outlier reconciliation amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
40-756
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E-3, PART III
Net Federal PPS Payment
Medicare SSI ratio (IRF PPS only)(see instructions)
IRF LIP Payments
IRF Outlier Payments
Unweighted intern and resident FTE count in the most recent cost
reporting period ending on or prior to November 15, 2004 (see inst.)
The amount of temporary increase if the IPF was awarded FTE cap slots
under §412.424(d)(1)(iii)(F)(1). (see instructions)
New Teaching program adjustment (see instructions)
Current year's unweighed FTE count of I&R other than FTE's in
the first 3 years of a "new teaching program".
Current year's unweighed I&R FTE count for residents within the
first 3 years of a "new teaching program".
Intern and resident count for IRF PPS medical education
adjustment (see instructions)
Medical Education Adjustment.
Nursing and Allied Health Managed Care payments
Primary payer payments
Deductibles
Coinsurance excluding any billed for professional
professional component of provider based physicians services
Allowable bad debts (see instructions)
Allowable bad debts for dual eligible
beneficiaries (see instructions)
Outlier payments reconciliation
Other adjustments (see instructions) (specify)
Other adjustments (see instructions) (specify)
Recovery of Accelerated Depreciation
Interim payments
Protested amounts
To be completed by contractor
Original outlier amount from Worksheet E-3, Part III line 4
Outlier reconciliation amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
Rev. 3
1
2
3
4
1
1
4
1
11
7
11
11
9
9.9(4)
9
9
5
1
11
9(3).99
5.01-5.20
6
1
1
9
11
-9(6).99
9(3).99
7
1
11
9(3).99
8
1
11
9(3).99
9
12
14
18
20
1
1
1
1
1
11
11
11
11
11
9(3).99
9
9
9
9
22
24
1
1
11
11
9
-9
26
30
31
31
31.99
33
36
1
1
0
1
1
1
1
11
11
36
11
11
11
11
9
9
X
9
-9
-9
-9
50
51
52
53
1
1
1
1
11
11
11
11
-9
-9
-9
-9
40-757
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E-3, PART IV
Net Federal PPS Payment
Outlier Payments
Nursing and Allied Health Managed Care payments
Organ acquisition (certified transplant centers only)
Teaching physicians
Primary payer payments
Deductibles
Coinsurance excluding any billed for professional component
of provider based physicians services
Allowable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries
Outlier payments reconciliation
Other adjustment (specify)
Other adjustment
Recovery of Accelerated Depreciation
Interim payments
Protested amounts
1
2
4
5
6
8
10
1
1
1
1
1
1
1
11
11
11
11
11
11
11
9
9
9
9
9
9
9
12
14
16
20
21
21
21.99
23
26
1
1
1
1
0
1
1
1
1
11
11
11
11
36
11
11
11
11
9
-9
9
9
X
-9
-9
9
-9
To be completed by contractor
Original outlier amount from Worksheet E-3, Part IV line 2
Outlier reconciliation amount (see instructions)
The rate used to calculate the Time Value of Money
Time Value of Money (see instructions)
50
51
52
53
1
1
1
1
11
11
11
11
-9
-9
-9
-9
1
2
3
5
1
1
1
1
11
11
11
11
9
9
9
9
20
1
11
9
23
25
1
1
11
11
9
-9
27
29
29
29.99
34
1
0
1
1
1
11
36
11
11
11
9
X
9
-9
-9
WORKSHEET E-3, PART V
Inpatient services
Nursing and Allied Health Managed Care payments
Organ acquisition (certified transplant centers only)
Primary payer payments
Deductibles, excluding any billed for the professional
component of PBP services
Coinsurance excluding any billed for professional
component of provider based physicians services
Allowable bad debts (see instructions)
Allowable bad debts for dual eligible
beneficiaries (see instructions)
Other adjustments (see instructions) (specify)
Other adjustments (see instructions) (specify)
Recovery of Accelerated Depreciation
Protest amounts
40-758
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E-3, PART VI
Resource Utilization Group Payment (RUGS)
Routine service other pass through costs
Ancillary service other pass through costs
Medical and other services
Deductibles (exclude professional component)
Coinsurance excluding any billed for professional component
of provider based physicians services
Allowable bad debts
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
Utilization review
Inpatient primary payments
Other adjustment (specify)
Other adjustment
Recovery of Accelerated Depreciation
Interim payments
Protested amounts
1
2
3
5
6
1
1
1
1
1
11
11
11
11
11
9
9
-9
-9
9
7
8
1
1
11
11
9
-9
9
11
13
14
14
14.99
16
19
1
1
1
0
1
1
1
1
11
11
11
36
11
11
11
11
-9
9
-9
X
-9
-9
9
-9
1
2
3
5
6
8
1
2
1
1
2
1
11
11
11
11
11
11
9
9
9
9
9
9
9
13
14
19
20
22
23
28
32
1&2
1&2
1&2
1&2
1&2
1&2
1&2
1&2
1&2
11
11
11
11
11
11
11
11
11
-9
9
9
9
9
9
9
9
9
33
34
35
37
37
41
43
1&2
1&2
1
0
1&2
1&2
1&2
11
11
11
36
11
11
11
9
-9
9
X
-9
9
-9
WORKSHEET E-3, PART VII
Inpatient hospital/SNF/NF services
Medical and other services
Organ acquisition (certified transplant centers only)
Inpatient primary payer payments
Outpatient primary payer payments
Routine service charges
Ancillary service charges for physicians' professional
services (see note to Worksheet E, Part B)
Aggregate amount collected
Amount collectible
Interns and residents service charges
Teaching physicians
Other than outlier payments
Outlier payments
Customary charges (title XIX PPS covered services only)
Deductibles (exclude professional component)
Coinsurance excluding any billed for professional component
of provider based physicians services
Allowable bad debts (see instructions)
Utilization review
Other adjustment (specify)
Other adjustment
Interim payments
Protested amounts
Rev. 3
40-759
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET E-4
COMPUTATION OF TOTAL DIRECT GME AMOUNT
Unweighted resident FTE count for allopathic and osteopathic
programs for periods ending on or before December 31, 1996
Unweighted FTE resident cap add-on for new programs
per 42 CFR 413.79(e)(1) (see instructions)
Amount of Reduction to Direct GME Cap Under Section
422 of MMA
Direct GME cap reduction amount Under ACA §5503 in accordance
with CFR §413.79(m). (see instructions for cost reporting
periods straddling 7/1/2011)
Adjustment (plus or minus) to the FTE cap for allopathic and
osteopathic programs due to a Medicare GME
affiliation agreement (42 CFR §413.75(b) and § 413.79 (f))
ACA §5503 increase to Direct GME FTE Cap (see instructions
for cost reporting periods straddling 7/1/2011)
ACA §5506 number of additional direct GME FTEs
(see instructions for cost reporting periods straddling
7/1/2011)
Unweighted resident FTE count for allopathic and osteopathic
programs for current year from your records
Weighted FTE count for primary care physicians in an allopathic
and osteopathic program for the current year
Weighted FTE count for all other physicians in an allopathic and
osteopathic program for the current year
Weighted dental and podiatric resident FTE count, current yr.
Total weighted FTE count
Total weighted resident FTE count for prior cost reporting year
If none, enter 1 here.
Total weighted resident FTE count for the penultimate cost
reporting year
Rolling average FTE count.
Adjustment for residents in initial years of new programs
Adjustment for residents displaced by program or hospital closure
Adjusted rolling average FTE count
Per resident amount
Additional unweighted allopathic and osteopathic direct GME FTE
resident cap slots received under 42 Sec. 413.79(c )(4)
GME FTE weighted Resident count over Cap (see instructions)
Adjustment for locality national average per resident amount
(see instructions)
Medicare outpatient ESRD charges (see instructions)
Part A reasonable cost (see instructions)
Part B reasonable cost (see instructions)
40-760
1
1
6
9(3).99
2
1
6
9(3).99
3
1
6
9(3).99
3.01
1
6
9(3).99
4
1
6
-9(3).99
4.01
1
6
-9(3).99
4.02
1
6
-9(3).99
6
1
6
9(3).99
8
1
6
9(3).99
8
10
11
2
2
1-2
6
6
6
9(3).99
9(3).99
9(3).99
12
1-2
6
9(3).99
13
14
15
16
17
18
1-2
1-2
1-2
1-2
1-2
1-2
6
6
11
11
11
11
9(3).99
9(3).99
9(3).99
9(3).99
9
9(8).99
20
21
1
1
11
11
9(8).99
9(8).99
23
35
41
44
1
1
1
1
11
11
11
11
9(8).99
9(8).99
9
9
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
FIELD
SIZE
USAGE
1
11
-9
2
11
-9
3
11
-9
4
11
-9
4-9, 12-17
1
0
2, 4, 6, 8
36
11
X
-9
4-9, 12-17
1, 3, 5, 7
11
-9
LINE(S)
COLUMN(S)
WORKSHEET G
For all hospitals or hospital complexes:
Balance sheet accounts
1-10, 12-29, 31-34,
37-44, 46-49, 52
For hospitals or hospital complexes using fund accounting:
Specific purpose fund account balances
Endowment fund account balances
Plan fund account balances
1-10, 12-29, 31-34,
37-41, 43-44, 46-49,
53
1-10, 12-29, 31-34,
37-41, 43-44, 46-49,
54-56
1-10, 12-29, 31-34,
37-41, 43-44, 46-49,
57-58
NOTE: All columns for line 6, 14, 16, 18, 20, 22, 24, 26 and 28 should contain negative amounts.
WORKSHEET G-1
For hospitals using fund accounting:
Text as needed for blank lines
Beginning fund balances
Additions and reductions to
beginning fund balances
Rev. 3
40-761
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET G-2
Part I:
Other patient revenue (specify)
Inpatient revenues for routine care by component
Inpatient revenues for intensive care by special care unit
Total revenues for routine and special care
Inpatient ancillary services revenue
Outpatient services revenue (associated with admissions)
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Ambulance revenue (associated with admissions)
ASC revenue
Hospice revenue
Other patient revenue (specify)
Inpatient ancillary services revenue (rendered in outpatient)
Outpatient services revenue
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Home health agency revenue
Ambulance revenue
Outpatient rehabilitation providers
ASC revenue
Hospice revenue
Other outpatient revenue
Total inpatient and outpatient revenue
Part II:
Text as needed for blank lines
Increases to operating expenses reported on Worksheet A
Decreases to operating expenses reported on Worksheet A
Total operating expenses
27
1-9
11-15
17
18
19
20
21
23
25
26
27
18
19
20
21
22
23
24
25
26
27
28
0
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
1-3
1-3
36
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
X
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
30-35, 37-41
30-35
37-41
43
0
1
1
2
36
11
11
11
X
9
9
9
24, 27
2
4
6-24
27
28
29
0
1
1
1
1
1
1
36
11
11
11
11
11
11
X
9
9
9
9
-9
-9
WORKSHEET G-3
Text as needed for blank lines
Contractual allowances and discounts on patients' accounts
Total operating expenses
Other revenues
Other expenses
Total other expenses
Net income
40-762
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
11
11
11
11
11
11
11
11
11
11
9
9
9
9
9
-9
-9
9
9
-9
WORKSHEET H
Salaries
Employee Benefits
Transportation
Contracted/Purchased Services
Other costs
Reclassifications
Adjustments
Net expense for allocation
Total
Total
3-23
3-23
1-23
3-23
1-23
1-23
1-23
1-23
24
24
1
2
3
4
5
7
9
10
1-5, 10
7,9
Note: Line 23.50 for Wksts. H through H-1,Part II and line 19.50 for Wkst. H-2 is to be used exclusively for telemedicine,
if applicable.
WORKSHEET H-1, PARTS I & II
Part I
Total
Cost allocation
24
6-23
1-5
6
11
11
9
9
Part II
Reconciliation
All cost allocation statistics
Total
5-23
1-23
24
5A
1-4*
1-5
11
11
11
-9
9
9
25
28
0-4 & 5-23
11
11
11
-9
9
9
11
11
11
-9
9
9
* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column.
WORKSHEET H-2, PARTS I & II
Part I
Post stepdown adjustment (including total)
Total cost after cost finding
Total cost
1-20
2-19
20
Part II
Centers - Statistical Basis
Reconciliation
5-19
4A-23A
All cost allocation statistics
1-19
1-23*
Total
20
1-28
* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column. Do not include
X on line 0 of accumulated cost column since this is a replica of Worksheet B-1.
WORKSHEET H-3, PART I & II
Part I
Total visits
Program visits
Total
CBSA numbers
Program visits by discipline and CBSA
Total
Total charges for DME rented and sold and medical supplies
Charges for medical supplies - Medicare Parts B
Part II
Total HHA charges
Total HHA shared ancillary costs
Rev. 3
1-6
1-6
7
8-13
8-13
14
15-16
16
4
6-7
4, 6,7
1
2&3
2&3
4
7-8
11
11
11
5
11
11
11
11
9
9
9
X
9
9
9
9
1-5
1-5
2
3
11
11
9
9
40-763
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET H-4, PART I & II
Part I
Total charges for title XVIII - Parts A and B services
Amount collected from patients
Amounts collectible from patients
Primary payer payments
Part II
PPS Payments
Part B deductibles billed to Medicare patients
Coinsurance billed to Medicare patients
Reimbursable bad debts
Reimbursable bad debts for dual eligible beneficiaries
(see instructions)
Other adjustments (specify)
Other adjustments (specify)
Interim payments (titles V and XIX only)
Protested amounts
2
3
4
9
1-3
1-3
1-3
1-3
11
11
11
11
9
9
9
9
11-20
21
25
27
1-2
2
2
1&2
11
11
11
11
9
9
9
-9
28
30
30
32
35
1&2
0
1&2
1
1&2
11
36
11
11
11
9
X
-9
9
-9
1
2
3.01-3.98
2&4
2&4
1&3
11
11
10
9
9
X
3.01-3.49
3.50-3.98
2&4
2&4
11
11
9
9
5.01-5.49
1&3
10
X
5.01-5.49
2&4
11
-9
5.50-5.98
1&3
10
X
5.50-5.98
8
8
2&4
0
1
11
36
5
-9
X
X
8
2
10
X
WORKSHEET H-5
Total interim payments paid to provider
Interim payments payable
Date of each retroactive lump sum adjustment (mm/dd/yyyy)
Amount of each lump sum adjustment:
Program to provider
Provider to program
Enter the date of the tentative payment
From Program to Provider
Enter the amount of the tentative payment
From Program to Provider
Enter the date of the tentative payment
From Provider to Program
Enter the amount of the tentative payment
From Provider to Program
Enter the name of the Contractor
Enter the Contractor's number
Enter the date of Notice of Program
Reimbursement
40-764
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET I-1
Total costs by department
Total cost
Statistics
FTEs per 2080 hours
Charges
1-8, 10-16, 18-26,
28-30
31
1-6
1-6
28-30
1
1
3
4
3
11
11
11
11
11
9
9
9(8).99
9(8).99
9
14
15
1-13, 16 & 17
17
6
6
11
1-8, 10
11
11
11
11
9
9
9
9
2-16
2-16
2-16
17
17
17
12
1, 5-8
2
3&4
1, 5-10
2
3&4
0
11
6
11
11
6
11
11
9
9(3).99
9(8).99
9
9(3).99
9(8).99
9
1-8, 11
9
10
1-8, 11
9
10
1-11
1-10
1
1
1
4
4
4
6
7
11
11
11
11
11
11
11
6
9
9
9
9
9
9
9
9(3).99
3
4
5
1
1
1
11
11
11
-9
9
-9
7
1
11
9
WORKSHEET I-2
EPO costs
ARANESP cost
Totals
Columnar totals
WORKSHEET I-3
All cost allocation statistics
Percentage of time statistics
Hourly statistics
Total all cost allocation statistics
Total percentage of time statistics
Total hourly statistics
Inpatient dialysis treatments
WORKSHEET I-4
Total number of outpatient treatments
Total CAPD patient weeks
Total CCPD patient weeks
Number of outpatient treatments - Medicare
CAPD patient weeks - Medicare
CCPD patient weeks - Medicare
Total program payment
Average Payment rates
WORKSHEET I-5
Part B deductibles billed
Part B coinsurance billed
Reimbursable bad debts
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
Rev. 3
40-765
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET J-1, PART I
General Service Cost Allocation
Net expenses for cost allocation
Post stepdown adjustments (including total)
Total (sum of lines 1-21)
1-21
1-22
22
0
25
0-4, 5-23
11
11
11
9
-9
9
1-21
1-21
22
4A-23A
1-23*
1-23
11
11
11
-9
9
9
WORKSHEET J-1, PART II
General Service Cost Statistics
Reconciliation
Cost allocation statistics
Total
* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column. Do not include
X on line 0 of accumulated cost column.
WORKSHEET J-2, PARTS I & II
Part I
Apportioned Outpatient Rehabilitation Costs
Total component charges
Title V charges
Title XVIII charges
Title XIX charges
Title XIX costs
Total
Part II
Charges for Allocation of A&G Costs
Title V charges
Title XVIII charges
Title XIX charges
Total
Title XIX costs
2-19
2-19
2-19
2-19
2-19
20
2
4
6
8
9
2, 4-9
11
11
11
11
11
11
9
9
9
9
9
9
21-27
21-27
21-27
28
21-29
4
6
8
4-8
9
11
11
11
11
11
9
9
9
9
9
1
2
3
4
5
6
7
8
14
19
21
1
1
1
1
1
1
1
1
1
1
1
11
11
11
11
11
11
11
11
11
11
11
9
9
9
9
9
9
9
9
9
9
-9
23
25
25
27
30
1
0
1
1
1
11
36
11
11
11
9
X
-9
9
-9
WORKSHEET J-3
To be completed separately for titles V, XVIII, and XIX
(data items apply to titles V, XVIII, and XIX, except
as indicated):
Cost of component services
PPS payments received including outliers
Outlier Payments
Primary payer payments
Total reasonable cost (see instructions)
Total charges for program services
Aggregated amount collected
Amount collectible
Part B deductibles billed
Actual coinsurance billed to program patients (from provider records)
Reimbursable bad debts
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
Other adjustments (see instructions) (specify)
Other adjustments (see instructions) (specify)
Interim payments (titles V and XIX only)
Protested amounts
40-766
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET J-4
Total interim payments paid to provider
Interim payments payable
Date of each retroactive lump sum adjustment (mm/dd/yyyy)
Amount of each retroactive lump sum adjustment:
Program to provider
Provider to program
Enter the date of the tentative payment
From Program to Provider
Enter the amount of the tentative payment
From Program to Provider
Enter the date of the tentative payment
From Provider to Program
Enter the amount of the tentative payment
From Provider to Program
Enter the name of the Contractor
Enter the Contractor's number
Enter the date of Notice of Program
Reimbursement
Rev. 3
1
2
3.01-3.98
2
2
1
11
11
10
9
9
X
3.01-3.49
3.50-3.98
2
2
11
11
9
9
5.01-5.49
1
10
X
5.01-5.49
2
11
-9
5.50-5.98
1
10
X
5.50-5.98
8
8
2
0
1
11
36
5
-9
X
X
8
2
10
X
40-767
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
FIELD
SIZE
USAGE
3
5
7
9
10
11
11
11
11
11
9
9
-9
-9
9
1-9
1-9
11
11
9
9
1-6
7
11
11
9
9
6A
1-5*
11
11
-9
9
25
28
0-2, 4-23
& 28
11
11
-9
9
11
9
11
11
-9
9
11
11
9
9
COLUMN(S)
WORKSHEET K
Transportation
Other costs
Reclassifications
Adjustments
Net expense for allocation
1-38
1-38
1-38
1-38
39
WORKSHEETS K-1, K-2, & K-3
Salaries, benefits & Contract Services
Total
3-21, 27-38
39
WORKSHEET K-4, PARTS I & II
Part I
Total
Cost allocation
39
7-38
Part II
Reconciliation
7-38
All cost allocation statistics
1-38
* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column.
WORKSHEET K-5, PARTS I & II
Part I
Post stepdown adjustment (including total)
Total cost after cost finding
Total cost
1-33
2-33
34
Part II
Centers - Statistical Basis
5A -23A
Reconciliation
1-33
All cost allocation statistics
1-33
1-23*
* See note to Worksheet B-1 for treatment of administrative and general accumulated cost column. Do not include
X on line 0 of accumulated cost column since this is a replica of Worksheet B-1.
WORKSHEET K-5, PART III
Total Hospice Charges (Provider records)
Hospice Share of ancillary costs
40-768
1-10
1-11
2
3
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET L
Part I - Fully Prospective Method:
Capital DRG other than outlier
Capital DRG outlier payments
Total inpatient days available divided by number of days in the
cost reporting period.
Indirect medical education percentage (see instructions)
Percentage of SSI recipient patient days to Medicare Part A
patient days.
Percentage of Medicaid patient days to total days
Allowable disproportionate share percentage (see instructions)
PART II - Payment Under Reasonable Cost:
Total inpatient program capital cost
Part III - Computation of Exception Payments:
Applicable exception percentage (see instructions)
Percentage adjustment for extraordinary circumstances
(see instructions)
Carryover of accumulated capital minimum payment level over
capital payment (prior year Worksheet L, Part II, line 14)
1
2
1
1
11
11
9
9
3
5
1
1
11
6
9(8).99
9(3).99
7
8
10
1
1
1
6
6
6
9.9(4) (*)
9.9(4) (*)
9.9(4) (*)
5
1
11
9
4
1
4
9.99
6
1
4
9.99
11
1
11
-9
1-23, 30-46, 50-60,
62-76, 88-91, 93-101,
105-117, 190-194
202
202
0
0
25
11
11
11
9
9
9
30-46, 50-60,
62-76, 88-91, 92.01- 101,
105-117, 190-194
26
11
9
202
26
11
9
30, 40-42
2
11
9
WORKSHEET L-1, PART I
Extraordinary capital related costs
Total extraordinary capital related costs
Total adjustments after cost finding
Total extraordinary capital related costs after
cost finding by department
Total extraordinary capital related costs after
cost finding in total
WORKSHEET L-1, PART II
Computation of program inpatient routine service capital
costs for extraordinary circumstances
Swing-bed adjustment
Rev. 3
40-769
4095 (Cont.)
FORM CMS 2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET M-1
Provider based cost
1-9, 11-13, 15-20,
23-27, & 29-30
1, 2, 4, 6-7
11
-9
1-3, & 5-7.02
1-3, 5-7.02, & 9
1-3
4
15
1
2
3
5
1
6
11
11
11
11
9(3).99
9
9
9
9
WORKSHEET M-2
Number of FTE personnel
Total visits
Productivity standard *
Greater of columns 2 or 4
Parent provider overhead allocated to facility (see instruct.)
* Use the standard visits per the instructions as the default. Those standards may change if an approved exception is granted.
(See Worksheet S-8 for response to approved exception to the standard productivity visits.)
WORKSHEET M-3
Adjusted cost per visit
Maximum rate per visit (from contractor)
Rate for program covered visits
Program covered visits excluding mental health services
(from your contractor)
Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3)
Total Program Charges (see instructions)(from contractor's records)
Total Program Preventive Charges (see inst.)(from provider's recds)
Total Program Cost (see instructions)
Program covered visits for mental health services (from your
contractor)
Primary payer payments
Beneficiary deductible for RHC only (from your contactor)
Beneficiary coinsurance for RHC/FQHC (from your contractor)
Reimbursable bad debts
Reimbursable bad debts for dual eligible
beneficiaries (see instructions)
Other adjustments (specify) (see instructions)
Other adjustments (specify) (see instructions)
Interim payments (titles V and XIX only)
Protested amounts
40-770
7
8
9
1
1&2
1&2
6
6
6
9(3).99
9(3).99
9(3).99
10
16
16.01
16.02
16.05
1&2
1&2
1&2
1&2
1&2
11
11
11
11
11
9
9
9
9
9
12
17
18
19
23
1&2
2
2
2
2
11
11
11
11
11
9
9
9
9
-9
24
25
25
27
30
2
0
2
2
2
11
36
11
11
11
9
X
9
9
9
Rev. 3
10-12
FORM CMS 2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN DESIGNATIONS
DESCRIPTION
LINE(S)
COLUMN(S)
FIELD
SIZE
USAGE
WORKSHEET M-4
Ratio of pneumococcal and vaccine staff time to total
health care staff time
Medical supplies cost - pneumococcal and influenza vaccine
Total number of pneumococcal and influenza vaccine injections
Number of pneumococcal and influenza vaccine injections
administered to Medicare beneficiaries
2
4
11
1&2
1&2
1&2
8
11
11
9.9(6)
9
9
13
1&2
11
9
1
2
3.01-3.98
2
2
1
11
11
10
9
9
X
3.01-3.49
3.50-3.98
2
2
11
11
9
9
5.01-5.49
1
10
X
5.01-5.49
2
11
-9
5.50-5.98
1
10
X
5.50-5.98
8
8
2
0
1
11
36
5
-9
X
X
8
2
10
X
WORKSHEET M-5
Total interim payments paid to provider
Interim payments payable
Date of each retroactive lump sum adjustment (mm/dd/yyyy)
Amount of each retroactive lump sum adjustment:
Program to provider
Provider to program
Enter the date of the tentative payment
From Program to Provider
Enter the amount of the tentative payment
From Program to Provider
Enter the date of the tentative payment
From Provider to Program
Enter the amount of the tentative payment
From Provider to Program
Enter the name of the Contractor
Enter the Contractor's number
Enter the date of Notice of Program
Reimbursement
Rev. 3
40-771
4095 (Cont.)
FORM CMS-2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
WORKSHEET A-8-3, PARTS II & III
WORKSHEET D, PARTS I & II
WORKSHEET D-1, PART IV
WORKSHEET D-2, PART III
WORKSHEET D-4, PART II
WORKSHEET H-4, PART I
WORKSHEET K-6
WORKSHEET L-1, PART II
TABLE 3B - TABLES TO WORKSHEET S-2
TABLE I: Type of Control
1=
2=
3=
4=
5=
6=
7=
Voluntary Nonprofit, Church
Voluntary Nonprofit, Other
Proprietary, Individual
Proprietary, Corporation
Proprietary, Partnership
Proprietary, Other
Governmental, Federal
8=
9=
10 =
11 =
12 =
13 =
Governmental, City-County
Governmental, County
Governmental, State
Governmental, Hospital District
Governmental, City
Governmental, Other
TABLE II: Type of Hospital
1=
2=
3=
4=
5=
40-772
General Short Term
General Long Term
Cancer
Psychiatric
Rehabilitation
6 = Religious Nonmedical Health Care
Institutions
7 = Children
8 = Alcohol & Drug
9 = Other
Rev. 3
10-12
FORM CMS-2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3C - LINES WHICH CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet S, Part I
Worksheet S, Part III; lines 1-3, 5-8, 200
Worksheet S-2, Part I: lines 1-4, 7-9, 11, 20-35, 37, 45-60, 61-64, 66-85, 90-157, 159, 165, 167-169
Worksheet S-2, Part II: ALL
Worksheet S-3, Part I: lines 1-7, 13-17,18, 21, 27-33
Worksheet S-3, Parts II : ALL, except for line 43
Worksheet S-3, Parts III - IV: ALL
Worksheet S-3, Parts IV: except line 25
Worksheet S-3, Parts V: lines 1-4, and 6-8.
Worksheet S-4: lines 1-17, 19, 21-38
Worksheet S-5
Worksheet S-6, lines 1-17
Worksheet S-7: except line 206
Worksheet S-8: lines 1-8, 10, 12-13, 15
Worksheet S-9, Parts I and II
Worksheet S-10
Worksheet A: lines 3, 30, 43-44, 46, 74, 94, 95-97, 100, 105-111, 113-115, 118, and 200
Worksheet A-6
Worksheet A-7, Parts I
Worksheet A-7, Parts II & III: line 3
Worksheet A-8: lines 1-32, and 50
Worksheet A-8-1, Part A:, lines 1-3
Worksheet A-8-1, Part B: lines 6-9
Worksheet A-8-2
Worksheet A-8-3
Worksheet B: Parts I-II SAME AS WORKSHEET A
Worksheet B-1: SAME AS WORKSHEET A
Worksheet B-2
Worksheet C, Part I: lines 30, 40, 41, 43- 46, 61, 74, 94, 95, 100,105-111, and 200-202.
Worksheet C, Part II: lines 61, 74, and 95.
Worksheet D, Part I:lines 30, 40, 41, 43, and 200.
Worksheet D, Part II:lines 61, 74, 95, and 200.
Worksheet D, Part III: lines 30, 40, 41, 43, 44, and 200.
Worksheet D, Part IV: lines 61, 74, 94 and 200.
Worksheet D, Part V: lines 61, 74, 94 , 95, and 200-202.
Worksheet D-1, Part I
Worksheet D-1, Part II, (except lines 43-47)
Worksheet D-1, Part III & IV
Worksheet D-2, Part I: lines 1-2, 8, 9, 10, 11, 13, 15, 20, 27-31, 37-39, 41-42, 43-47 and 49.
Worksheet D-2, Part II: lines 26-28.
Worksheet D-3: lines 30, 40-41, 43, 61, 74, 94 , 95, and 200-202.
Worksheet D-4, Part I, lines 1, 7, 19, 32, and 41.
Worksheet D-4, Part II, lines 42, 48, and 55.
Worksheet D-4, Parts III and IV
Worksheet D-5, Parts I and II: except for line 17.
Worksheet E, Part A (except lines 70)
Worksheet E, Part B (except line 39, 90-91).
Worksheet E-1, Part I, lines 1, 2, 3.01-3.04, 3.50-3.53, 4, 6 and 8.
Worksheet E-1, Part II
Worksheet E-2 (except line 16)
Rev. 3
40-773
4095 (Cont.)
FORM CMS-2552-10
10-12
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3C - LINES WHICH CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet E-3, Part I (except line 17)
Worksheet E-3, Part II (except lines 30, 52-53).
Worksheet E-3, Part III (except lines 31, 52-53).
Worksheet E-3, Part IV:(except lines 21, 52-53).
Worksheet E-3, Part V (except line 29)
Worksheet E-3, Part VI:(except line 14).
Worksheet E-3, Part VII:((except line 30).
Worksheet E-4
Worksheet G
Worksheet G-1, line 1, 3, 10-11, 18-19.
Worksheet G-2, Part I, lines 1-3, 4-7, 9, 10, 16-19, 23, and 25-26.
Worksheet G-2, Part II, line 27, 34, 40 and 41
Worksheet G-3, lines 1-5, 6-23, 25, 26, 28 and 29.
Worksheet H (except line 23)
Worksheet H-1, Parts I and II (except line 23)
Worksheet H-2, Parts I and II (except line 23)
Worksheet H-3, Parts I and II
Worksheet H-4, Part I
Worksheet H-4, Parts II:(except line 30).
Worksheet H-5, Parts I and II
Worksheet H-6, lines 4, 6 and 8.
Worksheet I-1 (except line 30)
Worksheet I-2
Worksheet I-3
Worksheet I-4
Worksheet I-5
Worksheet J-1, Parts I and II
Worksheet J-2, Part I
Worksheet J-3 (except line 25)
Worksheet J-4, lines 1-2, 4 and 6-8.
Worksheet K
Worksheet K-1
Worksheet K-2
Worksheet K-3
Worksheet K-4, Part I
Worksheet K-4, Part II
Worksheet K-5, Part I
Worksheet K-5, Part II
Worksheet K-6
Worksheet L
Worksheet L-1, Part I: SAME AS WORKSHEETS A & B
Worksheet L-1, Part II: lines 30, 40, 41, 43, 200.
Worksheet M-1
Worksheet M-2
Worksheet M-3: (except line 25).
Worksheet M-4
Worksheet M-5, lines 1-2, 4 and 6-8.
40-774
Rev. 3
08-11
FORM CMS-2552-10
4095 (Cont.)
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 3D - PERMISSIBLE PAYMENT MECHANISMS
P = Prospective Payment
T = TEFRA
Component
Hospital
IPF
IRF
Subprovider
Swing-Bed SNF
Swing-Bed NF
SNF
NF
ICF/MR
HHA
ASC (Distinct Part)
RHC
FQHC
CMHC
O = Other
N = Not applicable
Title V
P, T, or O
P, T, or O
P, T, or O
P, T, or O
P or O
O
P or O
P or O
O
P or O
O
O
O
O
Title XVIII
P, T, or O
P
P
P, T, or O
P or O
*
P
*
*
P
O
O
O
O
(a)
Title XIX
P, T, or O
P, T, or O
P, T, or O
P, T, or O
P or O
O
P or O
P or O
O
P or O
O
O
O
O
(a) For CAH the payment method should be "O" since they are paid under cost.
TABLE 3E - LINE NUMBERING FOR SPECIAL CARE UNITS
Cost center integrity for variable worksheets (listed below) must be maintained throughout the cost report.
If you use a line designated as "(specify)" or subscript a line, the relative position must flow throughout
the cost report.
EXAMPLE:
If you add a special care unit after the surgical intensive care unit on line 11 of Worksheet S-3,
Part I, it must also be on the first additional special care unit line of Worksheet A (line 35),
Worksheet D-1, Part II (line 47), Worksheet D-2, Part I (line 7), etc.
Worksheet
S-3, Part I
A
B, Parts I-III
B-1
L-1, Part I
C, Part I
D, Part I
D-1, Part II
D-2, Part I
D-2, Part II
D-4, Part I
D-4, Part II
G-2, Part I
Rev. 2
Burn
Care
10
33
"
"
"
"
"
45
5
34
4
45
13
Surgical
Care
11
34
"
"
"
"
"
46
6
35
5
46
14
Lines for Additional Special Care Units
#1
#2
12
12.01
35
35.01
"
"
"
"
"
"
"
"
"
"
47
47.01
7
7.01
36
36.01
6
6.01
47
47.01
15
15.01
#3
12.02
35.02
"
"
"
"
"
47.02
7.02
36.02
6.02
47.02
15.02
40-775
4095 (Cont.)
FORM CMS 2552-10
08-11
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 4 - NUMBERING CONVENTION FOR MULTIPLE COMPONENTS
This table provides line and column numbering conventions for health care complexes with more than one hospital-based
component of the same kind. Table 4 is necessary to insure that data associated with each component is consistently
identified throughout the cost report. This table provides for four additional components. Component II is subline .01,
component III is .02, component IV is .03, and component V is .04. The only deviation from this subline numbering
is to CMHC component on Worksheets S-2 and S-3 as listed below. Providers should continue this numbering
conventions for multiple components in excess of five (5) components.
SUB
WKST
PART
COLUMNS
LINES
LINES
I.
For use in facilities with more than one subprovider
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
OTHER SUBPROVIDER I-X
S
S-2
S-2
S-3
A
B
B
B-1
C
D
D-2
D-2
G-2
L-1
L-1
III
I
I
I
I
II
I
III
I
II
I
I
II
1-3 & 5
1-8
1
1-3 & 5-15
1-2 & 7
26
0, 26
1-23
6-7
1, 2
1, 6
6
1
0,26
2
4
6
158
18
42
42
42
42
42
42
12
40
4
42
42
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-9
1-3, 5
1-3 & 5-8
1 & 5-11
1-2 & 7
1
4, 8, & 9
1
1
10
12
22
101
8-9
15-16
41-51
64, 72, 75,
& 77
101
101
101
101
20
101
1-9
1-9
1-9
1-9
1-9
1-9
1-9
II. For use in facilities with more than one HHA
HHA II-X
HHA II-X
HHA II-X
HHA II-X
HHA II-X
HHA II-X
HHA II-X
HHA II-X
S
S-2
S-3
A
A-8-3
A-8-3
A-8-3
A-8-3
HHA II-X
HHA II-X
HHA II-X
HHA II-X
HHA II-X
HHA II-X
B
B
B
B-1
G-2
L-1
II
I
I
I
I
IV
VI-VII
I
II
III
I
I
26
0, 26
0, 26
1-23
2
0, 26
1-9
1-9
1-9
1-9
1-9
1-9
1-9
III. For use in facilities with multiple outpatient rehabilitation facilities *
O/P Rehab. Provider
S
II
1-3, 5
12
O/P Rehab. Provider
S-2
I
1-3 & 5-8
17
O/P Rehab. Provider
S-3
I
7-8 & 10-11
25
O/P Rehab. Provider
A
1-2 & 7
99
O/P Rehab. Provider
B
I
26
99
O/P Rehab. Provider
B
II
0, 26
99
O/P Rehab. Provider
B
III
0, 26
99
O/P Rehab. Provider
B-1
1-23
99
O/P Rehab. Provider
D-2
1
17
O/P Rehab. Provider
G-2
I
2
22
O/P Rehab. Provider
L-1
I
0, 27
98
* Subscripts for this line are CMHC 00-09, CORF 10-19, OPT 20-29, OOT 30-39, and OSP 40-49.
40-776
0-49
0-49
0-49
0-49
0-49
0-49
0-49
0-49
0-49
0-49
0-49
Rev. 2
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 5 - COST CENTER CODING
4095 (Cont.)
INSTRUCTIONS FOR PROGRAMMERS
Cost center coding is required because there are thousands of unique cost center names in use by
providers. Many of these names are peculiar to the reporting provider and give no hint as to the actual
function being reported. By using codes to standardize meanings, practical data analysis becomes
possible. The methodology to accomplish this must be rigidly controlled to enhance accuracy.
For any added cost center names (the preprinted cost center labels must be precoded), the preparer
must be presented with the allowable choices for that line or range of lines from the lists of standard
and nonstandard descriptions. They will then select a description that best matches their added
label. The code associated with the matching description, including increments due to choosing
the same description more than once, will then be appended to the user's label by the software.
Additional guidelines are:
o
Any pre-existing codes for the line must not be allowed to carry over.
o
All "Other . . ." lines must not be precoded.
o
The order of choice is standard first, followed by specific nonstandard, and, lastly, the nonstandard
"Other . . ." cost centers.
o
When the nonstandard "Other . . ." is chosen, the preparer must be prompted with "Is this the most
appropriate choice?" and offered a chance to answer yes or to select another description.
o
The cost center coding process must be able to be invoked again for purposes of making corrections.
o
A separate list showing the preparer's added cost center names on the left with the chosen standard
or nonstandard description and code on the right must be printed for review.
o
The number of times a description can be selected on a given report must be displayed on the screen
next to the description and this number must decrease with each usage to show the remaining numbers
available. The numbers are shown on the standard and nonstandard cost center tables.
o
Standard cost center lines, descriptions, and codes are not to be changed. The acceptable format for
these are displayed in the STANDARD COST CENTER DESCRIPTIONS AND CODES listed on
pages 40-780 and 40-781. The proper line number is the first two digits of the cost center code.
The only exceptions to the descriptions are: "Paramedical Education Program-(specify)" for which the
parenthesis and specify are to be replaced by the program name, i.e., Radiology, Cytotechnology;
and "Other Organ Acquisition (specify)" should be changed to specify the acquisition as listed on
lines105-111. All "Other" nonstandard lines should be changed to the appropriate cost center name and
"Subprovider (specify)" type should be indicated.
Rev. 3
40-777
4095 (Cont.)
FORM-CMS 2552-96
ELECTRONIC
ELECTRONIC
REPORTING
REPORTING
SPECIFICATIONS
SPECIFICATIONS
FOR FORM
FOR FORM
CMS 2552-92
CMS 2552-10
TABLE 5 - COST CENTER CODING
10-12
INSTRUCTIONS FOR PREPARERS
Coding of Cost Center Labels
Cost center coding is a methodology for standardizing the meaning of cost center labels as used by
hospitals on the Medicare cost report. The use of this coding methodology allows providers to
continue to use their labels for cost centers that have meaning within the individual institution.
The five digit codes that are required to be associated with each label provide standardized
meaning for data analysis. Normally, it is only necessary to code any added labels because the
preprinted STANDARD labels are automatically coded by CMS approved cost report software.
Additional cost center descriptions have been identified through analysis of provider labels. The
meanings of these additional descriptions were sufficiently different when compared to the Standard
labels to warrant their use. These additional descriptions are hereafter referred to as the NONSTANDARD
labels. Included with the nonstandard descriptions are "Other . . ." designations to provide for situations
where no match in meaning can be found. Refer to Worksheet A, lines 18, 35, 76, 93, 98, 117, and 194.
Both the standard and nonstandard cost center descriptions along with their cost center codes are shown
on Table 5. The "USE" column on that table indicates the number of times that a given code can be
used on one cost report. You are required to compare your added label to the descriptions shown on
the standard and nonstandard table for purposes of selecting a code. CMS approved software
provides an automated process to present you with the allowable choices for the line/column being coded
and automatically associate the code for the selected matching description with your label.
Additional Guidelines
Categories
You must make your selection from the proper category such as general service description for general
service lines, ancillary descriptions for ancillary cost center lines, etc.
Additional Hospital-Based Components
The Form CMS 2552-10 provides a preprinted label for one subprovider on line 42. However, this
designation should be changed to coincide with the specific provider name. Where the preparer
has the need to report more subproviders, line 42 must be subscripted as needed. After the
provider's label for the first subprovider is entered, the standard description for subprovider (code 04200)
is selected. The preparer then enters the provider's label for the second subprovider on subscripted
line 42.01. The appropriate description "subprovider" is again selected as the correct match. The
standard code 04200, incremented by one (04201), is applied to the second subprovider. Additional
subproviders are handled in the same manner. This same procedures applies to all multiple components.
(See Table 4.) Lines 99 and 112 require specific designations from the nonstandard cost center listing.
40-778
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 5 - COST CENTER CODING
4095 (Cont.)
Intensive Care Cost Centers
When an intensive care type of cost center label is added and it does not closely match the standard
or nonstandard cost center descriptions, then a subscript of the intensive care description (code 03100)
should be used or a nonstandard code, i.e., 03101-03119 and/or one of the nonstandard inpatient
routine service cost center codes. There is no "Other Intensive Care" description available.
Use of Cost Center Coding Description More Than Once
Often a description from the standard or nonstandard tables applies to more than one of the labels
being added by the preparer. In the past, it was necessary to determine which code was to be used and
then increment the code number upwards by one for each subsequent use. This was done to provide a
unique code for each cost center label. Now, most approved software associate the proper code, including
increments as required, once a matching description is selected. Remember to use your label. You are
matching to CMS's description only for coding purposes.
Cost Center Coding and Line Restrictions
Cost center codes may only be used in designated lines in accordance with the classification of the cost
center(s), i.e., lines 1 through 23 may only contain cost center codes within the general service cost center
category of both standard and nonstandard coding. For example, in the general service cost center
category for Operation of Plant cost, line 7 and subscripts thereof should only contain cost center codes
of 00700-00719 and nonstandard cost center codes. This logic must hold true for all other cost center
categories, i.e., ancillary, inpatient routine, outpatient, other reimbursable, special purpose, and nonreimbursable cost centers. There are exceptions, which are contained in Table 6 edits. An example of
an exception is A&G cost. Line 5 and subscripts thereof may only contain cost center codes of 00500,
00510-00569, 01080-01099, and 01140-01179 (standard and nonstandard cost center codes). Other cost center
lines contain exceptions that only the standard cost center codes and subscripts (usage) of that code may
be used on that line and subscripts of that line. These exceptions are also contained in Table 6.
Rev. 3
40-779
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 5 - STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
GENERAL SERVICE
COST CENTERS
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Other Cap Related Cost
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Dietary
Cafeteria
Maintenance of Personnel
Nursing Administration
Central Services & Supply
Pharmacy
Medical Records & Library
Social Service
Nonphysician Anesthetists
Nursing School
I&R Services-Salary & Fringes Apprvd
I&R Services-Other Prgm. Costs Apprvd
00100
00200
00300
00400
00500
00600
00700
00800
00900
01000
01100
01200
01300
01400
01500
01600
01700
01900
02000
02100
02200
(50)
(50)
(01)
(20)
(1 )
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
(20)
40-780
USE
06200
06300
06400
06500
06600
06700
06800
06900
07000
07100
07200
07300
07400
07500
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(01)
(30)
08800
08900
09000
09100
09200
(25)
(25)
(99)
(20)
(01)
09400
09500
09600
09700
10000
10100
(01)
(01)
(20)
(20)
(01)
(10)
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Interst Expense
Utilization Review-SNF
10500
10600
10700
10800
10900
11000
11100
11300
11400
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
(01)
Ambulatory Surgical Center (D.P.)
Hospice
11500
11600
(20)
(05)
19000
19100
19200
19300
(20)
(20)
(20)
(20)
Whole Blood & Packed Red Blood Cells
Blood Storing, Processing, & Trans.
Intravenous Therapy
Respiratory Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
Electrocardiology
Electroencephalography
Medical Supplies Charged to Patients
Impl. Dev. Charged to Patients
Drugs Charged to Patients
Renal Dialysis
ASC (Non-Distinct Part)
OUTPATIENT SERVICE
COST CENTERS
Rural Health Clinic (RHC)
Federally Qualified Health Center (FQHC)
Clinic
Emergency
Observation Beds (Non-Distinct Part)
OTHER REIMBURSABLE COST CENTERS
03000
03100
03200
03300
03400
04000
04100
04200
04300
04400
04500
04600
(01)
(20)
(20)
(20)
(20)
(1)
(1)
(10)
(01)
(01)
(01)
(01)
05000
05100
05200
05300
05400
05500
05600
05700
05800
05900
06000
06100
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(30)
(01)
ANCILLARY SERVICE
COST CENTERS
Operating Room
Recovery Room
Delivery Room & Labor Room
Anesthesiology
Radiology - Diagnostic
Radiology - Therapeutic
Radioisotope
CT Scan
Magnetic Resonance Imaging (MRI)
Cardiac Catheterization
Laboratory
PBP Clinical Lab. Service - Prgm. Only
CODE
ANCILLARY SERVICE
COST CENTERS (Continued)
INPATIENT ROUTINE SERVICE
COST CENTERS
Adults & Pediatrics
Intensive Care Unit
Coronary Care Unit
Burn Intensive Care Unit
Surgical Intensive Care Unit
Subprovider - IPF
Subprovider - IRF
Subprovider (specify)
Nursery
Skilled Nursing Facility
Nursing Facility
Other Long Term Care
10-12
Home Program Dialysis
Ambulance Services
Durable Medical Equip. - Rented
Durable Medical Equip. - Sold
I&R Services - Not Apprvd. Prgm.
Home Health Agency
SPECIAL PURPOSE COST CENTERS
NONREIMBURSABLE COST CENTERS
Gift, Flower, Coffee Shop, & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 5 - NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE
USE
GENERAL SERVICE COST CENTERS
Nonpatient Telephones
Data Processing
Purchasing Receiving and Stores
Admitting
Cashiering/Accounts Receivable
Other Administrative and General
Inservice Education
Management Services
Communications
Other General Service Cost Center
Paramed. Ed. Prgm.-(specify)
Other Special Care-(specify)
00540
00550
00560
00570
00580
00590
01080
01140
01160
01850
02300
02400
(10)
(10)
(10)
(10)
(10)
(10)
(20)
(20)
(20)
(50)
(100)
(50)
02040
02060
02080
02120
02140
02180
04510
(20)
(20)
(20)
(20)
(20)
(20)
(01)
ANCILLARY SERVICE COST CENTERS
Acupuncture
Angiocardiography
Audiology
Bacteriology & Microbiology
Biopsy
Birthing Center
Cardiology
Cardiopulmonary
Chemistry
Chemotherapy
Circumcision
Cytology
Dental Services
Echocardiography
EKG and EEG
Electromyography
Electroshock Therapy
Endoscopy
Gastro Intestinal Services
Hematology
Histology
Holter Monitor
Immunology
Laboratory - Clinical
Laboratory - Pathological
Rev. 3
CODE
USE
ANCILLARY SERVICE COST CENTERS (Continued)
INPATIENT ROUTINE SERVICE COST CENTERS
Detoxification Intensive Care Unit
Neonatal Intensive Care Unit
Pediatric Intensive Care Unit
Premature Intensive Care Unit
Psychiatric Intensive Care Unit
Trauma Intensive Care Unit
ICF/MR
4095 (Cont.)
03020
03030
03040
03050
03060
03070
03140
03160
03180
03190
03220
03240
03250
03260
03280
03290
03320
03330
03340
03350
03360
03370
03380
03390
03420
(10)
(10)
(10)
(10)
(10)
(10)
(20)
(20)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
Mammography
Nuclear Medicine - Diagnostic
Nuclear Medicine - Therapeutic
Oncology
Ophthalmology
Osteopathic Therapy
Prosthetic Devices
Psychiatric/Psychological Services
Pulmonary Function Testing
Recreational Therapy
Stress Test
Ultra Sound
Urology
Vascular Lab
Other Ancillary Service Cost Centers
Blood Clotting Factors for Hemoph.
Cardiac Rehabilitation
Hyperbaric Oxygen Therapy
Lithotripsy
03440
03450
03470
03480
03520
03530
03540
03550
03560
03580
03620
03630
03640
03650
03950
06250
07697
07698
07699
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(10)
(47)
(10)
(1)
(1)
(1)
04040
04050
04950
09201
(10)
(10)
(50)
(10)
05950
06630
06730
(50)
(05)
(05)
09900
09910
09920
09930
09940
(10)
(10)
(10)
(10)
(10)
06950
08600
(50)
(20)
07950
(50)
OUTPATIENT SERVICE COST CENTERS
Family Practice
Telemedicine
Other Outpatient Service Cost Center
Observation Beds (Distinct Part)
OTHER REIMBURSABLE COST CENTERS
Other Reimbursable Cost Centers
Support Surfaces - Rented
Support Surfaces - Sold
Outpatient Rehabilitation Providers:
CMHC
CORF
OPT
OOT
OSP
SPECIAL PURPOSE COST CENTERS
Other Special Purpose Cost Centers
Other Organ Acquisition (specify)
NONREIMBURSABLE COST CENTERS
Other Nonreimbursable Cost Centers
40-781
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Medicare cost reports submitted electronically must meet a variety of edits. These include mathematical
accuracy edits, certain minimum file requirements, and other data edits. Any vendor software which
produces an electronic cost report file for Medicare hospitals must automate all of these edits. Failure
to properly implement these edits may result in the suspension of a vendor's system certification until
corrective action is taken. The vendor's software should provide meaningful error messages to notify the
hospital of the cause of every exception. The edit message generated by the vendor systems must contain
the related 5 digit and 1 alpha character, where indicated, reject/edit code specified below. Any file
submitted by a provider containing a level I edit will be rejected by the fiscal intermediary. Notification
must be made to CMS for any exceptions.
The edits are applied at two levels. Level I edits (10000 series reject codes) are those which test the
format of the data to identify for correction of those error conditions which will result in a cost report
rejection. These edits also test for the presence of some critical data elements specified in Table 3.
Level II edits (20000 series edit codes) identify potential inconsistencies and/or missing data items.
These items should be resolved at the provider site and appropriate worksheets and/or data submitted
with the cost report. Failure to submit the appropriate data with your cost report may result in
payments being withheld pending resolution of the issue(s).
The vendor requirements (above) and the edits (below) reduce both contractors (MAC) processing time
and unnecessary rejections. Vendors should develop their programs to prevent their client hospitals
from generating an electronic cost report file where Level I edits conditions exist. Ample warnings
should be given the provider where Level II edit conditions are violated.
The Level I edit conditions are to be applied against title XVIII services only. However, any
inconsistencies and/or omission which would cause a Level I condition for non title XVIII
services should be resolved prior to acceptance of the cost report. [05/01/2010b]
Note: Dates in brackets [ ] at end of edit indicate effective date of that edit for cost reporting periods
ending on or after that date. Dates followed by a "b" are for cost reporting periods beginning
on or after and the date followed by an "s" are for services rendered on or after the specified
date. [05/01/2010b]
I. Level I Edits (Minimum File Requirements)
Edit
Condition
10000
The first digit of every record must be either 1, 2, 3, or 4 (encryption code only). [05/01/2010b]
10050
No record may exceed 60 characters. [05/01/2010b]
10100
All alpha characters must be in upper case. This is exclusive of the vendor information,
type 1 record, record number 3 and the encryption code, type 4 record, record numbers
1, 1.01, and 1.02. [05/01/2010b]
10150
For micro systems, the end of record indicator must be a carriage return and line feed, in
that sequence. [05/01/2010b]
40-782
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
10200
The hospital provider number (record #1, positions 17-22) must be valid and numeric. [05/01/2010b]
10250
All calendar format dates must be edited for 10 character format, e.g., 01/01/2010
(MM/DD/YYYY). [05/01/2010b].
10300
All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian format and
a possible date. [05/01/2010b]
10350
The fiscal year beginning date (record #1, positions 23-29) must be less than the fiscal year
ending date (record #1, positions 30-36). [05/01/2010b]
10400
The vendor code (record #1, positions 38-40) must be a valid code. [05/01/2010b]
10450
The type 1 record #1 must be correct and the first record in the file. [05/01/2010b]
10500
All record identifiers (positions 1-20) must be unique. [05/01/2010b]
NOTE: Contractor's attempt to correct if all record identifiers are not unique in their working
copy and continue processing the cost report. If the condition is correctable,
they notify the provider's vendor and send a copy of the ECR and PI files to the vendor
and CMS Central Office. CMS Central Office requires a vendor software update
to resolve condition. [05/01/2010b]
10550
Only a Y or N are valid for fields which require a yes/no response. [05/01/2010b]
10600
Variable columns (Worksheet B, Parts I, II, and Worksheet B-1) must have a corresponding
type 2 record (Worksheet A label) with a matching line number. [05/01/2010b]
Rev. 3
40-783
4095 (Cont.)
Edit
10650
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
All line, subline, column, and subcolumn numbers (positions 11-13, 14-15, 16-18, and 19-20,
respectively) must be numeric, except as noted below for reconciliation columns. [05/01/2010b]
NOTE: If the administrative and general (A&G) cost center (Worksheet A, line 5) is fragmented
into two or more cost centers, then line 5 must be deleted. Fragmented A&G lines must
be in sequential order. Any cost center with accumulated costs as its statistic must
have its Worksheet B-1 reconciliation column numbered the same as its Worksheet A line
number followed by an "A" as part of the line number followed by the subline number.
For example, the following cost centers appear on Worksheet A, lines 5.01 to 5.06.
5.01 Nonpatient telephones
5.02 Data processing
5.03 Purchasing, receiving, and stores
5.04 Admitting
5.05 Cashiering/accounts receivable
5.06 Other administrative and general
0054 0
0055 0
0056 0
0057 0
0058 0
0059 0
If line 5.06, other administrative and general, is allocated based on accumulated cost,
then the reconciliation column must be numbered 5A.06. This edit does not require
consecutive numbering, only sequential. Line numbers may be skipped but must
be in sequential order, e.g., 5.01, 5.02, 5.04, 5A.06. [05/01/2010b]
10655
40-784
The cost center code (positions 21-25) (type 2 records) must be a code from Table 5, Cost
Center Coding, and each cost center code must be unique. [05/01/2010b]
Rev. 3
10-12
Edit
10700
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
The following standard cost centers listed below must be reported on the lines as indicated
and the corresponding cost center codes may only appear on the lines as indicated.
No other cost center codes may be placed on these lines or subscripts of these lines,
unless indicated herein. [05/01/2010b]
Cost Center
Cap Rel Costs- Bldg & Fixt
Cap Rel Costs- Moveable Equip
Other Cap Rel Costs
Employee Benefits
Adults & Pediatrics
Subprovider - IRF
Subprovider - IPF
Subprovider
Nursery
Skilled Nursing Facility
Nursing Facility
ICF/MR
Other Long Term Care
PBP Clinical Lab Services-Prgm Only
Whole Blood & Packed Red Blood Cells
Blood Clotting for Hemophiliacs
Renal Dialysis
Observation Beds (Non-Distinct Part)
Observation Beds (Distinct Part)
Home Program Dialysis
Ambulance Services
I&R Services-Not Apprv Prgm
Home Health Agency
Kidney Acquisition
Heart Acquisition
Liver Acquisition
Lung Acquisition
Pancreas Acquisition
Intestinal Acquisition
Islet Acquisition
Organ Acquisition
Interest Expense
Utilization Review- SNF
Ambulatory Surgical Center (D.P.)
Hospice
Gifts, Flower, Coffee Shop & Canteen
Research
Physicians' Private Offices
Nonpaid Workers
Rev. 3
4095 (Cont.)
Line
1
2
3
4
30
40
41
42
43
44
45
45.01
46
61
62
62.30
74
92
92.01
94
95
100
101
105
106
107
108
109
110
111
112
113
114
115
116
190
191
192
193
Code
00100-00149
00200-00249
00300
00400-00419
03000
04000
04100
04200
04300
04400
04500
04510
04600
06100
06200-06229
06250-06259
07400
09200
09201-09210
09400
09500
10000
10100-10109
10500
10600
10700
10800
10900
11000
11100
08600-08619
11300
11400
11500-11519
11600-11604
19000-19019
19100-19119
19200-19219
19300-19319
40-785
4095 (Cont.)
Edit
10750
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
Cost center integrity for variable worksheets must be maintained throughout the cost report. For
subscripted lines, the relative position must be consistent throughout the cost report. (See
Table 3E). [05/01/2010b]
EXAMPLE: If you add a neonatal intensive care unit on line 12 of Worksheet S-3, Part I, it must
also be on the first other special care unit line of Worksheet A (line 35), Worksheet
D-1, Part II (line 47), Worksheet D-2, Part I (line 7), etc.
10800
For every line used on Worksheets A; B, Part I; C, Part I; D, Part I-V; and D-2, D-3, D-4 and G-2
there must be a corresponding type 2 record. [05/01/2010b]
10850
Fields requiring numeric data (days, charges, discharges, costs, FTEs, etc.) may not contain
any alpha character. [05/01/2010b]
10900
A numeric field cannot exceed more than 11 positions. Apply to all cost reports. [05/01/2010b]
10950
In all cases where the file includes both a total and the parts which comprise that total,
each total must equal the sum of its parts. [05/01/2010b]
EXAMPLE: The inpatient departmental charges on Worksheet C, Part I, column 6,
sum of lines 30-117 must equal total departmental charges as reported
on Worksheet C, Part I, column 6, line 200.
11000
All dates must be possible, e.g., no "00", no "30" or "31" of February, and the date cannot
be greater than the current date. [05/01/2010b]
10000S
The hospital address, city, state, zip code and county (Worksheet S-2, Part I, lines 1 and
2, columns 1, 2, 3, and 4, respectively) must be present and valid. [05/01/2010b]
10050S
The cost report beginning date (Worksheet S-2, Part I, column 1 , line 20) must be on
or after 05/01/2010.[05/01/2010b]
10100S
The type of control (Worksheet S-2, Part I, column 1, line 21) must be present and a valid code of
1 thru 13. [05/01/2010b]
10150S
All provider and component numbers displayed on Worksheet S-2, Part I, column 2, lines 3-10,
12-19 and line 140, column 2 must contain six (6) alphanumeric characters. [05/01/2010b]
10200S
The cost report period beginning date (Worksheet S-2, Part I, column 1, line 20) must precede the
cost report ending date (Worksheet S-2, column 2, line 20). [05/01/2010b]
40-786
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
10250S
The hospital name, CCN number, CBSA, Provider type, certification date, and title XVIII
payment mechanism (Worksheet S-2, Part I, line 3, columns 1 - 5, and 7, respectively)
must be present and valid [05/01/2010b]
10300S
If Worksheet S-2, Part I, either of lines 3, 4, 5 or 6, column 7 is P, Worksheet S-3, Part II,
column 2, sum of lines 2-43 must be greater than zero. This edit applies to Short Term Acute Care
Hospitals subject to PPS but not an LTCH (Provider number 2000-2299), an IRF (Provider
number 3025-3099), or a Psychiatric (Provider number 4000-4499), or if the third digit of the
provider number is an "S" or a "T". [05/01/2010b]
10350S
For each provider name reported (Worksheet S-2, Part I, column 1, lines 3-10 and 12-19), there
must be corresponding entries made on Worksheet S-2, Part I, lines 3-10 and 12-19 for the provider
number (column 2), the CBSA (column 3), provider type (column 4), the certification date (column 5), and
the payment system for either titles V, XVIII, or XIX (columns 6, 7, or 8, respectively except lines 14, 18
and 19) indicated with a valid code(P, T, O, or N). (See Table 3D) If there is no component
name entered in column 1, then columns 2 through 8 for that line must also be blank. [05/01/2010b]
10400S
If Worksheet S-2, Part I, lines 3-10 and 12-19 column 2 has a response then column 3 must
have a response. [05/01/2010b]
10450S
On worksheet S-2 part I, there must be a response in every ECR file for:
Column 1: lines 21, 22 , 26-27, 56, 59, 60, 63, 70, 75, 80, 85-86, 105, 108, 115, 116, 117,
121, 125, 140, 144-149, 165 and 167.
Columns 1 and 2: 20, 90, 93-94, 96, 120.
Column 2 only: 45-47, 92.
If lines 3-6, 9 and/or 12 have a CCN in column 2, then the respective component, lines 155-160
columns 1 and 2, must be present.
If line 17 has a CCN in column 2, then line 161, column 2 must be present.
If line 22 column 1="Y", then line 22, column 2 and line 23, columns 1 and 2 must be present.
If line 26 column 1 does not equal line 27 column 1, then line 27, column 2 must have a date.
If line 94 (column x, where x = 1 or 2) is "Y", then line 95 (column x) must be present.
If line 96 (column x, where x = 1 or 2) is "Y", then line 97 (column x) must be present.
If CAH (line 105="Y") AND line 56="Y", then line 107, columns 1 and 2, and line 58,
column 1 must be present.
If CAH (line 105="Y"), then line 106, column 1 must be present.
If CAH (line 105="Y"), then line 109 (columns 1-4) must be present.
If NOT CAH (line 105 not="Y") and line 167="Y", then line 169 column 1 must be present.
If line 47, column 2="Y", then line 48, column 2 must be present.
If line 56, column 1="Y" AND not a CAH (line 105 not="Y"), then lines 57 and 58
column 1 must be present.
If line 56, column 1="Y", then line 61, column 1 must be present.
If line 57, column 1="Y", then line 57, column 2 must be present.
If line 61, column 1="Y", then columns 2 and/or 3, must be present.
Rev. 3
40-787
4095 (Cont.)
Edit
10450S
(cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
If line 63, column 1="Y", then lines 66 and/or 67 must be present.
If line 70="Y", then line 71, column 1 must be present.
If line 71, column 1="Y", then line 71, column 2 must be present.
If line 75, column 1="Y", then line 76, column 1 must be present.
If line 76, column 1="Y", then line 76, column 2 must be present.
If line 90, (column x, where x=1 or 2)="Y", then line 91 (column x) must be present.
If line 91, column 1 or 2="Y" (Title V or XIX), then lines 45 and 46, same respective
columns 1 or 3 (Title V or XIX), must be present.
If line 115, column 1="Y", then line 115, column 2 must be present.
If line 117="Y" then line 118, column 1; line 118.01, columns 1 or 3, and line 118.02, column 1
must be present. [06/30/2012]
If line 140, column 1="Y", and column 2 is not blank, then lines 141-143 (all columns except PO Box)
must be present (i.e. Home Office info).
If line 165="Y", then line 166, columns 0-5, must be present.
NOTE: Line 86 contains a default response of "N" for facilities which do not contain a
subprovider type component. [05/01/2010b]
10500S
If there is an IPF (S-2, Part I, line 3 or 4 and subscript, column 2 is in the range of 4000 to 4499,
or there is a “S” or "M" in the third position of the provider number). If line 71 column 1, is "Y" for yes,
and column 2 is "Y" for yes, then column 3 must be 1, 2, 3, 4 or 5. If there is not an IPF as
the provider or subprovider, then Worksheet S-2, Part I, line 70, column 1 must be "N". [05/01/2010b]
10550S
If there is an IRF (S-2, Part I, line 3 or 5 and subscript, column 2 is in the range of 3025 to 3099,
or there is a “T” or "R" in the third position of the provider number). If line 76 column 1, is "Y" for yes,
and column 2 is "Y" for yes, then column 3 must be 1, 2, 3, 4 or 5. If there is not an
IRF as the provider or subprovider, then Worksheet S-2, Part I, line 75, column 1 must be "N".
[05/01/2010]
10600S
For CAH, if Worksheet S-2, Part I, column 1, line 56 equal "Yes" , and column 1, line 105 is also "Yes",
then questions 56-59 do not apply and are replaced with question 107. [05/01/2010b]
10650S
If there is an LTCH (S-2, Part I, line 3, column 2 is in the range of 2000 to 2299), Worksheet S-2,
Part I, line 80, column 1 must be "Y". If there is not a LTCH, as a provider, then Worksheet S-2,
Part I, line 80 must be "N". [05/01/2010b]
10700S
If Worksheet S-2, Part I, column 7, either of lines 3 or 6 contain a "P," then lines 45, column 2
must contain either a "Y", "N" or "P" response. [05/01/2010b]
11750S
If Worksheet S-2, Part I, line 56 response is "Y", then line 57 must contain a response "Y"
or "N". This edit does not apply if Worksheet S-2, Part I, line 107 is "Y". [05/01/2010b]
12000S
If Worksheet S-2, Part I, line 22, column 2 is “Y”, then Worksheet E, Part A, line 33 must be 35
percent. [05/01/2010b]
40-788
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Edit
4095 (Cont.)
Condition
12005S
If Worksheet S-2, Part I, line 22, column 1 is “Y”, and has a CCN of XX-0001 through
XX-0879 and Worksheet S-3, Part I, line 1, column 7 is greater than zero, then Worksheet S-2,
Part I, line 24, the sum of columns 1 through 4 and 6, must be greater than zero. In addition,
if Worksheet S-3, Part I, line 2, column 7 is greater than zero, then Worksheet S-2, Part I,
line 24, column 5 must be greater than zero. If Worksheet S-2, Part I, line 22, column 1
is "N", do not apply this edit.[06/30/2012]
12010S
If Worksheet S-2, Part I, line 3, column 2 has a CCN of XX-3025 through XX-3099, and Worksheet S-3,
Part I, line 1, column 7 is greater than zero, then Worksheet S-2, Part I, line 25, the sum of columns 1
through 4 and 6, must be greater than zero. In addition, if Worksheet S-3, Part I, line 2, column 7 is
greater than zero, then Worksheet S-2, Part I, line 25, column 5 must be greater than zero. [06/30/2012]
12015S
If Worksheet S-3, Part I, line 17, column 7 is greater than zero, then Worksheet S-2, Part I, line 25,
the sum of columns 1 through 4 and 6 must be greater than zero, and if Worksheet S-3, Part I, line 4,
column 7 is greater than zero, then Worksheet S-2, Part I, line 25, column 5 must be greater than
zero. [06/30/2012]
12030S
Worksheet S-2, Part I, column 2, lines as indicated below may only contain those provider
numbers as indicated for that line. The type of provider is also indicated. [05/01/2010b]
This was a Level 2 Edit # 20550S but now changed to Level 1 as a rejectable edit
to be consistent with HCRIS edits.
Line
3
4-6
9
Rev. 3
Provider # (1)
Type Provider
0001-0899
1225-1299
1300-1399
1990-1999
2000-2299
3025-3099
3300-3399
4000-4499
Short Term Hospitals
Medical Assistance Facility
RPCH/CAH
Christian Science Hospitals
Long Term Hospitals
Rehabilitation Hospitals
Children's Hospitals
Psychiatric Hospitals
3rd digit of provider number is M (Psychiatric unit in Critical Access Hospital)*
3rd digit of provider number is R (Rehabilitation unit in Critical Access Hospital)*
3rd digit of provider number is S (Psychiatric unit)*
3rd digit of provider number is T (Rehabilitation unit)*
3rd digit of provider number is U (Swing bed designation for Short Term Hospital)*
3rd digit of provider number is V (Swing bed designation for Long Term Care Hospital)*
3rd digit of provider number is Y (Swing bed designation for Rehabilitation Hospital)*
3rd digit of provider number is Z (Swing bed designation for Critical Access Hospital)*
0001-0899
Short Term Unit of Non-PPS Hospital
3025-3099
Rehabilitation Hospital as Subprovider
4000-4499
Psychiatric Hospital as Subprovider
5000-6499
6990-6999
Hospital-Based SNF
Skilled Nursing Facilities
40-788.1
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Edit
10-12
Condition
Line
Provider # (1)
Type Provider
G000-G999
H000-H999
ICF/MR
"
12
3100-3199
7000-8499
9000-9999
Home Health Agencies
"
"
"
"
13
C000-C999
Ambulatory Surgical Center
14
1500-1799
Hospital-Based Hospice
15
3400-3499
3975-3999
8500-88 99
Hospital-Based RHC
"
"
"
"
1000-1199
Hospital-Based FQHC
"
"
10.01
16
1800-1989
* These are hospital components (excluded unit) whose last three (3) numbers
match those last three (3) numbers of the hospital.
17
1400-1499
4600-4799
4900-4999
3200-3299
4500-4599
4800-4899
6500-6989
CMHC
"
"
CORF
"
"
O/P Rehab. Providers (OPT, OOT, OSP)
18
2300-2499
3500-3799
Renal - Hospital Satellites
"
134
3rd digit of provider number is P (Organ Procurement Organization)*
134
9800-9899
Transplant Centers
(1) The first two characters of the provider number (not listed here) identify the state.
The last 4 characters (listed above) identify the type of provider.
(*) EXCEPTION - Organ procurement organization (OPOs) are assigned a 6-digit CCN.
The first 2 digits identify the State code. The third digit is the alpha character "P". The
remaining 3 digits are unique facility identifier.
40-788.2
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
12050S
If this hospital qualifies for sole community hospital (SCH) status (see 42 CFR 412.92) and
Worksheet S-2, Part I, line 35 is greater than zero, then the beginning and ending dates on line
36 must be present. The number entered on line 35 should agree with the number of times line
36 is being subscripted and vice versa. The beginning and ending dates, line 36 and any continuation
of the subscripts, columns 1 and 2 must be within the parameters of the cost reporting period's
beginning and ending dates, and the ending date may not be earlier than the beginning
date. Conversely, if there is a date on line 36, then line 35 must be greater than zero.
Line 35, column 1, can only have a response of -0-, 1, or 2. [05/01/2010b]
12100S
If this hospital qualifies for medical dependent hospital (MDH) status (see 42 CFR 412.108) and
Worksheet S-2, Part I, line 37 is greater than zero, then the beginning and ending dates on line
38 must be present. The beginning and ending dates, line 38 and any continuation of
of the subscripts, columns 1 and 2 must be within the parameters of the cost reporting period's
beginning and ending dates, and the ending date may not be earlier than the beginning
date. Conversely, if there is a date on line 38 then line 37 must be greater than zero. [05/01/2010b]
12150S
If Worksheet S-2, Part I, column 1, line 115 equals "Yes", column 2, line 115 must have a
designation of A, B, or E. [05/01/2010b]
Rev. 3
40-789
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
12200S
If Worksheet S-2, Part I, line 47, column 2 equals "Y", then line 48 , column 2 must have a response
for all cost reports.[05/01/2010b]
12300S
If the hospital has rendered title XIX inpatient services (Worksheet S-2, Part I, line 90 column 2 is 'Y'),
then title XIX hospital days (Worksheet S-3, Part I, column 7, line 14) and title XIX hospital
discharges (Worksheet S-3, Part I, column 14, line 14) must both be greater than zero. [05/01/2010b]
12350S
All amounts reported on Worksheet S-3, Part I must not be less than zero. [05/01/2010b]
12400S
For Worksheet S-3, Part I, the sum of the inpatient days/outpatient visits in columns 5, 6,
and 7 for each of lines 1, 5-20, 22, 24-26, 28 and 30-32 must be equal to or less than the total
inpatient days/outpatient visits in column 8 for each line. [05/01/2010b]
12450S
If the hospital and/or subprovider is subject to PPS but not an LTCH (Provider number 2000-2299),
an IRF (Provider number 3025-3099), or a Psychiatric (Provider number 4000-4499), or if the third
digit in the provider number is an "S' or a "T". For a CAH a "M" or "R". (Worksheet S-2, Part I, line 3
and/or 6, column 7="P"). Worksheet S-3, Part II, column 5 lines 1-43 must be equal to or
greater than zero. [05/01/2010b]
12500S
For Worksheet S-3, Part I, the sum of the discharges in columns 12, 13, and 14 for each of
lines 1, 14, 16-18 must be equal to or less than the total discharges in column 15 for
each line indicated. [05/01/2010b]
12550S
If Worksheet S-2, Part I, column 1, line 75 equals "Y", then column 7, line 3 if it is the hospital or line 5
if it is the subprovider has to be "P". If column 1, line 75, is "N", then column 2 line 3, if it is the
hospital, cannot be in the range 3025-3099, and line 5 must be blank. [05/01/2010b]
40-790
10-12
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
12600S
If there is a LTCH (Worksheet S-2, Part I, line 3, column 2 is in the range of 2000 to 2299), then
Worksheet S-2, Part I, line 80, column 1 must be "Y" [05/01/2010b]
12650S
If Worksheet S-2, Part I, line 71, column 1 is "Y", then Worksheet S-2, Part I, line 70, column 1
must be "Y". [05/01/2010b]
12660S
If Worksheet S-2, Part I, line 120, column 1 , is “Y” and the providers beds on Worksheet E,
Part A, line 4 are greater than 100, and the provider’s cost report period overlaps March 1, 2012,
then Worksheet D, Part V, sum of the charges on lines 50-98, column 2.01, must be greater
than zero, If Worksheet S-2, Part I, line 120, column 1, is "Y" and the providers beds
on Worksheet E Part A, line 4 are less than or equal to 100, do not apply this edit. [05/01/2010b]
12800S
If Worksheet S-2, Part I, line 121 is answered “Y” then there must be an amount greater than 0 on
line 72, column 26 on worksheet B, Part I and vice versa.[05/01/2010b]
12850S
If Worksheet S-2, Part I, line 167, column 1 is “Y”, then Worksheet S-2, Part I, line 20,
column 1 (cost report beginning date) must be on or after 10/01/2010. [05/01/2010b]
12900S
If Worksheet S-7, column 1, line 1 equals "Y", then Worksheet S-3, Part I, column 6,
line 19 must equal zero and vice versa. If Worksheet S-7, column 1, line 2 equals “N”, then
Worksheet S-3, Part I, column 6, line 5 must equal zero and vice versa. [05/01/2010b]
12905S
If Worksheet S-2, Part II, column 1, line 9 is "Y", then Worksheet S-2, Part I, column 1, line 56
must also be "Y" and Worksheet A, column 7, sum of line 21 and 22 must be greater than 0,
and Worksheet E-4 for title XVIII must also be completed.[06/30/2012]
12910S
Worksheet S-2, Part II must have a response in every ECR file for:
Column 1 : lines 1-12, and 15.
If line 1, column 1 = "Y", then line 1, column 2 must be present.
If line 2, column 1 = "Y", then line 2, columns 2 and 3 must be present.
If line 4, column 1 = "Y", then line 4, columns 2 must be present.
If line 6, column 1 = "Y", then line 6, column 2 must be present.
If line 12, column 1 = "Y", then lines 13 and 14, column 1 must be present.
If line 16, column 1 = "Y", then line 16, column 2 must be present.
If line 16, column 3 = "Y", then line 16, column 4 must be present.
If line 17, column 1 = "Y", then line 17, column 2 must be present.
If line 17, column 3 = "Y", then line 17, column 4 must be present.
If lines 16 or 17, (column x, where x = 1 or 3) is "Y", then line 18, column x must be present.
If lines 16 or 17, (column x, where x = 1 or 3) is "Y", then line 19, column x must be present.
If lines 16 or 17, (column x, where x = 1 or 3) is "Y", then line 20, column x must be present.
If line 20, columns 1 or 3 are “Y”, then line 20, column 0 must be present
Columns 1 and 3: lines 16, 17, and 21.[06/30/2012]
Rev. 3
4095 (Cont.)
40-791
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
12920S
If Worksheet S-2, Part I, line 3, column 7 is "T" or "O" (except for children's hospitals (CCN XX-3300
thru XX-3399)), then Worksheet S-2, Part II must have a response in every ECR file for:
Column 1 : lines 22-32, 34 and 36.
If line 32, column 1 = "Y", then line 33, column 1 must be present.
If line 34, column 1 = "Y", then line 35, column 1 must be present.
If line 36, column 1 = "Y", then line x (where x = 37, 38, 39, or 40), column 1; must be present.
If line 38, column 1 = "Y", then line 38, column 2 must be present.[06/30/2012]
12930S
The cost report preparer information (Worksheet S-2, Part II, lines 41-43, all columns) must
be valid and present. [06/30/2012]
The following Wage Index edits are to be applied against PPS Short Term Acute Care Hospital Providers only,
edit numbers 13000S, 13050S, 13100S, 13150S, 13200S and 13250S. These edits do apply if the hospital
is subject to PPS but not an LTCH (Provider number 2000-2299), an IRF (Provider number 3025-3099),
a Psychiatric (Provider number 4000-4499) or if the third digit of the provider number is an "S" or a "T".
If the third digit of provider number is M (Psychiatric unit in Critical Access Hospital) or the third digit of
provider number is R (Rehabilitation unit in Critical Access Hospital).
13000S
For Worksheet S-3, Part II, sum of columns 2 and 3, each of lines 1-43 and subscripts
as applicable must be equal to or greater than zero. [05/01/2010b]
13050S
The amount of salaries reported for Interns & Residents in approved programs,
Worksheet S-3, Part II, column 1, line 7 must be equal to the amount on Worksheet A,
column 1, line 21 (including subscripts). [05/01/2010b]
13100S
The amount on Worksheet S-3, Part II, sum of columns 2 & 3, line 9 must equal the
corresponding amount on Worksheet A, column 1, line 44 plus or minus any related
amounts reported on Worksheet A-6, columns 4 and/or 8 for line 44 designation indicated
in columns 3 and/or 7. [05/01/2010b]
13150S
The amount on Worksheet S-3, Part II, sum of columns 2 & 3, line 10 must equal the
corresponding amount on Worksheet A, column 1, lines 20, 23, 40-42, 45-46, 88, 89 , 94-95,
98-101, 105-112, 114, 115-117 and 190-194, and subscripts thereof, plus or minus any
related amounts reported on Worksheet A-6, columns 4 and/or 8 for lines 20, 23, 40-42,
45-46, 88, 89 , 94-95, 98-101, 105-112, 114, 115-117 and 190-194 and subscripts thereof,
indicated in columns 3 and/or 7. [05/01/2010b]
13200S
Worksheet S-3, Part II, sum of columns 2 & 3, line 17 must be greater than zero. Apply
this edit to PPS providers only. [05/01/2010b]
13250S
If Worksheet S-3, Part II, sum of columns 2 and 3, lines 1-16 and 26-43 is greater than zero,
then the corresponding line for column 5 must be greater than zero. If the sum of column 5,
lines 9 and 10 divided by the sum of column 5, line 1 minus lines 2, 3, 5, 6, 7 and 8 is less than
15%, then lines 26-43 are not required to be completed. [05/01/2010b]
13275S
For IPPS (Worksheet S-2, Part I, line 3, column 7 is "P") and the CCN is XX-0001 through
XX-0899, then the amount on Worksheet S-3, Part IV, line 24 must be greaterthan zero.[05/01/2010b]
40-792
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
13300S
Eliminated as of 05/01/2010b.
13350S
If Worksheet S-4, line 20, column 1 has data then it must be five numeric digits
(CBSA). [05/01/2010b]
13375S
If Worksheet S-5, line 13 is greater than zero, line 15 must be greater than zero (and vice versa).
If line 14 is greater than zero, line 16 must be greater than zero (and vice versa).
If line 17 is greater tha zero, line 19 must be greater than zero (and vice versa).
If line 18 is greater than zero, line 20 must be greater than zero (and vice versa).
Additionally, if Worksheet S-5, lines 13 or 17 are greater than zero, Worksheet A,
line 74, column 7 must be greater than zero and if Worksheet S-5, line 14 or 18
are greater than zero, Worksheet A, line 94, column 7 must be greater than zero.[06/30/2012]
13400S
The sum of Worksheet S-7, column 2 , lines 3 thru 199 must agree with Worksheet S-3,
Part I, column 6, line 19. The sum of Worksheet S-7, column 3, lines 3 through 199 must
agree with Worksheet S-3, Part I, column 6, line 5,excluding CAH. [05/01/2010b]
10000A
Worksheet A, columns 1 or 2, line 200 must be greater than zero. [05/01/2010b]
10050A
If the hospital is not a rural hospital qualifying for an exception to the CRNA fee schedule
(Worksheet S-2, Part I, line 108, column 1 = "N"), then nonphysician anesthetist costs after
reclassification and adjustment (Worksheet A, column 7, line 19) must equal zero. [05/01/2010b]
10100A
Interest expense, utilization review-SNF, and other capital-related costs after reclassification
and adjustment (Worksheet A, column 7, lines 3 and 113-114) must equal zero. [05/01/2010b]
10150A
Worksheet A, Line 3, column 7 should be zero for the cost reporting period.[05/01/2010]
10200A
For reclassifications reported on Worksheet A-6, the sum of all increases (columns 4 and 5)
must equal the sum of all decreases (columns 8 and 9). [05/01/2010b]
10250A
Worksheet A-6, column 1 must be present and in all uppercase alpha characters for each line
with a column 3, 4, 5, 7, 8, 9, or 10 entry. There must be an entry on each line of columns 4
or 5 for each entry in column 3 and vice versa and an entry on each line of columns 8 or 9 for
each entry in column 7 and vice versa. All entries must be valid; for example, no salary
adjustment on column 3 and/or 7, lines 1-3 for capital, 61, 92, and 113 . [05/01/2010b]
10300A
If Worksheet S-2, Part I, column 7, if any of lines 3 - 6 equals P and Worksheet S-2, Part I,
line 21 equals 1, 2, 3, 4, 5, or 6, then Worksheet A-7, Part I, columns 1-3, line 10 minus
column 5, line 10 must be greater than zero and Worksheet A-7, Part III, sum of columns 9-14,
lines 1-2 must be greater than zero. [05/01/2010b].
10350A
Worksheet A-7, Part III sum of column 9-14, lines 1-2 and subscripts (for each line, respectively)
must equal the corresponding line on Worksheet A, column 7, lines 1-2 and subscripts. [05/01/2010b]
Rev. 3
40-793
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
10351A
If Worksheet A-7, Part III, line 3, sum of columns 5, 6 and 7 is greater than zero, then
the sum of A-7 Part III, line 3, columns 1 and 2 must also be greater than zero. [05/01/2010b]
10400A
For Worksheet A-8 adjustments on lines 3-9, 11, 13-22, 29 and 32, if either columns 1,
2, or 4 has an entry, then all three columns for that line must have entries and if any one
of columns 0, 1, 2, or 4 for lines 33-49 and subscripts thereof has an entry, then all four
columns for that line must have entries. [05/01/2010b]
10425A
For Worksheet A-8 adjustments on lines 1-2, 26 and 27, if any column 1, 2 and 5
have an entry, then all three columns for those lines must have entries.[05/01/2010b]
10450A
If Worksheet A-8-1, Part A, either of columns 4 or 5, lines 1 through 4 does not equal
zero, then column 1, the corresponding line must be present. [05/01/2010b]
10500A
If there are any transactions with related organizations or home offices as defined in CMS
Pub. 15-1, chapter 10 (Worksheet S-2, Part I, column 1, line 140 is "Y"), Worksheet A-8-1,
Part A, columns 4 or 5 (amounts in columns 4 or 5 must have a parallel line number in column 1
and vice versa), sum of lines 1-4 must be greater than zero; and Part B, column 1, any one
of lines 6-10 must contain any one of alpha characters A thru G. Conversely, if Worksheet
S-2, Part I, column 1, line 140 is "N", Worksheet A-8-1 should not be present. [05/01/2010b]
10550A
Worksheet A-8-2, column 3 must be equal to or greater than the sum of columns 4 and 5 and
columns 6 and 7 must each be greater than zero if column 5 is greater than zero. Critical Access
Hospitals (CAH) are exempt from completing columns 6 & 7. [05/01/2010b]
10600A
Worksheet A-6, column 10 must contain values of 9-14 (Worksheet A-7, Part III, column
reference) for the corresponding line of column 3 or column 7 which contains a capital
related line number value of 1-2 and/or subscripts thereof. [ [05/01/2010b]].
10650A
Worksheet A-8, column 5 must contain a value of 9-14 (Worksheet A-7, Part III, column
reference) for any line in column 4, including lines 1-2 and 26-27 which contain a capital
related line reference of 1-2 and/or subscripts thereof and has a basis code in column 1
and/or an amount in column 2. [05/01/2010b]
10700A
Worksheet A-8-1, Part A, column 7, lines 1-4 and subscripts thereof must contain a value
of 9-14 (Worksheet A-7, Part III, column 7 reference) if column 1, the corresponding
line is 1-2 and/or subscripts thereof. [05/01/2010b].
10750A
If Worksheet A-8-3, sum of columns 1-4, line 47 is equal to zero, column 5, line 51 must also
be equal to zero. Conversely, if Worksheet A-8-3, sum of columns 1-4, line 47 is greater than
zero, column 5, line 51 must be greater than sum of columns 1-4, line 47 and equal to or
less than 2080 hours. [05/01/2010b]
10800A
If Worksheet S-2, Part I, line 144 equals "Y", then Worksheet A-8-2 column 3 must be greater
than zero and vice versa . [05/01/2010b]
40-794
10-12
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
10000B
On Worksheet B-1, all statistical amounts must be greater than zero, except for
reconciliation columns. [05/01/2010b]
10050B
Worksheet B, Part I, column 26, line 202 must be greater than zero. [05/01/2010b]
10100B
For each general service cost center with a net expense for cost allocation greater than zero
(Worksheet B-1, columns 1 through 23, line 202), the corresponding total cost allocation
statistics (Worksheet B-1; column 1, line 1; column 2, line 2, etc.) must also be greater than
zero. Exclude from this edit any column which uses accumulated cost as its basis for allocation
and any reconciliation column. [05/01/2010b]
10150B
For any column which uses accumulated cost as its bases of allocation (Worksheet B-1), if there
is a -1 in the accumulated cost column, then there may not be an amount in the reconciliation column
for the same cost center line. [05/01/2010b]
10000C
On Worksheet C, Part I, all amounts must be equal to or greater than zero. [05/01/2010b]
10050C
Worksheet C, Part I, column 1, line 92 must equal the sum of all title XVIII, Worksheets D-1,
column 1, line 89 for hospital and subprovider components. [05/01/2010b]
10100C
If Worksheet S-3, Part I, column 8, lines 1, 8 through 12 are greater than zero, the
corresponding line (lines 30 through 35) on Worksheet C, Part I, column 6 must
also be greater than zero and vice versa . [05/01/2010b]
Rev. 3
40-795
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
10050D
If Medicare hospital inpatient days (Worksheet S-3, Part I, column 6, line 14) and Medicare
hospital inpatient ancillary pass through costs (Worksheet D, Part IV, column 11, line 200)
are greater than zero and the hospital does not have an all inclusive rate (Worksheet S-2, Part I
column 1, line 115 is "N"), then Medicare hospital inpatient ancillary service costs (Worksheet
D-3, column 3, line 200) must also be greater than zero. [05/01/2010b]
10100D
The total inpatient charges on each line of Worksheet C, Part I, column 6 must be greater
than or equal to the sum of all Worksheets D-3, column 2, lines as appropriate. [05/01/2010b]
10150D
Worksheet D-1, Part IV, line 87 for title XVIII hospital must equal Worksheet S-3, Part I,
column 8, line 28. [05/01/2010b]
10200D
Worksheet D-1, column 1, sum of lines 5 and 6 must equal Worksheet S-3, Part I,
column 8, line 5 and Worksheet D-1, column 1, sum of lines 10 and 11 must be equal to or
less than Worksheet D-1, column 1, sum of lines 5 and 6. [05/01/2010b]
10250D
Worksheet D-1, Title 18, sum of lines 10 and 11, must equal Worksheet S-3 Part I,
line 5, column 6. [05/01/2010b]
10300D
If the sum of Worksheet D-2, Part I, column 1, lines 2-8, 10-19, and 21-26 is greater than
zero, then line 28, column 1 must equal 100 percent. [05/01/2010b]
10350D
The sum of all Worksheets D-1, column 1, line 85 for all titles for both SNF and/or NF
components must be equal to or less than the absolute value of Worksheet A-8, line 25.
If Worksheet S-7, line 2, column 1, equals "Y", add Worksheet(s) E-2, column 1, line 7 to
Worksheet D-1 for the comparison of the absolute value of Worksheet A-8, line 25. [05/01/2010b]
10400D
If any of the hospital's Worksheet D-1, lines 17-20 are greater than zero, then each D-1
with line 21 greater than zero for Title V, Title XVIII and Title XIX must have the same
rates for line 17-20. Do not apply this edit to CAH. [05/01/2010b]
10450D
If Worksheet S-3, Part I, column 6, lines 1, 8-12 (or lines 16-17 for psych or rehab subproviders)
are greater than zero, then the corresponding line on Worksheet D-3, column 2, lines 30-41
must also be greater than zero and vice versa. [05/01/2010b]
10500D
If Worksheet D-4, lines 1-6, column 1 or lines 8-40 columns 2 or 3 have data, then
Worksheet S-2, Part I, lines 126 through lines 133 and subscripts of column 1 must have a
a certification date. [06/30/2012]
10550D
If Worksheet S-2, Part I, line 60 is “N” for no, then Worksheet D, Part III, columns 1 and 2
and Worksheet D, Part IV, columns 2 and 3 must also be zero and vice versa.[06/30/2012]
40-796
10-12
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
10000E
If Worksheet S-2, Part I, line 22, is "N", then Worksheet E, Part A for lines 32-34
must each be equal to zero and conversely if line 22 is "Y" each of the aforementioned
lines must be greater than zero. [05/01/2010b]
10100E
Worksheet E, Part A, line 40, column 1, if applicable (for hospital, title XVIII only) must
be equal to or less than Worksheet S-3, Part I, column 13, line 14. [05/01/2010b]
10150E
Worksheet E, Part A, line 30 must equal Worksheet L, Part I, line 7 where both amounts are
present. [05/01/2010b]
10170E
If Worksheet E, Part A, line 48 is greater than zero, Worksheet S-2, Part I, lines 35 or 37 must
be greater than zero and conversely, if Worksheet S-2, Part I, lines 35 or 37 is greater than zero
then Worksheet E, Part A, line 48 must be greater than zero. For title XVIII PPS
providers whose certification date is after 10/01/1987, do not apply this edit. [05/01/2010b]
10200E
If Worksheet S-2, Part I, line 3 or 5 column 4, equals "5", line 75, column 1, equals "Y", then
line 1 on worksheet E-3, Part III, for the rehabilitation facility must be greater than zero and
"vice versa". If there is no Medicare Utilization for the Rehab component (Worksheet S-3,
Part I, line 1 or 17, column 6), then the payment on Worksheet E-3, Part III line 1 must be zero,
and the vice versa does not apply. The provider number on Worksheet S-2, Part I, line 3, column 2
must be in the range of 3025-3099 or line 5, column 2 must be in the range of 3025-3099 or have in
the third position the letter code "T". A CAH with a IRF subprovider must have in the
third position the letter "R" in the provider number. [05/01/2010b]
10250E
If Worksheet S-2, Part I, line 76, column 1 is "Y", and column 2 is "N", then Worksheet E-3,
Part III, line 5 must have an amount greater than zero and vice versa. If there is no Medicare
Utilization for the Rehab component (Worksheet S-3, Part I, line 1 or 17, column 6 is zero),
then the payment on Worksheet E-3, Part III line 1 must be zero, and the vice versa does
not apply.[05/01/2010b]
10300E
If Worksheet S-2, Part I, line 76, column 1 is "N" and column 2 is "Y", and column 3 is
1, 2, or 3, then Worksheet E-3, Part III, line 8 must be greater than zero. If there is no
Medicare Utilization for the Rehab component (Worksheet S-3, Part I line 1 or 17, column 6 is zero),
then the payment on Worksheet E-3, Part III, line 1 must also be zero. [05/01/2010b]
Rev. 3
40-797
4095 (Cont.)
Edit
10350E
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
If Worksheet S-2, Part I, line 76, column 1 is "N", column 2 is "Y", column 3 is "4", then
Worksheet E-3, Part III lines 6, 7 and 8 must be greater than zero. If there is no
Medicare Utilization for the Rehab component (Worksheet S-3, Part I, line 1 or 17,
column 6 is zero), then the payment on worksheet E-3, Part III line 1 must also
be zero. [05/01/2010b]
10400E
If Worksheet S-2, Part I, line 76, column 1 is "N", column 2 is "Y", column 3 is "5", then
Worksheet E-3, Part III, lines 6 and 7 must be greater than zero. If there is no
Medicare Utilization for the Rehab component (Worksheet S-3, Part I, line 1 or 17,
column 6 is zero), then the payment on worksheet E-3, Part III line 1 must also
be zero. [05/01/2010b]
10450E
If Worksheet S-2, Part I, line 3 column 4 equal "2", and line 80, column 1 is "Y", then Worksheet
E-3, Part IV, line 1, for Long Term Care Facility must be greater than zero and vice versa.
The provider number on Worksheet S-2, Part I, line 3, column 2 must be in the range of 2000-2299.
If there is no Medicare Utilization for the Long Term Care facility (Worksheet S-3, Part I, line 1,
column 6 is zero), then the payment on Worksheet E-3, Part IV, line 1 must be zero and
vice versa does not apply. [05/01/2010b]
10500E
If Worksheet S-2, Part I, lines 3 or 4, column 4, equals "4", and line 70, column 1 is "Y",
then Worksheet E-3, Part II, line 1 for Inpatient Psychiatric Facility must be greater than
zero and vice versa. The provider number on Worksheet S-2, Part I, line 3, column 2 must be
in the range of 4000-4499 or line 4, column 2, must be in the range of 4000-4499 or
have in the third position letter "S". A CAH with a Psychiatric subprovider must have
the third position the letter "M" in the provider number. If there is no Medicare Utilization
for the Inpatient Psychiatric Facility (Worksheet S-3, Part I, line 1 or 16, column 6
is zero), then the payment on worksheet E-3, Part II line 1 must be zero and vice versa
does not apply. [05/01/2010b]
10600E
40-798
If Worksheet S-2, Part I, line 71, column 1 is "Y", and column 2 is "N", then Worksheet E-3,
Part II, line 4 must have an amount greater than zero and vice versa. If there is no
Medicare Utilization for the Inpatient Psychiatric facility (Worksheet S-3, Part I,
line 1, or 16 column 6 is zero), then the payment on Worksheet E-3, Part II,
line 4 must be zero and vice versa does not apply. [05/01/2010b]
Rev. 3
10-12
Edit
10650E
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
If Worksheet S-2, Part I, line 71, column 1 is "N" and column 2 is "Y", and column 3 is
1, 2, or 3, then Worksheet E-3, Part II line 7 must be greater than zero. If there is no
Medicare Utilization for the Inpatient Psychiatric facility (Worksheet S-3, Part I, line 1 or
3 column 6 is zero), then the payment on Worksheet E-3, Part II, line 7 must also
be zero. [05/01/2010b]
10700E
If Worksheet S-2, Part I, line 71, column 1 is "N", column 2 is "Y", and column 3 is
"4", then Worksheet E-3, Part II lines 5, 6 and 7 must be greater than zero. If there is no
Medicare Utilization for the Inpatient Psychiatric facility (Worksheet S-3, Part I, line 1 or 16,
column 6 is zero), then the payment on Worksheet E-3, Part II, lines 5, 5, and 7 must also
be zero. [5/01/2010b]
10750E
If Worksheet S-2, Part I, line 71, column 1 is "N", column 2 is "Y", and column 3 is "4", then
"4", then Worksheet E-3, Part II, lines 5 and 6 must be greater than zero. If there is no
Medicare Utilization for the Inpatient Psychiatric facility (Worksheet S-3, Part I, line 1 or 16
column 6), then the payment on Worksheet E-3, Part II, line 5 and 6 must also
be zero. [05/01/2010b]
10800E
Worksheet E-3, Part VI, Line 9 Bad Debt for dual eligible beneficiaries new amounts,
cannot exceed the total bad debt line 8 (e.g. Worksheet E-3, Part I, line 13 cannot exceed
line 11, E-3, Part II, line 25 cannot exceed line 23, E-3, Part III, line 26 cannot exceed
line 24, E-3, Part IV, line 16 cannot exceed line 14, E-3, Part V, Line 27 cannot exceed line 25).
Do not apply this edit if total bad debt is negative. [05/01/2010b]
10850E
If Worksheet S-2, Part I, line 61 , column 1 is "Y", then Worksheet E, Part A line 8.01 or
E-4, line 4.01 must be greater than zero and vice versa.[05/01/2010b]
10900E
If Worksheet E, Part A, line 24 is less than or equal to zero, then lines 25-28 should be zero.
[05/01/2010b]
Rev. 3
40-799
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
10000H
Worksheet H-2, Part II, sum of lines 1-19 for each of columns 1-4, and 5-23 (including
the reconciliation column and accumulated cost column with negative one entries only)
must equal the corresponding column of Worksheet B-1, line 101 and subscripts as
appropriate. [05/01/2010b]
10050H
Worksheet H-2, Part I, columns 0 -4, 5-23, and 25, lines 1-19 must agree with the
corresponding columns on Wkst B, Part I, line 101 and subscripts as
applicable. [05/01/2010b]
10100H
If Worksheet H-1, Part I, any of columns 1-4, line 24 is greater than zero, then Worksheet
H-1, Part II, sum of the corresponding columns must be greater than zero. [05/01/2010b]
10150H
Total visits on Worksheet H-3, Part I, sum of column 4, lines 1-6 must be equal to or greater
than the unduplicated census count, Worksheet S-4, sum of columns 1-4, line 2.
Do not apply this edit if Worksheet S-4, sum of columns 1-3, line 2 equal zero.
[05/01/2010b]
10175H
If Worksheet H-3, line 7 (sum of columns 6 and 7) is greater than zero, then Worksheet H-4,
line 22 (sum of columns 1 and 2) and Worksheet H-5, line 4 (sum of columns 2 and 4) must
be greater than zero and vice versa. [06/30/2012]
10200H
Worksheet H, column 10, line 24 must equal Worksheet A, column 7, line 101 and/or
subscripts as applicable.[05/01/2010b]
10250H
Worksheet H-3, Part I, sum of lines 1 through 6, column 4, must equal Worksheet S-3, Part I,
column 8, line 22 and subscripts as applicable. [05/01/2010b]
10300H
Worksheet H-3, Part I, the Medicare visits, columns 6-7, lines 1-6 respectively, must be equal to
Worksheet S-4, columns 1-4, lines 21, 23, 25, 27, 29, and 31 respectively. Also, Worksheet H-3,
Part I, lines 8 through 13, columns 2 and 3, sum of all CBSA’s, for each respective discipline,
must equal the total visits for the same respective discipline, on lines 1 through 6, columns 6 and 7.
[05/01/2010b]
40-800
10-12
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
10000I
Worksheet I-1(Renal Dialysis), column 1, sum of lines 1-8 and 10-16 must equal Worksheet A,
column 7, line 74. Worksheet I-1 (Home Program), column 1, sum of lines 1-8 and 10-16 must
equal Worksheet A, column 7, line 94. If worksheet S-2, part I, line 145 equals "Y", do not apply this edit
to Renal Dialysis department. (Do not complete Renal Dialysis department Worksheets I-1 through
I-4 for this cost report). [05/01/2010b]
10050I
Worksheet I-1 (Renal Dialysis), column 1, sum of lines 1-8, 10-16, and 18-26 must equal the
amount from Worksheet B, Part I, column 26, line 74. Worksheet I-1(Home Program), column 1,
sum of lines 1-8, 10-16, and 18-26 must equal the amount from Worksheet B, Part I, column 26, line 94.
If Worksheet S-2, Part I, line 145 equals "Y", do not apply this edit to Renal Dialysis departments. Do not
complete Renal Dialysis department Worksheets I-1 through I-4 for this cost report.[05/01/2010b]
10100I
If Worksheet B, Part I, Line 74, column 26 is greater than zero, or if Worksheet I-4 (Renal), line 11,
column 4 is greater than zero, then Renal Dialysis Worksheets S-5, I-1, I-2, I-3, and I-4, and I-5
should be present (containing any data) and Worksheet I-3 line 17, column 3 should be greater than
zero and vice versa. Do not apply this edit if S-2, Part I, line 145, column 1 is "Y". [05/01/2010b]
10150I
If Worksheet B, Part I, Line 94, column 26 is greater than zero, or if I-4 (Home Program), line 11,
column 4 is greater than zero, then Home Program Worksheets S-5, I-1, I-2, I-3, I-4 and I-5
should be present (containing any data) and vice versa and Worksheet I-3, line 17, column 3
should be greater than zero. [05/01/2010b]
10200I
If Worksheet I-2, any of columns 1-8, line 1 is greater than zero, then Worksheet
I-3 for related columns 1-8, sum of lines 2-16 must be greater than zero. [05/01/2010b]
10250I
If Worksheet S-2, Part I, line 145 equals "N" and Worksheet A, column 7, line 74 is greater
than zero, then the I series worksheets must be present for renal dialysis
services. [05/01/2010b]
10300I
If Worksheet I-1, column 1, line 31 is greater than zero, then Worksheet I-4, column 1,
sum of lines 1-10 must also be greater than zero. [05/01/2010b]
Rev. 3
40-801
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Condition
10000J
Worksheet J-1, Part I, sum of columns 0-4, 5-23, and 25, line 22 must equal Worksheet B, Part I,
column 26, line 99 or applicable subscript and vice versa. [05/01/2010b]
10050J
Worksheet J-1, Part II, sum of lines 1-21 for each of columns 1-4 and 5-23 must equal
the corresponding columns of Worksheet B-1, line 99 and/or subscripts as appropriate.
Include reconciliation and accumulated cost columns with negative one entries
only. [05/01/2010b]
10000L
Worksheet L, Part I, line 11 must be zero and Worksheet S-2, Part I, line 45, column 2
must contain a response of “N” if: Worksheet S-2, Part I, line 3, column 3 is Urban
(not 999xx CBSA code), and Worksheet E, Part A, line 4 is less than 100; or Worksheet S-2,
Part I, line 3, column 3 is 999xx (CBSA is Rural). [05/01/2010b]
10050L
If Worksheet S-2, Part I, line 46 is "N", then Worksheet L-1, should not be completed. [05/01/2010b]
10000M
If Worksheet S-8 is present, then worksheet M-1 must be present. Conversely,
if Worksheet M-1 is present, then Worksheet S-8 must be present. [05/01/2010b]
10050M
If Worksheet S-8, line 12 equals "Y", Worksheet M-2, column 3, lines 1, 2, and 3 must each be
greater than zero and at least one line must contain a value other than the standard amount.
Conversely if Worksheet S-8, line 12 equals "N", Worksheet M-2, column 3, lines 1, 2, and 3
must contain the values 4200, 2100, and 2100. Apply this edit to both the RHC and FQHC
components. [05/01/2010b]
10100M
If Worksheet S-8, line 15 equals "Y", Worksheet M-1, column 7, line 20 must equal
Worksheet B, Part I, sum of columns 21 and 22 for line 88 or 89 as applicable. [05/01/2010b]
10150M
The sum of Worksheet M-1, column 7, lines 1-9, 11-13, 15-19, 23-27, and 29-30 must equal the
amount on Worksheet A, column 7, RHC/FQHC line as appropriate. [05/01/2010b]
10250M
The sum of Worksheet M-3, line 16.02, columns 1 and 2, must be less than or equal to the sum
of line 16.01, columns 1 and 2. [05/01/2010b]
40-802
10-12
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
II. Level II Edits (Potential Rejection Errors)
These conditions are usually, but not always, incorrect. These edit errors should be cleared
when possible through the cost report. When corrections on the cost report are not feasible,
provide additional information in schedules, note form, or any other manner as may be
required by your fiscal intermediary. Failure to clear these errors in a timely fashion,
as determined by your FI, may be grounds for withholding of payments.
Edit
Condition
20000
All type 3 records with numeric fields and a positive usage must have values equal to or greater
than zero (supporting documentation may be required for negative amounts). [05/01/2010b]
20050
Only elements set forth in Table 3, with subscripts as appropriate, are required in the
file. [05/01/2010b]
20100
Moved to Level 1 edit 10655.
20150
Standard cost center lines, descriptions, and codes should not be changed. (See Table 5 for
standard descriptions and codes.) This edit applies to the standard line only and not subscripts
of that code. [05/01/2010b]
20200
All standard cost center codes must be entered on the designated standard cost center
line and subscripts thereof as indicated in Table 5. [05/01/2010b]
20250
All nonstandard cost center codes may be placed on any standard subscripted cost center
line and or generic cost center line within the cost center category, i.e. only nonstandard
cost center codes of the general service cost center may be placed on standard cost
center lines of general service cost centers. Exceptions are listed in edit 10700. [05/01/2010b]
20300
The cost to charge ratio on Worksheet C, Part I column 11 should not be more than 100%,
or less than .1%. [05/01/2010b]
20350
Administrative and general cost center codes 00500 and 00510-00569 (standard and
nonstandard) may only appear on line 5 and subscripts of line 5. Other nonstandard
descriptions and codes may also appear on subscripts of line 5, but must be within
the general services cost center category. [05/01/2010b]
20450
The cost reporting period must be greater than 27 days and less that 459 days. [05/01/2010b]
20500
Bad debt for dual eligible beneficiaries new amounts cannot exceed total bad debts (e.g. for Worksheet
E part A, line 66, must be less than or equal to line 64). Do not apply this edit if the total bad debt line is
negative. This edit applies to the following worksheets: E part A, line 66; E Part B, line 36; E-2, line 18;
E-3 Part I, line 13; E-3 Part II, line 25 ; E-3 Part III, line 26; E-3 Part IV, line 16; E-3 Part V, line 27;
E-3 Part VI, line 9 ; H-4 Part II, line 28; I-5, line 7; J-3, line 23; and M-3, line 24. [05/01/2010b].
Rev. 3
40-803
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
20000S
Worksheet S, Part III, sum of columns 2 and 3 for line 200 (title XVIII) should not equal zero.
[05/01/2010b]
20050S
The combined amount due the provider or program (Worksheet S, Part III, line 200, sum of
columns 1-5) should not equal zero. [05/01/2010b]
20100S
The hospital certification date (Worksheet S-2, Part I, column 5, line 3-6) should be on or before
the cost report beginning date (Worksheet S-2, Part I, column 1, line 20). [05/01/2010b]
If the Medicare hospital payment mechanism (Worksheet S-2, Part I, column 7, line 3) is equal
to P, then apply the following edits for codes 20200S and 20250S for acute care hospitals:
20200S
a. The DRG payments other than outlier payments (Worksheet E, Part A, column 1,
line 1) should be both greater than zero and greater than the outlier payments
(Worksheet E, Part A, column 1, line 2). [05/01/2010b]
20250S
b. The cost of Medicare Part A services under TEFRA (Worksheet E-3, Part I, column 1,
line 1) should not be present. [05/01/2010b]
20300S
If Worksheet S-2, Part I, line 26 and 27 differ, for Standard Geographic Reclassification (not Wage),
then lines 26 and 27 must have a response in the ECR File. [05/01/2010b]
20350S
A valid code for the type of hospital must be present in Worksheet S-2, Part I, column 4, line 3, as
indicated in Table 3B. [05/01/2010b]
20400S
For every valid subprovider on Worksheet S-2, Part I, line 4-6 and subscripts thereof, a corresponding
line 4-6 and subscripts, column 4, as appropriate, must be present with a valid type of hospital code from
Table 3B. [05/01/2010b]
20460S
If Worksheet S-2, Part I, line 63 is "Y", then the FTE count should be completed on lines 64,
65, 66 or 67 as applicable . If any of lines 64 through 67, column 1 are completed, all columns for
that line must be completed. [05/01/2010b]
20465S
If Worksheet S-2, Part I, line 63 is "Y", then the sum of Worksheet S-2, Part I, line 66, columns 1
and 2 and line 67, columns 3 and 4, must be greater than or equal to the sum of Worksheet E-4,
line 6, column 1 and line 10, column 2. [06/30/2012]
20500S
If the provider has a charge structure (Worksheet S-2, Part I, column 1, line 115 is No), for each
cost center on lines 30-40, 43-91, 92.01-92.10, 99.xx, 101 and 105-117 if either total charges
Worksheet C, Part I, sum of column 6 and 7), or total costs after stepdown (Worksheet B, Part I ,
column 26) equal zero, then both should equal zero. [05/01/2010b]
20525S
If Worksheet S-2, Part I, CAH (line 105="Y") and line 167="Y", then line 168,
must be present.[06/30/2012]
40-804
Rev. 3
10-12
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Edit
20550S
Condition
This edit is no longer applicable Level 2 edit. It was changed to a Level 1 Edit 12030S in order
to be consistent with the rejectable edits in HCRIS rather than just a warning. [05/01/2010b]
Worksheet S-2, Part I, lines as indicated below may only contain those provider
numbers as indicated for that line. The type of provider is also indicated.
Line
3
4-6
9
Provider # (1)
Type Provider
0001-0899
1225-1299
1300-1399
1990-1999
2000-2299
3025-3099
3300-3399
4000-4499
Short Term Hospitals
Medical Assistance Facility
RPCH/CAH
Christian Science Hospitals
Long Term Hospitals
Rehabilitation Hospitals
Children's Hospitals
Psychiatric Hospitals
3rd digit of provider number is M (Psychiatric unit in Critical Access Hospital)*
3rd digit of provider number is R (Rehabilitation unit in Critical Access Hospital)*
3rd digit of provider number is S (Psychiatric unit)*
3rd digit of provider number is T (Rehabilitation unit)*
3rd digit of provider number is U (Swing bed designation for Short Term Hospital)*
3rd digit of provider number is V (Swing bed designation for Long Term Care Hospital)*
3rd digit of provider number is Y (Swing bed designation for Rehabilitation Hospital)*
3rd digit of provider number is Z (Swing bed designation for Critical Access Hospital)*
0001-0899
Short Term Unit of Non-PPS Hospital
3025-3099
Rehabilitation Hospital as Subprovider
4000-4499
Psychiatric Hospital as Subprovider
5000-6499
6990-6999
Hospital-Based SNF
Skilled Nursing Facilities
G000-G999
H000-H999
ICF/MR
"
12
3100-3199
7000-8499
9000-9999
Home Health Agencies
"
"
"
"
13
C000-C999
Ambulatory Surgical Center
14
1500-1799
Hospital-Based Hospice
10.01
Rev. 3
4095 (Cont.)
40-805
4095 (Cont.)
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
Edit
10-12
Condition
Line
15
16
Provider # (1)
Type Provider
3400-3499
3975-3999
8500-8999
Hospital-Based RHC
"
"
"
"
1000-1199
Hospital-Based FQHC
"
"
1800-1989
* These are hospital components (excluded unit) whose last three (3) numbers
match those last three (3) numbers of the hospital.
17
1400-1499
4600-4799
4900-4999
CMHC
"
"
18
2300-2499
3500-3799
Renal - Hospital Satellites
"
19
6500-6989
O/P Rehab. Providers (OPT, OOT, OSP)
134
3rd digit of provider number is P (Organ Procurement Organization)*
134
9800-9899
Transplant Centers
(1) The first two characters of the provider number (not listed here) identify the state.
The last 4 characters (listed above) identify the type of provider.
(*) EXCEPTION - Organ procurement organization (OPOs) are assigned a 6-digit CCN.
The first 2 digits identify the State code. The third digit is the alpha character "P". The
remaining 3 digits are unique facility identifier.
20600S
If Worksheet S-2, Part I, column 1, line 146 response is "Y", providers should insure that proper
documentation has been submitted to their Medicare Contractor in accordance with CMS
Pub. 15-2, §4020. [05/01/2010b]
20650S
If Worksheet S-2, Part I, column 1, line 105 response is "Y", then Worksheet S-3, Part I, column 4
the sum of lines 1, and 7 through 12 should be greater than zero. [05/01/2010b]
20700S
If Worksheet S-2 part II, columns 1 or 3, line 16 equals “Y”, then line 16 the corresponding
column 2 or 4 must have a paid through date of the PS&R, after the cost report fiscal
year end date. [05/01/2010b].
20750S
Eliminated as of 05/01/2010b - The edit was incorporated into 20700S.
40-806
Rev. 3
10-12
Edit
21000S
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
The following statistics from Worksheet S-3, Part I should be greater than zero:
a. Number of beds for the hospital (column 2, line 14) [05/01/2010b];
b. Number of beds for the facility (column 2, sum of lines 14-24) [05/01/2010b];
d. Total inpatient days for all patients in the hospital (column 8, line 14) [05/01/2010b]; and
e. Total inpatient days for all patients in the facility (column 8, sum of lines 1-13
and 15-26). [05/01/2010b]
21050S
If Medicare hospital inpatient days (Worksheet S-3, Part I, column 6, line 14) is greater than
zero, then the following fields on Worksheet S-3, Part I should also be greater than zero.
a. Total hospital discharges (column 15, line 14) [05/01/2010b];
b. Medicare hospital discharges (column 13, line 14) [05/01/2010b]; and
c. Hospital full time equivalent employees (column 10, line 14). [05/01/2010b]
21100S
Total hospital inpatient days (Worksheet S-3, Part I, column 8, lines 1, 8-12, 16-21, & 24)
should be less than or equal to hospital bed days available (Worksheet S-3, Part I,
column 3, lines 1, 8-12, 16-21, & 24). [05/01/2010b]
21150S
The hospital and each component in a health care complex reporting interns and residents
in full time equivalents (Worksheet S-3, Part I, column 9, lines 14 and 16-26) should
have corresponding cost allocation statistics for interns and residents (Worksheet B-1,
sum of columns 21 and 22, sum of lines 30-46, 88-89, 94, 99, 115, and 116, respectively)
and conversely there should be FTEs on the aforementioned Worksheet S-3 if there are
statistics on the aforementioned Worksheet B-1. [05/01/2010b]
21200S
For prospective payment system hospital cost reports, where the ratio of Worksheet S-3,
Part II, column 5, sum of lines 9 and 10 divided by the result of column 5, line 1 minus
the sum of column 5, lines 3, 5, and 8 is equal to or greater than 5 percent, Worksheet
S-3, Part III, columns 2 and 5, line 7 must be present. [05/01/2010b]
21250S
For prospective payment system hospital cost reports, where the ratio of Worksheet S-3,
Part II, column 5, sum of lines 9 and 10 divided by the result of column 5, line 1 minus
the sum of column 5, lines 3, 5, and 8 is equal to or greater than 15 percent, Worksheet
S-3, Part II, column 2, lines 26 through 43 must be present, if the corresponding line on
Worksheet A, column 1 is greater than zero. [05/01/2010b]
Rev. 3
40-807
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
21300S
If Worksheet S-3, Part II, sum of columns 2 & 3, lines 9 and 10 are greater than zero,
then the sum of columns 2 & 3, line 19 must also be greater than zero. Provider should
submit supporting documentation when the sum of lines 9 and 10 is greater than zero
and line 19 equals zero. [05/01/2010b]
21350S
If Worksheet S-2, Part I, column 1, line 12 and subscripts are present, then Worksheet S-4,
column 1, line 19 must be greater than zero and the number of CBSA codes
on line 20 and subscripts must equal the number identified on line 19. [05/01/2010b]
20000A
Worksheet A-6, column 1 (reclassification code) must be an alpha character. [05/01/2010b]
20050A
Worksheet A-7, Part III, column 2 must be less than or equal to column 1 for
lines 1-2 and subscripts thereof. [05/01/2010b]
20100A
If there are provider-based physician adjustments on Worksheet A-8-2, then column 1
may only contain Worksheet A, line numbers 4-99, 105-112, 115, and subscripts thereof.
[05/01/2010b]
20150A
If Worksheet A, column 7, either of lines 74 or 94 is greater than zero, then Worksheet
S-5, columns 1 or 2, line 21 must contain an X. DO NOT APPLY IF WORKSHEET
S-2, Part I, line 145 ="Y".[05/01/2010b]
Column headings (Worksheets B-1, B, Parts I, and II, J-1, Part II, and L-1, Part I)
are required as indicated for codes 20000B and 20050B:
20000B
a.
At least one cost center description (lines 1-3), at least one statistical bases label
(lines 4-5), and one statistical bases code (line 6) (capital cost center lines only) must
be present for each general service cost center with cost greater than zero (Worksheet
B-1, columns 1 through 23, line 202). Exclude any reconciliation columns from this
edit. [05/01/2010b]
20050B
b.
The column numbering among these worksheets must be consistent. For example, data
in old capital related costs - buildings and fixtures is identified as coming from column 1
on all applicable worksheets. [05/01/2010b]
40-808
Rev. 3
10-12
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
20100B
Worksheet B, Part II, column 26, sum of lines 30-117 and 190-194 and subscripts as
allowed must be equal to or greater than zero. Not applicable for critical access hospitals (CAH).
[05/01/2010b]
20000D
The total outpatient charges on each line of Worksheet C, Part I, column 7 must
be greater than or equal to the sum of all Worksheets D, Part V, columns 2-4. [05/01/2010b]
20050D
If the provider has a charge structure (Worksheet S-2, Part I, line 115, column 2 is not A,
B, or E) and total inpatient days (Worksheet D-1, column 1, line 1 for the hospital
and all components and all titles) is greater than zero, then general inpatient routine
service charges (Worksheet D-1, column 1, line 28, for the hospital and all components
and all titles) must also be greater than zero. If Worksheet D-1, column 1, line 3
equals line 2, do not apply this edit. [05/01/2010b]
20100D
If Worksheet D-4, Part III, column 1, line 66 is greater than zero or Part IV, sum of columns 1
and 2, lines 76-80 are greater than zero, then both must be greater than zero. [05/01/2010b]
20150D
If Worksheet B, Part I, column 26, lines 105-112, as appropriate, is greater than zero or
Worksheet D-4, Part IV, sum of columns 1 and 2, lines 70-73 are greater than
zero, then both should be greater than zero. [05/01/2010b]
20200D
Worksheet D-4, Part IV, sum of columns 1 and 2, lines 70-73 should equal the sum of
columns 1 and 2, lines 75-83. [05/01/2010b].
20500E
If Worksheet S-2, Part I, line 120, column 2 is "Y", then Worksheet E, Part A line 4 must be less than
or equal to 100. [05/01/2010b]
Rev. 3
40-809
4095 (Cont.)
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
10-12
Condition
20000G
Total assets on Worksheet G (sum of each of columns 1-4, lines 1-10, 12-29 (subscripts as
indicated), and 31-34) must equal total liabilities and fund balance (sum of each of columns
1-4, lines 37-44, 46-49, and 52-58). [05/01/2010b]
20050G
Total patient revenue (Worksheet G-2, Part I, column 3, line 28 ) should equal the sum of
inpatient and outpatient revenue (Worksheet G-2, Part I, sum of columns 1 and 2, line 28 ).
[05/01/2010b]
20100G
Net income or loss (Worksheet G-3, column 1, line 29) should not equal zero. [05/01/2010b]
20000I
If Worksheet I-1, column 1, lines 1-6 have amounts greater than zero, then the corresponding
line for columns 3 and 4 must contain amounts which do not equal zero. [05/01/2010b]
20050I
If Worksheet I-1, column1, line 31 is greater than zero, then worksheet I-4, column 7, sum of
lines 1-10 must be greater than zero and vice versa. [05/01/2010b]
20100I
Worksheet I-2, column 11, sum of lines 2-16 and 18 must equal Worksheet I-1, column 1,
sum of lines 1-8, 10-16, 18-26, and 28-30. [05/01/2010b]
20150I
If Worksheet I-2, column 11, line 12 is greater than zero, then the treatments reported
on Worksheet I-3, column 0, line 12 should also be greater than zero. [05/01/2010b]
20200I
Worksheet I-4, column 4, lines 1 through 10 should be equal to or less than the
corresponding amounts in column 1 for each line. [05/01/2010b]
20250I
If Worksheet I-4, column 1, sum of lines 1 through 10 is greater than zero, then Worksheet
I-2, column 11, sum of lines 2 through 11 must also be greater than zero. [05/01/2010b]
Apply the following K series edits if Worksheet S-2, columns 2 and 5, line 14 are present.
20000K
Worksheet A, column 7, line 116 must be greater than zero.[05/01/2010b]
20050K
Worksheet K, column 10 line 39 must be equal to Worksheet A, column 7, line 116.
[05/01/2010b]
20100K
Worksheet K-5, Part I, sum of columns 0-3, 4-22, and 24, plus subscripts, line 34 must
equal Worksheet B, Part I, column 26, line 116.[05/01/2010b]
40-810
Rev. 3
08-11
Edit
FORM CMS 2552-10
ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 2552-10
TABLE 6 - EDITS
4095 (Cont.)
Condition
20000M
Worksheet M-2, sum of column 2, lines 1-3, 5-7, and 9 should agree with Worksheet
S-3, Part I, column 8, line 26, and subscripts as applicable. [05/01/2010b]
20050M
Total FTEs on Worksheet M-2, column 1, sum of lines 1-3 and 5-7 should be equal to
or less than the FTEs on Worksheet S-3, Part I, column 10, line 26, and subscripts as
applicable [05/01/2010b]
NOTE: CMS reserves the right to require additional edits to correct deficiencies that
become evident after processing the data commences and, as needed, to meet
user requirements.
Rev. 2
40-811
| File Type | application/pdf |
| File Title | 2552-09 SPECS |
| Subject | ECR SPECIFICATIONS |
| Author | Nadia Massuda |
| File Modified | 2013-05-10 |
| File Created | 2012-11-01 |