Crosswalk

Revisions to Form CMS-1984-14 Hospice Cost Report Application/Update Form

The forms are revised in accordance with the Patient Protection and Affordable Care Act of 2010 section 3132 which requires that CMS collect appropriate data and information to facilitate hospice payment reform. Additionally, the forms are revised to incorporate data previously reported on the Provider Cost Report Reimbursement Questionnaire, Form CMS-339.

Changes

Issue #	Instructions Page #	Form Page #	Section	New Package Form CMS-1984-14 (60 day comment)	New Package Form CMS-1984-14 (30 day comment)	Reason for the Change Application of the instructions and accompanying worksheets	Burden Effect
1	43-9	43-104	4307.1	S-1	S-1	Removed line 22 , cost of OTC drugs	Decrease
2	43-10	43-105	4307.2	S-1	S-1	Removed line 35 & 36, Unduplicated census count and Average length of stay	Decrease
3	43-13	43-107	4308	S-2	S-2	Added Cost report preparer contact information, lines 12-14	N/A
4	43-14, 43-15 and 43-22	43-108	4310	A	A	Reordered, renamed, and added lines to identify various general service, direct patient care service and nonreimbursable cost centers.	Increase
5	43-24 and 43-25	43-110 to 43-113	4316 and 4318	A-1, A-2 , A-3, A-4	A-1, A-2 , A-3, A-4	Added 3 cost centers to collect additional direct patient care service costs	Increase
6	43-26	43-115	4318	A-8	A-8	Added line to identify adjustments to expenses for state redirected room and board revenue.	N/A
7	43-28 through 43-30	43-117 through 43-120	4320	B, B-1	B, B-1	Reordered and added lines to identify various general service cost centers, renamed a nonreimbursable cost center and deleted columns to parallel Worksheet A cost center changes.	Decrease
8	43-28 through 43-30	43-121 to 43-124	4320	B-1	B-1	Added rows and columns to parallel Worksheet A cost center changes and revised the statistical basis to be used for various cost centers.	N/A
9	43-30 and 43-31	43-125	4330	C	C	Revised various column references to agree with changes on Worksheet B.	N/A

Issue #	Instructions Page #	Form Page #	Section	New Package Form CMS-1984-14 (60 day comment)	New Package Form CMS-1984-14 (30 day comment)	Reason for the Change Application of the instructions and accompanying worksheets	Burden Effect
10	43-1 and 43-34	43-127	4350.2		F-1	Re-added worksheet for Statement of Changes in Fund Balance (formely Wkst G-1) that was removed from 1984-14, 60 day comment package.	N/A
11	43-1 and 43-34	43-128	4350.3	F-1	F-2	Modified lines to worksheet	N/A

2