CMS-2088-92 Outpatient Rehabilitation Provider Cost Report Identific

06-13

FORM CM S 2088-92

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result
in all interim payments made since the beginning of the cost reporting period being deemed
as overpayments (42 USC 1395g).
OUTPATIENT REHABILITATION PROVIDER COST
PROVIDER CCN:
REPORT IDENTIFICATION DATA, CERTIFICATION
AND SETTLEMENT SUMMARY
_______________
Contractor Use Only:
[ ] Audited
Date Received
Contractor No.
[ ] Desk Reviewed
PART I - IDENTIFICATION DATA
Outpatient Rehabilitation Facility:
1 Name:
1.01 Street:
1.02 City:
State:
1.03 Cost Reporting Period (mm/dd/yyy)

Provider No.
1

2

_______________
_______________

FORM APPROVED
OMB NO. 0938-0037
PERIOD:
WORKSHEET S,
From: ___________
PARTS I - III
To: ___________

[ ] Initial
[ ] Final

[ ] Re-opened

1
1.01
1.02
1.03

P.O. Box:
Zip Code:
To:

From:

Type of Control
(see instructions)
3

1890 (Cont.)

Type of Provider
(see instructions)
4

Date Certified
5

2

2

3
3.01
3.02
3.03
4

3
3.01
3.02
3.03
4

List malpractice premiums and paid losses:
Premiums
Paid Losses
Self Insurance
Are malpractice premiums and/or paid losses reported in other than the Administrative and General cost center?
If yes, submit a supporting schedule listing cost centers and amounts contained therein.
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY
CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF
SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY
OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR
IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR DIRECTOR OF THE AGENCY
I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Outpatient Rehabilitation Provider
Cost Report and the Balance Sheet and Statement of Revenue and Expenses prepared by _______________________________________
(Provider name(s) and number(s)) for the cost report beginning _____________________and ending __________________________, and
that to the best of my knowledge and belief, it is a true, correct and complete report prepared from the books and records of the provider in
accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the
provision of health care services, and that the services identified in this cost report were provided in compliance with such laws and
regulations.
(Signed) __________________________________________
Officer or Director
__________________________________________
Title
__________________________________________
Date
PART III - SETTLEMENT SUMMARY
TITLE XVIII
PART B
1
6 OUTPATIENT REHABILITATION PROVIDER (specify type)

6

"According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0037. The
time required to complete this information collection is estimated to average 226 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850."
FORM CMS-2088-92-S (06-2013 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECS. 1802-1802.3)

Rev. 9

18-303

1890 (Cont.)

FORM CM S 2088-92

OUTPATIENT REHABILITATION
PROVIDER COST REPORT
STATISTICAL DATA
REIMBURSABLE
COST CENTERS

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

PERIOD:
FROM __________________
TO _____________________
Medicare
Patients
1

VISITS
Other
Patients
2

06-13
PROVIDER CCN:

WORKSHEET S
PART IV

___________________
PATIENTS

Total
3

Medicare
4

CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies
DME-Sold
DME-Rented
Other Services
CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education
Other Services
OTHER PROVIDERS
Physical Therapy
Speech Pathology
Occupational Therapy
Other Services
Total (Sum of lines 1-27)
Unduplicated Census Count

Other
5

Total
6

Staff
Therapists
7

FTE ON PAYROLL
Social
Physicians
Workers
8
9

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

FORM CMS-2088-92-S (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2,SECS.1802.4)

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06-13
ANALYSIS OF PAYMENTS TO
OUTPATIENT REHABILITATION
PROVIDERS FOR SERVICES RENDERED
TO PROGRAM BENEFICIARIES

FORM CM S 2088-92
PROVIDER CCN:
______________

PERIOD:
FROM: ______________
TO: _______________

DESCRIPTION

1 Total interim payments paid to Outpatient Rehabilitation Provider
2 Interim payments payable on individual bills either, submitted or to
be submitted to the contractor , for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
3 List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Also show date of each payment. If none write
"NONE" or enter a zero. (1)

1890 (Cont.)
SUPPLEMENTAL
WORKSHEET S-1

PART B
1
2
mm/dd/yyyy
Amount
1
2

Program
to
Provider

Provider
to
Program
SUBTOTAL (Sum of lines 3.01-3.49, minus sum
of lines 3.50-3.98)
4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)
(Transfer to Wkst D, Part I, line 18)

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

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54

.99

3.99
4

TO BE COMPLETED BY CONTRACTOR
5 List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. (1)

SUBTOTAL (Sum of lines 5.01-5.49, minus sum
of lines 5.50-5.98)
6 Determine net settlement amount (balance due) based
on the cost report (SEE INSTRUCTIONS). (1)

Program
to
Provider
Provider
to
Program

Program
to
Provider
Provider
to
Program

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

5.01
5.02
5.03
5.50
5.51
5.52

.99

5.99

.01

6.01

.02

6.02
7

7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)
Name of Contractor

Contractor Number

Signature of Authorized Person

Date: (Month, Day, Year)

(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-2088-92-S-1 (06-2013 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.
1806)
Rev. 9

18-305

1890 (Cont.)

FORM CM S 2088-92

06-13

PROVIDER CCN:
RECLASSIFICATION AND ADJUSTMENT OF
TRIAL BALANCE OF EXPENSES (Omit Cents)

COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14

0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200

15
16
17
18
19
20
21
22
23
24
25
26
27

1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600

29
30
31
32
33
34
35
36
37
38

2900
3000
3100
3200
3300
3400
3500
3600
3700

___________
SALARIES
1

OTHER
2

TOTAL
(Col 1 + Col 2)
3

GENERAL SERVICE COST CENTERS
Cap Rel Costs-Bldg & Fixt
Cap Rel Costs-Mvble Equip
Employee Benefits
Administrative & General
Maintenance & Repairs
Operation of Plant
Laundry & Linen Service
Housekeeping
Cafeteria
Central Services & Supply
Medical Records & Library
Pro Ed & Training (Apprvd)
Other (specify)
Other (specify)
REIMBURSABLE SERVICE COST CENTERS
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Medical Supplies Charged to Patients
DME-Sold
DME-Rented
Other (specify)
CMHC
Drugs & Biologicals
Occupational Therapy
Psychiatric/Psychological Services
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education
Other (specify)

RECLASS.
(from
Wkst. A-1)
4

PERIOD:
FROM ___________
TO ___________
RECLASSIFIED
TRIAL BALANCE
(Col 3 +/- Col 4)
5

WORKSHEET A
Page 1 of 2
ADJUSTMENTS
(from
Wkst. A-3)
6

NET EXPENSES
FOR ALLOCATION
(Col 5 +/- Col 6)
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

FORM CMS-2088-92 (06-2013 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2,SEC.1804)

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Rev. 9

06-13

FORM CM S 2088-92

1890 (Cont.)

PROVIDER CCN:
RECLASSIFICATION AND ADJUSTMENT OF
TRIAL BALANCE OF EXPENSES (Omit Cents)

COST CENTERS
40
41
42
43

4000
4100
4200
4300

45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60

4500
4600
4700
4800
4900
5000
5100
5200
5300
5400
5500
5600
5700
5800
5900

61
62
63
64
65

6100
6200
6300
6400

___________
SALARIES
1

OTHER
2

TOTAL
(Col 1 + Col 2)
3

OTHER PROVIDERS
Physical Therapy
Speech Therapy
Occupational Therapy
Other (specify)
NONREIMBURSABLE COST CENTERS
Sheltered Workshops
Recreational Programs
Resident Day Camps
Pre-school Programs
Diagnostic Clinics
Home Employment Programs
Equipment Loan Service
Physicians' Private Offices
Fund Raising
Coffee Shops & Canteen
Research
Investment Property
Advertising
Franchise Fees and Other Assessments
Pro Ed & Training (Not Apprvd)
Other (specify)
CMHC NON-REIMBURSABLE COST CENTERS
Meals and Transportation
Activity Therapies
Psychosocial Programs
Vocational Training
TOTAL(sum of lines 1- 64)

RECLASS.
(from
Wkst. A-1)
4

PERIOD:
FROM ___________
TO ____________
RECLASSIFIED
TRIAL BALANCE
(Col 3 +/- Col 4)
5

WORKSHEET A
Page 2 of 2
ADJUSTMENTS
(from
Wkst. A-3)
6

NET EXPENSES
FOR ALLOCATION
(Col 5 +/- Col 6)
7
40
41
42
43
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65

FORM CMS-2088-92 (06-2013 ) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 1804)

Rev. 9

18-307

1890 (Cont.)

FORM CM S 2088-92

06-13

PROVIDER CCN:
RECLASSIFICATIONS
EXPLANATION OF
RECLASSIFICATION ENTRY

PERIOD:
FROM ___________
TO ___________

___________
CODE
(1)
1

COST CENTER
2

INCREASE
LINE NO.
3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 TOTAL RECLASSIFICATIONS(Sum of Col. 4
must equal Col. 7)

AMOUNT(2)
4

COST CENTER
5

WORKSHEET A-1

DECREASE
LINE NO.
6

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

(1) A letter (A,B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A. column 4, line as appropriate.
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 1805)

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08-99

FORM CM S 2088-92

ADJUSTMENTS TO EXPENSES

DESCRIPTION (1)

1 Payments received from
specialists
2 Investment income
(chapter 2)
3 Trade, quantity and time discounts
(chapter 8)
4 Refunds and rebates of expenses
(chapter 8)
5 Laundry and linen service
6 Cafeteria--employees,
guests, etc.
7 Sale of medical and surgical
supplies to other than patients
8 Sale of workshop products
or services
9 Coffee shops and canteen
10 Vending Machines
11 Rental of building or office
space to others
12 Sale of scrap, waste,
etc.(Chapter 23)
13 Related organization transactions
(chapter 10)
14 Provider-based physician
adjustment
15 Respiratory Therapy limit
adjustment
16 Physical therapy limit
adjustment
17 Respiratory Therapy limit
adjustment
17.1 Physical therapy limit
adjustment
17.2 Occupational therapy limit
adjustment
17.3 Speech pathology limit
adjustment
18 Other (Specify) (3)
19 Other (Specify) (3)
20 Capital Related Costs-Buildings
and fixtures
21 Capital Related Costs- Movable
Equipment
22 TOTAL (Sum of lines 1-21)
(Transfer to Worksheet A, col.6, line 65)

1890 (Cont.)

PROVIDER CCN: PERIOD:
WORKSHEET A-3
FROM ____________
____________
TO _______________
EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
BASIS (2)
AMOUNT
COST CENTER
LINE NO.
1
2
3
4
1
B
2
B

3

B

4
Laundry and Linen Service

7

Cafeteria
Central Services and
Supply

9

5
6
7

10
8
9
10
11
12

Supp. Wks
A-3-1
Supp. Wks.
A-8-2
Supp. Wks.
A-8-4
Supp. Wks.
A-8-3
Supp. Wks.
A-8-5
Supp. Wks.
A-8-5
Supp. Wks.
A-8-5
Supp. Wks.
A-8-5

A
A

13
14
15
16
17
17.1
17.2
17.3

Capital Related Costs
Buildings & Fixtures
Capital Related Costs
Movable Equipment

18
19
20
1
21
2
22

(1) Include amounts not already applied against expenses included on Worksheet A, column 3
(2) Basis for adjustment (SEE INSTRUCTIONS).
A. Costs -- if cost, including applicable overhead, can be determined.
B. Amount Received -- if cost cannot be determined.
(3) Additional adjustments may be made on subscripts of this line.
Chapter references are to CMS Pub.15-I
FORM CMS-2088-92 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 1806)

Rev. 3

18-309

1890 (Cont.)

FORM CM S 2088-92

08-99

PROVIDER CCN:

PERIOD:
STATEMENT OF COSTS OF SERVICES
FROM ___________
FROM RELATED ORGANIZATIONS
___________
TO ___________
A. Are there any costs included in Worksheet A which resulted from transactions with related
organizations as defined in CMS Pub. 15-I, chapter 10?

SUPPLEMENTAL
WORKSHEET A-3-1

[ ] Yes (If "Yes," complete Parts B and C)
[ ] No
B. Costs incurred and adjustments required as a result of transactions with related organizations:
Location and amount included on Worksheet A, Column 5
Line No.
1

Cost Center
2

Amount
3

Net
Adjustments
(Col 3 minus
Col 4)
5

Amount
Allowable
In Cost
4

1
2
3
4
5

TOTALS (Sum of lines 1-4)
(Transfer col. 5, line 5 to
Worksheet A-3, line 13)
C. Interrelationship to related organization(s):
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security
Act, requires that you furnish the information requested under Part C of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its intermediaries in
determining that the costs applicable to services, facilities and supplies furnished by
organizations related to you by common ownership or control, represent reasonable costs as
determined under section 1861 of the Social Security Act. If you do not provide all or any
part of the requested information, the cost report is considered incomplete and not acceptable
for purposes of claiming reimbursement under title XVIII.

Symbol
(1)

Name
1

2

Percentage
of
Ownership
3

Name
4

Related Organization(s)
Percentage
of
Ownership
5

Type of
Business
6

1
2
3
4
5
(1) Use the following symbols to indicate interrelationship to related organizations:
A. Individual has financial interest (stockholder, partner, etc.) in both related
organization and in provider.
B. Corporation, partnership or other organization has financial interest in provider.
C. Provider has financial interest in corporation, partnership, or other organization.
D. Director, officer, administrator or key person of provider or relative of such
person has financial interest in related organization.
E. Individual is director, officer, administrator or key person of provider and
related organization.
F. Director, officer, administrator or key person of related organization or relative
of such person has financial interest in provider.
G. Other (financial or non-financial) specify __________________________________________________

FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 1807)

18-310

Rev. 3

12-04

FORM CM S 2088-92

1890 (Cont.)

PROVIDER CCN:
COST ALLOCATION
GENERAL SERVICE COSTS

COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

____________
Net Expenses
(from Wkst.A,
Col.7)
0

Capital Related
Buildings &
Movable
Fixtures
Equipment
1
2

Employee
Benefits
3

PERIOD:
FROM ___________
TO ___________
Subtotal
(cols. 0-4)
3A

WORKSHEET B
Page 1 of 3

Administrative Maintenance
& General
& Repairs
4
5

Gen. Service Cost Ctrs.
Cap. Rel. Costs--Bldg.&Fixt.
Cap. Rel. Costs--Movable Eqp.
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supply
Medical Records and Library
Prof. Educ. & Training(1)
REIMBURSABLE COST CTRS.
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Supplies Charged to Patients
DME-Sold
DME-Rented
CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Service
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education

OTHER PROVIDERS
40 Physical Therapy
41 Speech Pathology
42 Occupational Therapy
43
NON-REIM. COST CENTERS
45 Sheltered Workshops
46 Recreational Programs
47 Resident Day Camps
48 Preschool Programs
49 Diagnostic Clinics
50 Home Employment Programs
51 Equipment Loan Service
52 Physicians' Private Office
53 Fundraising
54 Coffee Shops &Canteen
55 Research
56 Investment Property
57 Advertising
58 Franchise & Other Ass'mt
59 Prof. Ed. & Training(2)
60
CMHC NON-REIMBURSABLE
61 Meals and Transportation
62 Activity Therapies
63 Psychosocial Programs
64 Vocational Training
65 Negative Cost Center
66 TOTAL
(1) Approved Educational Activity
(2) Not an Approved Educational Activity

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38
40
41
42
43
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66

FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1808)

Rev. 7

18-311

1890 (Cont.)
COST ALLOCATION
GENERAL SERVICE COSTS

COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

12-04

FORM CM S 2088-92
PROVIDER CCN:

___________
Operation
of
Plant
6

Laundry
and Linen
Services
7

Housekeeping
8

PERIOD:
FROM ____________
TO ____________
Medical
Supplies
Cafeteria
9
10

WORKSHEET B
Page 2 of 3
Medical
Records
Library
11

Gen. Service Cost Ctrs.
Cap. Rel. Costs--Bldg.&Fixt.
Cap. Rel. Costs--Movable Eqp.
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supply
Medical Records and Library
Prof. Educ. & Training(1)
REIMBURSABLE COST CTRS.
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Supplies Charged to Patients
DME-Sold
DME-Rented
CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Service
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education

OTHER PROVIDERS
40 Physical Therapy
41 Speech Pathology
42 Occupational Therapy
43
NON-REIM. COST CENTERS
45 Sheltered Workshops
46 Recreational Programs
47 Resident Day Camps
48 Preschool Programs
49 Diagnostic Clinics
50 Home Employment Programs
51 Equipment Loan Service
52 Physicians' Private Office
53 Fundraising
54 Coffee Shops &Canteen
55 Research
56 Investment Property
57 Advertising
58 Franchise & Other Ass'mt
59 Prof. Ed. & Training(2)
60
CMHC NON-REIMBURSABLE
61 Meals and Transportation
62 Activity Therapies
63 Psychosocial Programs
64 Vocational Training
65 Negative Cost Center
66 TOTAL
(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1808)

18-312

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58
59
60
61
62
63
64
65
66

Rev. 7

12-04

FORM CM S 2088-92
PROVIDER CCN:

COST ALLOCATION
GENERAL SERVICE COSTS

COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

____________
Prof.
Education
and
Training
12

13

1890 (Cont.)
PERIOD:
FROM _____________
TO ____________

14

15

16

WORKSHEET B
Page 3 of 3

Total
17

Gen. Service Cost Ctrs.
Cap. Rel. Costs--Bldg.&Fixt.
Cap. Rel. Costs--Movable Eqp.
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supply
Medical Records and Library
Prof. Educ. & Training(1)
REIMBURSABLE COST CTRS.
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Supplies Charged to Patients
DME-Sold
DME-Rented
CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Service
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education

OTHER PROVIDERS
40 Physical Therapy
41 Speech Pathology
42 Occupational Therapy
43
NON-REIM. COST CENTERS
45 Sheltered Workshops
46 Recreational Programs
47 Resident Day Camps
48 Preschool Programs
49 Diagnostic Clinics
50 Home Employment Programs
51 Equipment Loan Service
52 Physicians' Private Office
53 Fundraising
54 Coffee Shops &Canteen
55 Research
56 Investment Property
57 Advertising
58 Franchise & Other Ass'mt
59 Prof. Ed. & Training(2)
60
CMHC NON-REIMBURSABLE
61 Meals and Transportation
62 Activity Therapies
63 Psychosocial Programs
64 Vocational Training
65 Negative Cost Center
66 TOTAL
(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1808)

Rev. 7

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38
40
41
42
43
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66

18-313

1890 (Cont.)

FORM CM S 2088-92

12-04

PROVIDER CCN:
COST ALLOCATION
(STATISTICAL BASIS)

____________

COST CENTERS
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

Capital Related
Buildings &
Movable
Fixtures
Equipment
(Square
(Square
Feet)
Feet)
1
2

Employee
Benefits
(Gross
Salaries)
3

PERIOD:
FROM ____________
TO ____________

Reconciliation
4A

Administrative Maintenance
& General
& Repairs
(Accum.
(Square
Cost)
Feet)
4
5

Gen. Service Cost Ctrs.
Cap. Rel. Costs--Bldg.&Fixt.
Cap. Rel. Costs--Movable Eqp.
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supply
Medical Records and Library
Prof. Educ. & Training(1)
REIMBURSABLE COST CTRS.
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Supplies Charged to Patients
DME-Sold
DME-Rented
CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Service
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education

OTHER PROVIDERS
40 Physical Therapy
41 Speech Pathology
42 Occupational Therapy
43
NON-REIM. COST CENTERS
45 Sheltered Workshops
46 Recreational Programs
47 Resident Day Camps
48 Preschool Programs
49 Diagnostic Clinics
50 Home Employment Programs
51 Equipment Loan Service
52 Physicians' Private Office
53 Fundraising
54 Coffee Shops &Canteen
55 Research
56 Investment Property
57 Advertising
58 Franchise & Other Ass'mt
59 Prof. Ed. & Training(2)
60
CMHC NON-REIMBURSABLE
61 Meals and Transportation
62 Activity Therapies
63 Psychosocial Programs
64 Vocational Training
65 Negative Cost Center
66 Cost to be Allocated
67 Unit Cost Multiplier
(1) Approved Educational Activity
(2) Not an Approved Educational Activity
FORM CMS-2088-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1808)

18-314

WORKSHEET B-1
Page 1 of 3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38
40
41
42
43
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67

Rev. 7

08-99

FORM CM S 2088-92
PROVIDER CCN:

COST ALLOCATION
(STATISTICAL BASIS)

COST CENTERS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

___________
Operation
of
Plant
(Square
Feet)
6

Laundry
and Linen
Services
(Pounds of
Laundry)
7

Housekeeping
(Hrs. of
Service)
8

1890 (Cont.)
PERIOD:
WORKSHEET B-1
FROM ____________
Page 2 of 3
TO _____________
Medical
Medical
Supplies
Records
Cafeteria
Library
Meals
(Costed
(Time
Served)
Requisitions)
Spent)
9
10
11

Gen. Service Cost Ctrs.
Cap. Rel. Costs--Bldg.&Fixt.
Cap. Rel. Costs--Movable Eqp.
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supply
Medical Records and Library
Prof. Educ. & Training(1)

1
2
3
4
5
6
7
8
9
10
11
12
13
14

REIMBURSABLE COST CTRS.
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Supplies Charged to Patients
DME-Sold
DME-Rented

15
16
17
18
19
20
21
22
23
24
25
26
27

CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Service
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education

OTHER PROVIDERS
40 Physical Therapy
41 Speech Pathology
42 Occupational Therapy
43
NON-REIM. COST CENTERS
45 Sheltered Workshops
46 Recreational Programs
47 Resident Day Camps
48 Preschool Programs
49 Diagnostic Clinics
50 Home Employment Programs
51 Equipment Loan Service
52 Physicians' Private Office
53 Fundraising
54 Coffee Shops &Canteen
55 Research
56 Investment Property
57 Advertising
58 Franchise & Other Ass'mt
59 Prof. Ed. & Training(2)
60
CMHC NON-REIMBURSABLE
61 Meals and Transportation
62 Activity Therapies
63 Psychosocial Programs
64 Vocational Training
65 Negative Cost Center
66 Cost to be Allocated
67 Unit Cost Multiplier
(1) Approved Educational Activity

29
30
31
32
33
34
35
36
37
38
40
41
42
43
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
(2) Not an Approved Educational Activity

FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1808)

Rev. 3

18-315

1890 (Cont.)

FORM CM S 2088-92
PROVIDER CCN:

COST ALLOCATION
(STATISTICAL BASIS)

COST CENTERS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
34
35
36
37
38

____________
Prof.Educ.
& Training
(Assigned
Time)
12

13

08-99

PERIOD:
FROM _____________
TO ____________

14

15

16

WORKSHEET B-1
Page 3 of 3

17

Gen. Service Cost Ctrs.
Cap. Rel. Costs--Bldg.&Fixt.
Cap. Rel. Costs--Movable Eqp.
Employee Benefits
Administrative and General
Maintenance and Repairs
Operation of Plant
Laundry and Linen Service
Housekeeping
Cafeteria
Central Services and Supply
Medical Records and Library
Prof. Educ. & Training(1)

1
2
3
4
5
6
7
8
9
10
11
12
13
14

REIMBURSABLE COST CTRS.
CORF
Skilled Nursing Care
Physical Therapy
Speech Pathology
Occupational Therapy
Respiratory Therapy
Medical Social Services
Psychological Services
Prosthetic and Orthotic Devices
Drugs and Biologicals
Supplies Charged to Patients
DME-Sold
DME-Rented

15
16
17
18
19
20
21
22
23
24
25
26
27

CMHC
Drugs and Biologicals
Occupational Therapy
Psychiatric/Psychological Service
Individual Therapy
Group Therapy
Individualized Activity Therapies
Family Counseling
Diagnostic Services
Patient Training & Education

OTHER PROVIDERS
40 Physical Therapy
41 Speech Pathology
42 Occupational Therapy
43
NON-REIM. COST CENTERS
45 Sheltered Workshops
46 Recreational Programs
47 Resident Day Camps
48 Preschool Programs
49 Diagnostic Clinics
50 Home Employment Programs
51 Equipment Loan Service
52 Physicians' Private Office
53 Fundraising
54 Coffee Shops &Canteen
55 Research
56 Investment Property
57 Advertising
58 Franchise & Other Ass'mt
59 Prof. Ed. & Training(2)
60
CMHC NON-REIMBURSABLE
61 Meals and Transportation
62 Activity Therapies
63 Psychosocial Programs
64 Vocational Training
65 Negative Cost Center
66 Cost to be Allocated
67 Unit Cost Multiplier
(1) Approved Educational Activity

29
30
31
32
33
34
35
36
37
38
40
41
42
43
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
(2) Not an Approved Educational Activity

FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1808)

18-316

Rev. 3

12-02

FORM CM S 2088-92

APPORTIONMENT OF PATIENT SERVICE COSTS

1890 (Cont.)

PROVIDER CCN:

PERIOD:
FROM __________
TO ___________

_________

CORF REIMBURSABLE SERVICE
COST CENTERS
15 Skilled Nursing Care
16 Physical Therapy
17 Speech Pathology
18 Occupational Therapy
19 Respiratory Therapy
20 Medical Social Services
21 Psychological Services
22 Prosthetic and Orthotic Devices
23 Drugs and Biologicals
24 Supplies Charged to Patients
25 DME-Sold
26 DME-Rented
27
28 TOTAL(Line 15 through 27)

TOTALS
1

RATIO OF COST
TO CHARGES
(Col. 1 line .01,
divided by Col. 1,
line .02)
2

TITLE XVIII
(See Instructions)
3

ALL OTHER
(See Instructions)
4

.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02

TITLE XVIII
CHARGES
ON OR AFTER
1/1/98
5

TITLE XVIII
COSTS ON
AFTER 1/1/98
6

WORKSHEET C
Page 1 of 2
REASONABLE
COST
REDUCTION
AMOUNT
7

TITLE XVIII
COST NET OF
APPLICABLE
REASONABLE
COST REDUCTION
8
15
16
17
18
19
20
21
22
23
24
25
26
27
28

CORF Providers--See instructions for amounts to transfer to Worksheet D, Part I.

FORM CMS-2088-92 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1809)

Rev. 6

18-317

1890 (Cont.)

FORM CM S 2088-92

APPORTIONMENT OF PATIENT SERVICE COSTS

12-02

PROVIDER CCN:

_________

CMHC REIMBURSABLE SERVICE
COST CENTERS
29 Drugs and Biologicals
30 Occupational Therapy
31 Psychiatric/Psychological Services
32 Individual Therapy
33 Group Therapy
34 Individualized Activity Therapy
35 Family Counseling
36 Diagnostic Services
37 Patient Training & Education
38
39 TOTAL (Lines 29 through 38)

TOTALS
1

42 Occupational Therapy
43
44 TOTAL (Lines 40 through 43)

ALL OTHER
(See Instructions)
4

REASONABLE
COST
REDUCTION
AMOUNT
7

TITLE XVIII
COSTS PRIOR
TO 8/1/00, 1/1/02,
1/1/03, or 1/1/04
(See Instructions)
8
29
30
31
32
33
34
35
36
37
38
39

TOTALS
1
41 Speech Pathology

TITLE XVIII
(See Instructions)
3

TITLE XVIII
CHARGES
ON OR AFTER
8/1/00, 1/1/02,
1/1/03, or 1/1/04
(See Instructions)
5

WORKSHEET C
Page 2 of 2

.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02
.01
.02

OTHER OUTPATIENT THERAPY
PROVIDERS
40 Physical Therapy

RATIO OF COST
TO CHARGES
(Col. 1 line a,
divided by Col. 1,
line b.
2

PERIOD:
FROM __________
TO ___________
TITLE XVIII
COSTS ON OR
AFTER 8/1/00,
1/1/02, 1/1/03, or
1/1/04
(See Instructions)
6

RATIO OF COST
TO CHARGES
(Col. 1 line .01,
divided by Col. 1,
line .02)
2

TITLE XVIII
(See Instructions)
3

ALL OTHER
(See Instructions)
4

.01
.02
.01
.02
.01
.02
.01
.02
.01
.02

TITLE XVIII
CHARGES
ON OR AFTER
1/1/1998
5

TITLE XVIII
COSTS
ON OR AFTER
1/1/1998
6

REASONABLE
COST
REDUCTION
AMOUNT
7

TITLE XVIII
COSTS NET OF
APPLICABLE
REASONABLE
COST REDUCTION
8
40
41
42
43
44

CMHC Providers--Transfer the amount entered in column 8, line 39 to Worksheet D, line 1.
Other Outpatient Therapy Providers--Transfer the amount entered in column 8, line 44 to Worksheet D, line 1.

FORM CMS-2088-92 (12-2002) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC.1809)

18-318

Rev. 6

04-13

FORM CM S 2088-92

CALCULATION OF REIMBURSEMENT
PROVIDER CCN:
PERIOD:
SETTLEMENT FOR OUTPATIENT
______________
FROM ________
REHABILITATION SERVICES-TITLE XVIII
TO __________
CORF
OPT
CMHC
PART I - COMPUTATION OF REIMBURSEMENT SETTLEMENT
DESCRIPTION
1 Cost of provider services (see instructions)
1.01 CMHC PPS payments including outlier payments
1.02 1996 CMHC specific payment to cost ratio (obtain this ratio from your contractor)
1.03 Line 1, column 1.01 times 1.02
1.04 Line 1.01 divided by line 1.03
1.05 CMHC transitional corridor payment
1.1 Cost of CORF services prior to 1/1/1998 (see instructions)
2 Adjustment for the cost of services covered by Workers' Compensation, and
other primary payers (see instructions)
3 Subtotal (line 1 plus line 1.1 minus line 2) (For CMHCs see instructions)
4 Deductibles billed to program patients. (Do not include coinsurance)
5 Total amount reimbursable to provider prior to application of Lesser of
reasonable cost or customary charges (line 3 minus line 4)
6 Excess of reasonable cost over customary charges (see instructions)
7 Subtotal (line 5 minus line 6)
8 80 percent of costs (line 7 x 80 percent)
9 Coinsurance billed to program patients (see instructions)
10 Net cost for comparison (line 7 minus line 9)
11 Reimbursable bad debts (see instructions)
11.01 Reimbursable bad debts for dual eligible beneficiaries (see instructions)
11.02 Adjusted reimbursable bad debts
12 TOTAL COST-- (see instructions)
13 Recovery of unreimbursed cost under the lesser of cost or
charges (from Worksheet D-1, Part I, line 3)
14 80% of recovery of unreimbursed cost under the lesser
of cost or charges (line 13 X 80 percent)
15 Total cost (see instructions)
16 Sequestration adjustment (see instructions)
16.5 Other Adjustments (see instructions) (specify)
17 Adjusted total cost (line 15 minus the sum of lines 16 and 16.5) (see instructions)
17.01 Sequestration adjustment (see instructions)
18 Interim Payments
18.5 Tentative settlement (For intermediary use only)
19 Balance due Provider/Program (line 17 minus lines 17.01 and 18) (Indicate overpayment in brackets)

1890 (Cont.)
WORKSHEET D

1
1
1.01
1.02
1.03
1.04
1.05
1.1
2
3
4
5
6
7
8
9
10
11
11.01
11.02
12
13
14
15
16
16.5
17
17.01
18
18.5
19

NOTE: FOR CORF SERVICES RENDERED PRIOR TO JANUARY 1, 1998 CORFS COMPLETE LINE 22.1 ONLY AS THESE
SERVICES ARE NOT SUBJECT TO THE LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES,
BUT ARE REIMBURSED BASED ON REASONABLE COSTS. FOR CORF RENDERED ON OR AFTER JANUARY 1,
1998, COMPLETE LINE 21 THROUGH 29 AS THESE SERVICES AS SUBJECT TO LCC.
PART II -COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
20 Reasonable cost of services
21 Cost of services (from Part I, line 1) (from Part I, line 1, column 1 for CMHCs) (see instructions)
21.1 Cost of services (from Part I, line 1.1 for CORFs) (see instructions)
22 TOTAL charges for medicare services
22.1 TOTAL CORF charges for medicare services prior to 1/1/1998
23 Customary Charges
24 Aggregate amount actually collected from patients liable for payment for services on a charge basis.
25 Amounts that would have been realized from patients liable for payment for services on a charge
basis had such payment been made in accordance with 42 CFR 413.13(e)
26 Ratio of line 24 to line 25 (not to exceed 1.000000)
27 Total customary charges (line 22 x line 26)
27.1 Total customary CORF charges prior to 1/1/1998 (line 22.1 x line 26)
28 Excess of customary charges over reasonable cost (Complete
only if line 27 exceeds line 21) (see instructions)
29 Excess of reasonable cost over customary charges (Complete
only if line 21 exceeds line 27) (see instructions)

1
20
21
21.1
22
22.1
23
24
25
26
27
27.1
28
29

FORM CMS-2088-92 (04-2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15 - 2, SEC.
1810, 1810.1 AND 1810.2)

Rev. 8

18-319

1890 (Cont.)
STATEMENT OF REVENUES
AND EXPENSES

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

FORM CM S 2088-92
PROVIDER CCN:
____________

PERIOD:
FROM ____________
TO ____________

04-13
WORKSHEET G

Total patient revenues
Less: Allowances and discounts on patients' accounts
Net patient revenues (Line 1 minus line 2)
Less: total operating expenses
Net income from service to patients (Line 3 minus line 4)
Other income:
Grants , gifts, and income designated by
donor for specific expenses
Payments received from specialists
Investment income on unrestricted funds
Trade , quantity ,time and other discounts on purchases
Rebates and refunds of expenses
Income from laundry and linen service
Income from cafeteria - employees , guests, etc.
Sale of medical supplies to other than patients
Sale of workshop products or services
Coffee shops and canteen
Vending machines
Rental of building or office space to others
Sale of scrap, waste, etc.
Sale of medical records and abstracts
Other(Specify)
Other(Specify)
Other(Specify)
Total other income (Sum of lines 6-22)
Total (Line 5 plus line 23)
Other expenses :
Fund raising
Gift, coffee shops, and canteen
Investment property
Other(Specify)
Other(Specify)
Other(Specify)
Total other expenses (Sum of lines 25 - 30)
Net income (or loss) for the period (line 24 minus line 31)

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

FORM CMS-2088-92 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15 - 2, SEC. 1812)

18-320

Rev. 8

08-99

FORM CM S 2088-92

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).
PROVIDER CCN:
PROVIDER-BASED PHYSICIANS ADJUSTMENTS
____________
Cost Center/
Wkst A
Physician
Total
Professional
Line No.
Identifier
Remuneration
Component
1
2
3
4

1890 (Cont.)
FORM APPROVED
OMB NO. 0938-0037
SUPPLEMENTAL
WORKSHEET A-8-2

PERIOD:
FROM ___________
TO _____________
Provider
Component
5

RCE
Amount
6

Physician/
Provider
Component Hours
7

Provider
Component
Share of
Col 14
15

Adjusted
RCE Limit
16

Unadjusted
RCE Limit
8

5 Percent of
Unadjusted
RCE Limit
9

TOTAL

Wkst A
Line No.
10

Cost Center/
Physician
Identifier
11

Cost of
Memberships
& Continuing
Education
12

Provider
Component
Share of
Col 12
13

Physician
Cost of
Malpractice
Insurance
14

RCE
Disallowance
17

Adjustment
18

TOTAL

FORM CMS-2088-92-A-8-2 (12-1992) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SEC. 1813)

Rev. 3

18-321

1890 (Cont.)
REASONABLE COST DETERMINATION FOR PHYSICAL
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS

1
2
3
4
5
6
7
8

9
10
11
12
12.01
13
13.01

FORM CM S 2088-92
(COM PL ETE THI S WORK SHEET
FOR SERVI CES PROVI DED
PRI OR TO APRI L 10, 1998)

08-99
PROVIDER CCN:
___________

PART I - GENERAL INFORMATION
Total number of weeks worked (During which outside suppliers (excluding aides) worked)
Line 1 multiplied by 15 hours per week
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 therapists (See Instructions)
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
Supervisors
1
Total hours worked
A H S E A (See Instructions)
Standard Travel Allowance (Cols. 1 and 2, one-half of col. 2, line 10; col. 3, one-half of col 3, line 10)
Number of travel hours - Provider site - (see instructions)
Number of travel hours - Provider offsite - (see instructions)
Number of miles driven - Provider site - (see instructions)
Number of miles driven - Provider offsite - (see instructions)

PART II - SALARY EQUIVALENCY COMPUTATION
Supervisors (Column 1, line 9 times column 1, line 10)
Therapists (Column 2, line 9 times column 2, line 10)
Assistants (Column 3, line9 times column 3, line10)
Subtotal Allowance Amount (Sum of lines 14-16)
Aides (Column 4, line 9 times column 4, line 10)
Total Allowance Amount (Sum of lines 17 and 18)
If the sum of columns 1-3, line 9, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the
amount from line 19. Otherwise complete lines 20 - 22.
20 Weighted average rate excluding aides (Line 17 divided by the sum of columns 1-3, line 9)
21 Weighted allowance excluding aides (Line 2 times line 20)
22 Total Salary Equivalency (Line 19 or sum of lines 18 plus 21)
14
15
16
17
18
19

PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
23 Therapists (Line 3 times column 2, line 11)
24 Assistants (Line 4 times column3, line 11)
25 Subtotal (Sum of lines 23 and 24)
26 Standard Travel Expense (Line 7 times sum of lines 3 and 4)
27 Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (Sum of lines 25 and 26)
FORM CMS-2088-92-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1814 - 1814.3)

18-322

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-8-3
PARTS I, II & III

1
2
3
4
5
6
7
8
Therapists
2

Assistants
3

Aides
4
9
10
11
12
12.01
13
13.01

14
15
16
17
18
19

20
21
22

23
24
25
26
27

Rev. 3

08-99

FORM CM S 2088-92

REASONABLE COST DETERMINATION FOR PHYSICAL
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS

(COM PL ETE THI S WORK SHEET
FOR SERVI CES PROVI DED
PRI OR TO APRI L 10, 1998)

28
29
30
31
32
33
34
35
36
37
38

1890 (Cont.)
PROVIDER CCN:

PERIOD:
FROM: ___________
TO: ___________

____________

WORKSHEET A-8-3
PARTS IV, V & VI

PART IV - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
Therapists (Line 5 times column 2, line 11)
Assistants (Line 6 times column 3, line 11)
Subtotal (Sum of lines 28 and 29)
Standard Travel Expense (Line 7 times the sum of lines 5 and 6)
Optional Travel Allowance and Optional Travel Expense
Therapists (Sum of columns 1 and 2, line 12.01 times column 2, line 10)
Assistants (Column 3, line 12.01 times column 3, line 10)
Subtotal (Sum of lines 32 and 33)
Optional Travel Expense (Line 8 times the sum of columns 1-3, line 13.01)
Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following three lines 36, 37, or 38, as appropriate.
Standard Travel Allowance and Standard Travel Expense (Sum of lines 30 and 31 - See Instructions)
Optional Travel Allowance and Standard Travel Expense (Sum of lines 34 and 31 - See Instructions)
Optional Travel Allowance and Optional Travel Expense (Sum of lines 34 and 35 - See Instructions)
PART V - OVERTIME COMPUTATION
Description

39 Overtime hours worked during cost reporting period (If column 4, line 39, is zero or equal to
or greater than 2,080, do not complete lines 40-47 and enter zero in each column of line 48)
40 Overtime rate (Multiply the amounts in columns 2-4, line 10 ( A H S E A ) times 1.5)
41 Total overtime (Including base and overtime allowance) (Multiply line 39 times line 40)
Calculation of Limit
42 Percentage of overtime hours by category (Divide the hours in each column on line 39 by the
total overtime worked - column 4, line 39)
43 Allocation of provider's standard workyear for one full-time employee times the percentages
on line 42. (See Instructions)
Determination of Overtime Allowance
44 Adjusted hourly salary equivalency amount ( A H S E A ) (From Part I, Columns 2-4, line 10)
45 Overtime cost limitation (Line 43 times line 44)
46 Maximum overtime cost (Enter the lessor of line 41 or line 45)
47 Portion of overtime already included in hourly computation at the A H S E A
(Multiply line 39 times line 44)
48 Overtime allowance (Line 46 minus 47 - if negative enter zero)(Column 4, sum of cols 1-3)
PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
49 Salary equivalency amount (from Part II, line 22)
50 Travel allowance and expense - provider site (from Part III, line 27)
51 Travel allowance and expense - offsite services (from Part IV, lines 36, 37 or 38)
52 Overtime allowance (from Part V, col. 4, line 48)
53 Equipment cost (See Instructions)
54 Supplies (See Instructions)
55 Total allowance (Sum of lines 49-54)
56 Total cost of outside supplier services (from your records)
57 Excess over limitation (line 56 minus line 55 - if negative, enter zero -- See Instructions) (Transfer amount to Wkst. A-3, line 16)
FORM CMS-2088-92-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 1814.4 - 1814.6)

Rev. 3

Therapists
1

28
29
30
31
32
33
34
35
36
37
38

Assistants
2

Aides
3

Total
4
39
40
41
42
43

44
45
46
47
48

49
50
51
52
53
54
55
56
57

18-323

1890 (Cont.)
REASONABLE COST DETERMINATION FOR RESPIRATORY
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS

FORM CM S 2088-92
(COMPLETE THIS WORKSHEET
FOR SERVICES PROVIDED
PRIOR TO APRIL 10, 1998)

08-99
PROVIDER CCN:
___________

PART I - GENERAL INFORMATION
1 Total number of weeks worked (During which outside suppliers (excluding aides and trainees) worked)
2 Line 1 multiplied by 15 hours per week
Number of unduplicated days on which the following category, as appropriate, has the highest A H S E A on the provider site ( See Instructions ):
3 Registered Therapist
4 Certified Therapist
5 Nonregistered, Noncertified Therapist
6 Standard travel expense rate
Supervisors
Therapists
Nonregistered
Description
Registered
Certified
Noncertified
Registered
Certified
1
2
3
4
5
7 Total Hours Worked
8 A H S E A (See Instructions)
9 Standard Travel Allowance (Enter in cols 1, 2, or 3, one-half of
the amounts on line 8, columns 4, 5 or 6 respectively. Enter in
cols. 4, 5 or 6 one-half of the amounts on line 8, columns 4, 5 or 6
respectively.)
PART II - SALARY EQUIVALENCY COMPUTATION
Supervisory Registered Therapist (Col 1, line 7 times col 1, line 8)
Supervisory Certified Therapist (Col 2, line 7 times col 2, Line 8)
Supervisory Non-Registered, Non-Certified Therapist (Col 3, line 7 times col 3, line 8)
Registered Therapists (Col 4, line 7 times col 4, line 8)
Certified Therapists (Col 5, line 7 times col 5, line 8)
Non-Registered, Non-Certified Therapists (Col 6, line 7 times col 6, line 8)
Subtotal Allowance Amount (Sum of lines 10-15)
Aides (Col 7, line 7 times col 7, line 8)
Trainees (Col 8, line 7 times col 8, line 8)
Total Allowance Amount (Sum of lines 16-18)
If the sum of cols 1-6, line 7, is greater than line 2, make no entries on lines 20 and 21 and enter on line 22 the amount from line 19.
Otherwise, complete lines 20-22.
20 Weighted average rate excluding aides and trainees (Line 16 divided by the sum of cols 1-6, line 7)
21 Weighted allowance excluding aides and trainees (Line 2 times line 20)
22 Total Salary Equivalency (Line 19 or sum of lines 17, 18 and 21)

10
11
12
13
14
15
16
17
18
19

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-8-4
PARTS I & II

1
2
3
4
5
6
Nonregistered
Noncertified
6

Aides
7

Trainees
8
7
8
9

10
11
12
13
14
15
16
17
18
19

20
21
22

FORM CMS 2088-92-A-8-4 (11-1998) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1815 - 1815.2 )

18-324

Rev. 3

08-99

FORM CM S 2088-92

REASONABLE COST DETERMINATION FOR RESPIRATORY
THERAPY SERVICES FURNISHED BY OUTSIDE SUPPLIERS

23
24
25
26
27
28

(COMPLETE THIS WORKSHEET
FOR SERVICES PROVIDED
PRIOR TO APRIL 10, 1998)

1890 (Cont.)
PROVIDER CCN:
___________

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-8-4
PARTS III, IV & V

PART III - STANDARD TRAVEL ALLOWANCE AND STANDARD TRAVEL EXPENSE COMPUTATION
Registered Therapists (Line 3 times col 4, line 9)
Certified Therapists (Line 4 times col 5, line 9)
Non-Registered, Non-Certified Therapists (Line 5 times col 6, line 9)
Subtotal (Sum of lines 23-25)
Standard Travel Expense (Line 6 times sum of lines 3-5)
Total Standard Travel Allowance and Standard Travel Expense (Sum of lines 26 and 27)

23
24
25
26
27
28

PART IV - OVERTIME COMPUTATION
Therapists
Description

Registered
1

Certified
2

Nonregistered
Noncertified
3

29 Overtime hours worked during cost reporting period ( If col 6, line 29,
is zero, or equal to or greater than 2,080, do not complete lines 30
through 37 and enter zero in each column of line 38 )
30 Overtime rate ( Multiply the amounts in cols 4-8, line 8 (the AHSEA)
times 1.5 )
31 Total overtime (Including base and overtime allowance)
(Multiply line 29 times line 30)
Calculation of Limitation
32 Percentage of overtime hours by category (Divide the hours in each
column on line 29 by the total overtime worked - column 6, line 29)
33 Allocation of provider's standard workyear for one full-time employee
times the percentage on line 32. (See Instructions)
Determination of Overtime Allowance
34 Adjusted hourly salary equivalency amount (AHSEA)
(From Part I, cols. 4-8, line 8)
35 Overtime cost limitation (Line 33 times line 34)
36 Maximum overtime cost (Enter the lessor of line 31 or 35)
37 Portion of overtime already included in hourly computation at the
A H S E A. (Multiply line 29 times line 34)
38 Overtime allowance (Line 36 minus line 37 - if negative enter zero)
(Col. 6, sum of cols. 1 - 5)

39
40
41
42
43
44
45
46

PART V - COMPUTATION OF RESPIRATORY THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
Salary equivalency amount (from Part II, line 22)
Travel allowance and expense (from Part III, line 28)
Overtime allowance (from Part IV, col 6, line 38)
Equipment cost (See Instructions)
Supplies (See Instructions)
Total allowance ( Sum of lines 39 - 43)
Total cost of outside supplier services (from your records)
Excess over limitation ( line 45 minus line 44, - if negative, enter zero - See Instructions) (Transfer to amount Wkst. A-3, line 15)

Aides
4

Trainees
5

Total
6
29

30
31

100%

32
33

34
35
36
37
38

39
40
41
42
43
44
45
46

FORM CMS 2088-92-A-8-4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 1815.3 - 1815.5 )

Rev. 3

18-325

1890 (Cont.)

FORM CM S 2088-92

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998

08-99
PROVIDER CCN:
___________

Check applicable box:

1
2
3
4
5
6
7
8

[

] Respiratory [

] Physical

[

] Occupational [

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-8-5
PARTS I & II

] Speech Pathology

PART I - GENERAL INFORMATION
Total number of weeks worked (during which outside (excluding aides worked)
Line 1 multiplied by 15 hours per week
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 therapists (see instructions)
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

1
2
3
4
5
6
7
8
Supervisors
1

Therapists
2

9 Total hours worked
10 AHSEA (see instructions)
11 Standard Travel Allowance (columns 1 and 2, one-half of column 2,
line 10; column 3, one-half of column 3, line 10)
12 Number of travel hours - Provider on site - (see instructions)
#### Number of travel hours - Provider offsite - (see instructions)
13 Number of miles driven - Provider on site - (see instructions)
#### Number of miles driven - Provider offsite - (see instructions)
PART II - SALARY EQUIVALENCY COMPUTATION
Supervisors (column 1, line 9 times column 1, line 10)
Therapists (column 2, line 9 times column 2, line 10)
Assistants (column 3, line 9 times column 3, line10)
Subtotal Allowance Amount (sum of lines 14-16)
Aides (column 4, line 9 times column 4, line 10)
Trainees (column 5, line 9 times column 5, line 10)
Total Allowance Amount (see instructions)
If the sum of columns 1 and 2 for respiratory therapy or columns 1-3 for physical therapy, speech pathology or occupational therapy, line 9, is greater than line 2,
make no entries on lines 21 and 22 and enter on line 23 the amount from line 20. Otherwise complete lines 21-23.
21 Weighted average rate excluding aides and trainees (see instructions)
22 Weighted allowance excluding aides and trainees (see instructions)
23 Total salary equivalency (see instructions)

14
15
16
17
18
19
20

Assistants
3

Aides
4

Trainees
5
9
10
11
12
####
13
####

14
15
16
17
18
19
20

21
22
23

FORM CMS-2088-92-A-8-5 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 1816 - 1816.2)

18-326

Rev. 3

08-99

FORM CM S 2088-92

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998

1890 (Cont.)
PROVIDER CCN:
____________

Check applicable box:

[

] Respiratory [

] Physical

[

] Occupational [

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-8-5
PARTS III & IV

] Speech Pathology

PART III - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - PROVIDER SITE
Standard Travel Allowance
24 Therapists (line 3 times column 2, line 11)
25 Assistants (line 4 times column 3, line 11)
26 Subtotal (sum of lines 24 and 25)
27 Standard Travel Expense (line 7 times sum of lines 3 and 4)
28 Total Standard Travel Allowance and Standard Travel Expense at the Provider Site (sum of lines 26 and 27)
Optional Travel Allowance and Optional Travel Expense
29 Therapists (sum of columns 1 and 2, line 12 times column 2, line 10)
30 Assistants (column 3, line 10 times column 3, line 12)
31 Subtotal (sum of lines 29 and 30)
32 Optional travel expense (line 8 times the sum of columns 1-3, line 13)
33 Standard travel allowance and standard travel expense (line 28)
34 Optional travel allowance and standard travel expense (sum of lines 27 and 30)
35 Optional travel allowance and optional travel expense (sum of lines 31 and 32)
PART IV - STANDARD AND OPTIONAL TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - SERVICES OUTSIDE PROVIDER SITE
Standard Travel Expense
36 Therapists (line 5 times column 2, line 11)
37 Assistants (line 6 times column 3, line 11)
38 Subtotal (sum of lines 36 and 37)
39 Standard Travel Expense (line 7 times the sum of lines 5 and 6)
Optional Travel Allowance and Optional Travel Expense
40 Therapists (sum of columns 1 and 2, line 12.01 times column 2, line 10)
41 Assistants (column 3, line 12.01 times column 3, line 10)
42 Subtotal (sum of lines 40 and 41)
43 Optional Travel Expense (line 8 times the sum of columns 1-3, line 13.01)
Total Travel Allowance and Travel Expense - Offsite Services; Complete one of the following
three lines 44, 45, or 46, as appropriate.
44 Standard Travel Allowance and Standard Travel Expense (sum of lines 38 and 39 - see instructions)
45 Optional Travel Allowance and Standard Travel Expense (sum of lines 39 and 42 - see instructions)
46 Optional Travel Allowance and Optional Travel Expense (sum of lines 42 and 43 - see instructions)

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

36
37
38
39
40
41
42
43

44
45
46

FORM CMS-2088-92-A-8-5 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 1816.3 - 1816.4)

Rev. 3

18-327

1890 (Cont.)

FORM CM S 2088-92

REASONABLE COST DETERMINATION FOR THERAPY SERVICES
FURNISHED BY OUTSIDE SUPPLIERS ON OR AFTER APRIL 10, 1998

08-99
PROVIDER CCN:
___________

Check applicable box:

[

] Respiratory [

] Physical

[

] Occupational [

PERIOD:
FROM: ___________
TO: ___________

WORKSHEET A-8-5
PARTS V & VI

] Speech Pathology

PART V - OVERTIME COMPUTATION
Therapists
1

Assistants
2

47

Overtime hours worked during reporting period (if column 5,
line 47, is zero or equal to or greater than 2,080, do not complete
lines 48-55 and enter zero in each column of line 56)
48 Overtime rate (see instructions)
49 Total overtime (including base and overtime allowance) (multiply
line 47 times line 48)
CALCULATION OF LIMIT
50 Percentage of overtime hours by category (divide the hours in each
column on line 47 by the total overtime worked - column 5, line 47)
51 Allocation of provider's standard workyear for one full-time
employee times the percentages on line 50) (see instructions)
DETERMINATION OF OVERTIME ALLOWANCE
52 Adjusted hourly salary equivalency amount (see instructions)
53 Overtime cost limitation (line 51 times line 52)
54 Maximum overtime cost (enter the lessor of line 49 or line 53)
55 Portion of overtime already included in hourly computation at the AHSEA (multiply line 47 times line 52)
56 Overtime allowance (line 54 minus line 55 - if negative enter zero) (column 5, sum of columns 1-4)

57
58
59
60
61
62
63
64
65

PART VI - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT
Salary equivalency amount (from Part II, line 23)
Travel allowance and expense - provider site (from Part III, lines 33, 34, or 35))
Travel allowance and expense - provider offsite services (from Part IV, lines 44, 45, or 46)
Overtime allowance (from Part V, column 5, line 56)
Equipment cost (see instructions)
Supplies (see instructions)
Total allowance (sum of lines 57-62)
Total cost of outside supplier services (from your records)
Excess over limitation (line 64 minus line 63 - if negative, enter zero -- See Instructions) (Transfer amount to Wkst. A-3, line 17, 17.1, 17.2 or 17.3 as applicable)

Aides
3

Trainees
4

Total
5
47

48
49

50
51

52
53
54
55
56

57
58
59
60
61
62
63
64
65

FORM CMS-2088-92-A-8-5 (11-1998) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 1816.5 - 1816.6)

18-328

Rev. 3