Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)

CHAPTER 33
ORGAN PROCUREMENT ORGANIZATION
AND TISSUE TYPING LABORATORY
COST REPORT
FORM CMS-216-94
Section
General .................................................................................................................3300
Recommended Sequence for Completing OPO/LAB Cost Report .....................3301
Worksheet S - Organ Procurement Organization/
Histocompatibility Laboratory General Data and
Certification Statement .....................................................................................3302
Part I - General ...............................................................................................3302.1
Part II - Certification By Officer or Administrator ........................................3302.2
Part III – Settlement Summary ......................................................................3302.3
Worksheet S-1 - Organ Procurement Organization/
Histocompatibility Laboratory Identification Data ...........................................3303
Part I - OPO Statistics ....................................................................................3303.1
Part II - Lab Statistics ....................................................................................3303.2
Part III - Full Time Equivalent Employees (FTEs) .......................................3303.3
Worksheet A - Reclassification and Adjustment of Trial
Balance of Expenses .........................................................................................3304
Worksheet A-1 - Administrative and General Expenses .....................................3305
Worksheet A-2 - Organ Acquisition Costs ..........................................................3306
Worksheet A-3 - Tissue Typing Laboratory Costs ..............................................3307
Worksheet A-4 - Reclassifications.......................................................................3308
Worksheet A-5 - Adjustments to Expenses .........................................................3309
Worksheet A-6 - Capital Expenditures and Depreciation
Reconciliation ...................................................................................................3310
Worksheet B - Cost Allocation - General Service Costs and
Worksheet B-1 - Cost Allocation - Statistical
Basis ..................................................................................................................3311
Worksheet C - Computation of Medicare Cost....................................................3312
Worksheet D - Calculation of Reimbursement Settlement ..................................3313
Worksheet E - Balance Sheet ...............................................................................3314
Worksheet E-1 - Statement of Operating Expenses and
Revenues ...........................................................................................................3315
Worksheet E-2 - Statement of Revenues and Expenses ......................................3316
Supplemental Worksheet A-5-1 - Statement of Costs of
Services From Related Organizations ...............................................................3317
Kidney Placement Efforts - Documentation Requirements .................................3318
Exhibit 1 - Form CMS-216-94 Worksheets .........................................................3390
Electronic Reporting Specifications for Form CMS-216-94 ............................ 3395

Rev. 4

33-1

11-05
3300.

FORM CMS-216-94

3300

GENERAL

All independent organ procurement organizations (OPOs) and independent histocompatibility
laboratories (Labs) must submit Form CMS-216-94 for cost reporting periods ending on or after
December 31, 1994. Substitute forms may be used with advance approval from the intermediary
and the Centers for Medicare and Medicaid Services (CMS). Substitute forms must contain all
information and data required by the standard form. Use Form CMS-216-94 unless advance
approval is obtained.
Form CMS-216-94 is used for the following cost reports:
o

Independent organ procurement organizations,

o

Independent histocompatibility labs, and

o
Independent organizations which operate both an OPO and a Lab that have two
Medicare numbers within the same administration.
Do not use the forms to calculate the amount of home office costs of a chain organization on the
OPO/Lab cost report. Chain organizations follow the procedure in CMS Pub. 15-II, chapter 10.
These forms are not to be used by any hospital-based OPOs.
When an OPO performs kidney procurement functions only (and has no cost associated with
other organizations or other non-kidney activities) bypass the allocation Worksheets B and B-1.
In these situations, flow the cost directly from the trial balance of expenses (Worksheet A) to the
computation of Medicare cost (Worksheet C) since there is no need to allocate overhead costs to
other cost centers.
When the OPO has acquired organs other than kidneys, complete a separate Worksheet A-2 for
each type of organ. The OPO must also go through cost finding when other internal organs are
acquired to ensure that overhead is allocated to all types of acquisitions. However, tissues, such
as skin, cornea, bone, heart valves, and pancreas islet absent adequate cost finding methodology
need not go through cost finding. Rather, income received is offset against cost associated with
transplant coordinator costs on Worksheet A.
When a lab performs only tissue (renal and non-renal) typing tests (and has no cost associated
with organ procurement clinical laboratory tests, blood bank activities, other components
requiring overhead allocations, and other non- tissue typing tests), bypass the allocation
Worksheets B and B-1. In these situations, flow the cost directly from the trial balance of
expenses (Worksheet A) to the calculation of reimbursement of tissue typing (Worksheet C).
The need for allocations does not exist, as the costs are 100 percent tissue typing. The Medicare
kidney related cost of the tissue typing lab is determined on Worksheet C. Few laboratories
qualify to bypass Worksheets B and B-1 since clinical laboratory tests are normally performed in
the same organization.

Rev. 4

33-3

3301

FORM CMS-216-94

11-05

3301.

RECOMMENDED SEQUENCE FOR COMPLETING OPO/LAB COST REPORT

Step
No.

Worksheet

Page

Part I - General Statistics and Expense Reclassifications
And Adjustments (To Be Followed By All OPOs/Labs)
1

Statistical Data General

1

Complete Part I - General except for
certification statement.

2

Statistical Data OPO

2

OPOs complete Part I.

3

Statistical Data Labs

2

Labs complete Part II.

4

Statistical Data FTEs

2

All complete Part III.

5

A-1

4

Complete entire page.

6

A-2

5

OPOs complete entire page. (One form must be
completed for each type of organ acquisition.)

7

A-3

6

Labs complete entire page.

8

A

3

Complete columns 1 through 3, lines 1 through 26.

9

A-4

7

Complete, if applicable.

10

A

3

Complete columns 4 and 5, lines 1 through 26.

11

A-5

8

Complete entire page.

12

Supplemental A-5-1

7

If any costs on Worksheet A are with a related
organization, complete Part A. If the answer to Part
A is yes, complete both Parts B and C.

13

A

3

Complete columns 6 and 7, lines 1 through 26.

14

A-6

9

Complete entire page as applicable.

Part II - Cost Allocation (To Be Followed For OPOs/Labs That
Need To Allocate Overhead Costs When OPO Is Not Totally
Kidney Related And Lab Is Not Totally Tissue Typing Lab)
NOTE: All OPOs that have acquired non-renal organs must complete Worksheets B and B-1.
1

B and B-1

10-11

Complete entire worksheet.

Part III - Computation Of Medicare Cost - To Be Completed By
All OPOs And Tissue Typing Labs
1
33-4

C

12

Complete entire worksheet.
Rev. 4

11-05
Step
No.

FORM CMS-216-94
Worksheet

3302.1

Page

Part IV - Calculation Of Reimbursement Settlement To OPOs/Labs
1

D

12

Complete entire worksheet and columns as
appropriate.

2

E

14

OPOs/Labs complete the worksheet.
Where multiple funds are maintained, combine
in the general fund.

3

E-1

15

Complete entire worksheet.

4

E-2

16

Complete entire worksheet.

5

Statistical Data

1

Complete certification statement.

6

S, Part III

3301.1.

ROUNDING STANDARDS FOR FRACTIONAL COMPUTATIONS

1

Complete settlement summary.

Throughout the Medicare cost report, required computations result in the use of fractions. The
following rounding standards must be employed for such computation.
1.

Round to 2 decimal places
a. Percentages
b. Averages
c. Full time equivalent employees
d. Per diems, hourly rates

2.

Round to 5 decimal places
a. Sequestration (e.g., 2.092 percent is expressed as .02092)
b. Payment reduction (e.g., outpatient cost reduction)

3.

Round to 6 decimal places
a. Ratios (e.g., unit cost multipliers, cost/charge ratios)

If a residual exists as a result of computing costs using a fraction, adjust the residual in the
largest amount resulting from the computation. For example, in cost finding, a unit cost
multiplier is applied to the statistics in determining costs. After rounding each computation, the
sum of the allocation may be more or less than the total cost being allocated. Adjust this residual
to the largest amount resulting from the allocation so that the sum of the allocated amounts
equals the amount being allocated.
3302.

WORKSHEET S - ORGAN PROCUREMENT ORGANIZATION/HISTOCOMPATIBILITY LABORATORY GENERAL DATA AND CERTIFICATION
STATEMENT

3302.1

Part I - General.--

Line 1.--Enter the full name of the independent/freestanding OPO or LAB and the provider
number.

Rev. 4

33-5

3302.1 (Cont.)

FORM CMS-216-94

11-05

Enter the OPO/LAB identification number that was provided by CMS. The number consists of
two digits followed by either a HL or P, followed two or more digits. (00-HL-00 or 00-P-000)
Apply the following definitions:
Organ Procurement Organization.--An independent OPO is an organization which performs, or
coordinates the performance of, all the following services as contained in 42 CFR 486.302:
Retrieving of donated organs; Preservation of donated organs; Transportation of donated organs;
and Maintenance of a system to locate prospective recipients for harvested organs.
Laboratory or Histocompatibility Lab or Tissue Typing Lab.--An independent histocompatibility
laboratory is a laboratory meeting the provisions of 42 CFR 405.2171(d).
Line 1.01.--Enter the street address and P.O. Box (if applicable) of the OPO/LAB.
Line 1.02.--Enter the city, State and zip code of the OPO/LAB.
Line 2.--Enter the full name of the OPO based LAB and the provider number.
Line 2.01.--Enter the Street address and P.O. Box (if applicable) of the OPO based LAB.
Line 2.02.--Enter the city, state and zip code of the OPO based LAB.
Line 3.--Enter the inclusive dates covered by this cost report. In accordance with 42 CFR
413.24(f), each provider is required to submit periodic reports of operations which generally
cover a consecutive 12-month period of the provider’s operations. (See CMS Pub. 15-II, §102.1
through §102.3 for situations where a short period cost report may be filed.)
Cost reports are due on or before the last day of the fifth month following the close of the period
covered by the cost report. A 30 day extension of the due date may, for good cause, be granted
by the intermediary.
The cost report from a provider which voluntarily or involuntarily ceases to participate in the
health insurance program or changes ownership is due no longer than 45 days following the
effective date of the termination of the provider agreement or change of ownership. Cost report
due dates may not be extended in termination or change of ownership cases.
Line 4.-Column 1--Type of Control--Indicate the ownership or auspices under which the OPO/LAB
operates by entering the number below that corresponds to the type of control.
Proprietary
1=Individual
2=Corporation
3=Partnership
4=Other (Specify)

Voluntary Non-Profit
5=Church
6=Corporation
7=Foundation
8=Other (Specify)

Government
9=Federal
10=State
11=County
12=City

If item 4 or 8 is selected, “Other (Specify)” category, specify the type of provider in column
2 of the worksheet.
Column 3.--Type of Provider--Enter the number which corresponds to the type of provider
as defined in the conditions of participation. Enter 1 for OPO and 2 for LAB.
Column 4.--Participation Date—Enter the date the OPO/LAB was certified for participation
in the Medicare program. All laboratories that were certified on October 1, 1978, have an
effective
33-6

Rev. 4

11-05

FORM CMS-216-94

3303.1

date of October 1, 1978, regardless of when the agreement was signed. If operations began
after October 1, 1978, enter the date found in the approval letter from the regional office of
the Department of Health and Human Services. Independent OPOs must have a certification
date on or after March 31, 1988.
3302.2 Part II - Certification By Officer or Administrator.--Prepare and sign the certification
after completion of the cost report.
3302.3 Part III - Settlement Summary.--Enter the balance due to or from the complex.
Transfer the settlement amounts from Worksheet D, line 8 (Organ Acquisition from column 1
and Tissue Typing from column 2).
3303.

WORKSHEET S-1 - ORGAN PROCUREMENT ORGANIZATION/HISTOCOMPATIBIITY LABORATORY IDENTIFICATION DATA

3303.1

Part I - OPO Statistics (To be completed by OPOs only).--

Line 1.--Enter the total number of kidneys retrieved and/or processed administratively. This
includes all viable and nonviable kidneys retrieved locally as well as kidneys obtained from all
other sources.
Line 2.--Enter the number of nonviable kidneys retrieved and/or processed administratively.
This includes kidneys that were not transplanted due to a defect and kidneys for which a
recipient was not located. Do not include kidneys that are sent to a foreign country for transplant
on this line. Include foreign kidneys on lines 1, 3, 4, and 6, as appropriate.
NOTE: Total kidneys included on line 1 and nonviable kidneys included on line 2
must include kidneys that were determined to be unusable at the time of excision. For
example, if a procurement is attempted and no kidneys are excised due to non viability,
two kidneys must be counted on both lines 1 and 2. However, kidneys that are
retrieved exclusively for research (known prior to retrieval) must be excluded from the
count of kidneys.
OPOs that have an agreement with military and VA hospitals to procure kidneys t no
charge, but must give the military/VA institution the first opportunity to use the
kidneys, count these kidneys as sent to a military or Department of Vetarans’ Affairs
(DVA) facility on line 5. These kidneys must also be shown as a local retrieval on lines
1, 2, and 3, as applicable, and counted sent to the military or VA hospital. In these
cases, no revenue is shown.
Line 3.--Enter the number of kidneys for which payment should have been received. It must
equal the amount entered on line 1 minus the amount entered on line 2 and correspond with the
number of kidneys transplanted and exported.
Line 4.--Enter the number of viable kidneys that were exported from your retrieval area. This
number includes viable kidneys sent to another independent or hospital-based OPO or to a
foreign country which received the kidney for potential transplant.
Line 5.--Enter the number of viable kidneys that were shared with a military hospital or DVA
hospital in your retrieval area. Include this number in the total viable kidneys on line 3 in the
total column. A kidney sent to another OPO, and subsequently sent to a VA or military hospital,
is counted as a DVA/military kidney by the second OPO, not the originating OPO.

Rev. 4

33-7

3303.2

FORM CMS-216-94

11-05

NOTE: OPOs that have an agreement with military and VA hospitals to procure kidneys at no
charge, but must give the military/VA institution the first opportunity to use the
kidneys, count these kidneys as sent to a military or VA hospital facility, as applicable,
and count as a sale to the military or VA hospital. Show no revenue in these cases. See
PRM 15-I, §2775.2 for an exception to this instruction.
Line 6.--Show the amount received for kidneys listed on line 5.
Line 7.--Enter the number of kidneys furnished to foreign countries. Indicate the number for
which payment was received and the number for which there was no payment. Show the amount
of payment received in the second column. Provide a supplemental schedule identifying the
organ, the country it was shipped to, the date of shipment, the amount charged, and the amount
of payment received. A kidney sent to another OPO, and subsequently sent to a foreign country,
is counted as a foreign kidney of the second OPO, not the originating OPO.
Line 8.--Enter for each organ identified the total number of organs/tissues (not kidneys) retrieved
and/ or processed administratively. In the second column, include the number of organs/tissue
that were retrieved, but not used for transplant. Include the amount of payment received for each
type of organ. Include the amount received for transplanted organs and organs sent to research.
If no payment was received, enter zero.
3303.2

Part II - Lab Statistics (To be completed by lab only).--

Line 1.--Enter the total number of all tests performed. This includes clinical laboratory tests as
well as tissue typing tests.
Line 2.--Enter the total number of tests performed by the tissue typing lab. This includes all tests
whether or not they are related to kidney transplantation.
Line 3.--Enter the total number of kidney pre-transplantation tests included on line 2. These tests
are performed for potential kidney recipients, living related donors, living unrelated donors, and
cadaver kidneys.
Line 4.--List the tests performed specifically for kidney pre-transplant and the number of each
type of test. The total must equal line 3.
3303.3

Part III - Full Time Equivalent Employees (FTEs).--

Line 1.--Enter the number of FTEs by type of employee at the facility. Where the number of
"Other" employees exceeds 10 percent of the total or is greater than 10 percent, provide a
supplemental schedule detailing their duties. Administrative employees in the first column are to
correspond with the salary shown on Worksheet A, lines 3 through 7, which includes Worksheet
A-1. OPO employees in the second column are to correspond with the salaries shown on all
Worksheet A-2s for all types of organ acquisition. Histo-lab employees in the third column are
to correspond with the salaries shown on Worksheet A-3. Prorate employees that perform
several different functions by type of function in the same manner as salaries are prorated on
Worksheets A-1, A-2, and A-3.
Line 2.--Enter the total number of FTEs at the facility. This number must equal the sum of all
categories appearing on line 1.
NOTE: FTEs are computed on the basis of 2080 hours per year. Accordingly, divide total
hours worked per category by 2080 to obtain the equivalent number of FTEs.

33-8

Rev. 4

11-05
3304.

FORM CMS-216-94

3304

WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES

This worksheet provides for recording the trial balance of expense accounts from the
OPO§s/Labs accounting records. It also provides for the necessary reclassification and
adjustments to certain cost centers. The cost centers on this worksheet are listed in a manner
which facilitates the transfer of the various cost center data to the cost finding worksheets.
Not all of the cost centers listed may apply to all OPO/Labs.
Under certain conditions, a provider may elect to use different cost centers for allocation
purposes. These conditions are stated in CMS Pub. 15-I, §2313.
Standard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If
a provider needs to use additional or different cost center descriptions, it may do so by adding
additional lines to the cost report. Added cost centers must be appropriately coded. Identify the
added line as a numeric subscript of the immediately preceding line. That is, if two lines are
added between lines 5 and 6, identify them as lines 5.01 and 5.02. If additional lines are added
for general services cost centers, corresponding columns must be added to Worksheets B and B1 for cost finding.
Also, submit the working trial balance of the facility with the cost report. A working trial
balance is a listing of the balances of the accounts in the general ledger to which adjustments are
appended in supplementary columns and is used as a basic summary for financial statements.
Cost center coding is a methodology for standardizing the meaning of cost center labels as used
by health care providers on the Medicare cost reports. Form CMS 2168-94 provides for 25
preprinted cost center descriptions that may apply to OPO/HL services on Worksheet A. In
addition, a space is provided for a cost center code. The preprinted cost center labels are
automatically coded by CMS- approved cost reporting software. These 20 cost center
descriptions are hereafter referred to as the standard cost centers. One additional cost center
description with general meaning has been identified. This additional description will hereafter
be referred to as a nonstandard label with an "Other..." designation to provide for situations
where no match in meaning to the standard cost centers can be found. Refer to Worksheet A,
line 8.
The use of this coding methodology allows providers to continue to use labels for cost centers
that have meaning within the individual institution. The four-digit cost center codes that are
associated with each provider label in their electronic file provide standardized meaning for data
analysis. The preparer is required to compare any added or changed label to the descriptions
offered on the standard or nonstandard cost center tables. A description of cost center coding
and the table of cost center codes are in Table 5 of the electronic reporting specifications.
Where the cost elements of a cost center are separately maintained on your books, a
reconciliation of the costs per the accounting books and records to those on this worksheet must
be maintained by you and is subject to review by the intermediary.
Column Descriptions
Columns 1, 2, and 3.--List on the appropriate lines in columns 1, 2, and 3 the total expenses
incurred during the cost reporting period. The expenses must differentiate between salaries
(column 1) and other (column 2). The sum of columns 1 and 2 must equal column 3. Include all
fringe benefits paid to the employee. See CMS Pub. 15-I, §2144.1 for a definition of fringe
benefits.
Column 1.--Include only those amounts for persons employed by the OPO/Lab. This includes all
persons reported on Federal Tax Form 941. Do not include any payments to individuals who are
self-employed. Show only salaried and hourly wage employees on which taxes are withheld and
paid in column 1.

Rev. 4

33-9

3304 (Cont.)

FORM CMS-216-94

11-05

Column 2.--Include all other expenses of the particular cost center not identified in column 1.
Column 3.--This amount represents the total expenses of the particular cost center and agrees
with the trial balance of expenses for that classification. Prepare a supplemental workpaper
which details the OPO’s/Lab’s expense accounts that tie into the cost centers shown on
Worksheet A. Line 26, column 3, must agree with total operating expenses on the income
statement.
Column 4.--Enter any reclassifications among the cost center expenses in column 3 which are
needed to affect proper cost allocation. Worksheet A-4 is provided to detail any reclassifications
affecting the expenses specified therein. This worksheet (explained in §3308) must be
completed to the extent that reclassifications are needed and appropriate for the allocation of
costs on Worksheet B. Show reductions in brackets.
The net total of entries in column 4 must equal zero on line 26. Also, the working trial balance
must be submitted with the cost report. A working trial balance is a listing of the accounts in the
general ledger to which adjustments are appended in supplementary columns and is used as a
basic summary for financial statements.
Column 5.--Adjust the amounts in column 3 by the amounts in column 4 (increase or decrease)
and extend the net balances to column 5. The total of column 5 must equal column 3, line 26.
Column 6.--Enter on the appropriate line in column 6 the amounts of any adjustments to
expenses indicated on Worksheet A-5 (explained in §3309). The total of Worksheet A, column
5, line 26, must equal the amount on Worksheet A-5, column 2, line 17.
Column 7.--Adjust the amounts in column 5 by the amounts in column 6 (increase or decrease)
and extend the net balances to column 7.
Line Descriptions
Line 1.--This cost center includes amounts for depreciation and leases and rentals for the use of
the facility. Include taxes, interest and insurance on land and buildings. Do not include costs for
the repair and maintenance of the facility. Other costs associated with taxes, interest, rentals,
leases, and insurance appear on Worksheet A-1 as part of administrative and general (A&G).
However, capital related costs included in A & G are reclassified to this cost center using column
4 and Worksheet A-4.
Line 2.--This cost center includes depreciation, leases, and rentals for the use of the equipment as
well as taxes, interest, and insurance on the equipment. Do not include costs for repair or
maintenance of the equipment. Other costs associated with taxes, interest, rentals, leases, and
insurance appear on Worksheet A-1 as part of A&G costs, but are reclassified to this cost center
using column 4 and Worksheet A-4.
Line 3.--Include in column 1 the salaries of employees working on employee benefit or
personnel matters, etc. Show the costs of other employee benefits in column 2, e.g.,
hospitalization insurance and pension plans. These costs may be reclassified out of
administrative and general (line 5) if they were included in that account on the financial
statements. This is done on Worksheet A-4.
Line 4.--Enter on this line for columns 1, 2, and 3 the total amount as shown on Worksheet A-1,
line 20, columns 1, 2, and 3. Worksheet A-1 is explained in §3305.
Line 5.--This line includes the salaries of maintenance personnel, plant engineers, etc. The
"other" column includes all maintenance supplies, heat, light, power, and any costs incurred for
other than capital repairs that relate to the physical functioning of the OPO/Lab.
Line 6.--Enter the total salaries of all personnel rendering janitorial and housekeeping activities.
Enter in column 2 the cost of supplies and contracted housekeeping services.

33-10

Rev. 4

11-05

FORM CMS-216-94

3304 (Cont.)

Line 7.--Enter the total salaries of employees working in central supply in column 1 and the cost
of medical supplies used in column 2.
Line 8.--Enter general overhead costs that cannot properly utilize one of the lines mentioned
above. Detail the cost of items included with supporting documentation. Report salary and other
costs separately in columns 1 and 2.
Line 9.--This cost center includes all of the salaries and other direct costs (personal travel
allowances, bonus, etc.) of the procurement coordinators. Some of these direct costs may be
reclassified from other cost centers using column 4 and Worksheet A-4, e.g., costs associated
with coordinators may be reclassified from A & G.
Line 10.--Enter all costs associated with the education of donor hospital personnel and
physicians. Include the expenses of meetings, seminars, slide shows, and presentations for the
benefit of the above mentioned individuals.
Line 11.--Enter the expenses of awareness programs designed to inform the general public of the
need for organs and organ transplant services.
Line 12.--Enter acquisition overhead costs that are applicable to the procurement of all type of
organs. Include a full description (e.g., technicians’ salaries) of the costs included on this line.
Line 13.--Enter in columns 1, 2, and 3 the total amount as shown on Worksheet A-2, columns 1,
2, and 3, line 23. Worksheet A-2 is explained in §3306. Do not enter costs for the acquisition of
non-renal organs on this line. Show costs for the acquisition of non-renal organs on lines 15
through 20 as appropriate.
Line 14.--Enter in columns 1, 2, and 3 the total amounts as shown on Worksheet A-3, columns 1,
2, and 3, line 11. Worksheet A-3 is explained in §3307.
Lines 15 through 20.--Enter in columns 1, 2, and 3 the total amount shown on Worksheet A-2,
columns 1, 2, and 3, line 23. Complete a separate line and Worksheet A-2 for each type of organ
acquisition.
Line 21.--Include the costs of non-reimbursable research. See CMS Pub. 15-I, chapter 5 for a
further explanation of research.
Line 22.--Enter costs which are totally directed to the operation of the blood bank. These are not
overhead costs which need to be allocated between the lab and the blood bank, but expenses that
are directly related only to the blood bank function.
Line 23.--Enter the direct costs of operating a non-tissue typing lab. Include salaries and other
expenses that are totally non-tissue typing. Tissue typing lab costs are shown on line 14.
Line 24.--Enter the direct costs associated with operating or furnishing services for maintenance
dialysis, peritoneal dialysis, training, self-dialysis, and home dialysis. These costs are totally
related to the furnishing of dialysis services and may not include any expenses that need to be
allocated to a reimbursable cost center.

Rev. 4

33-10.1

06-95

FORM HCFA-216-94

3305

Line 25.--Use this line to record other non-reimbursable activity not shown on this worksheet.
Indicate the type of activity and if there is more than one activity, provide a separate schedule for
each.
Line 26.--Enter the total of line 1 through 25 for each of the columns 1 through 7. The amounts
shown in column 7 are transferred as follows:
1. If any of the costs shown on lines 1 through 12 need to be allocated to more than one
of the cost centers shown on lines 13 through 25, then transfer the amounts in column 7 to the
appropriate columns on Worksheet B. It is necessary to transfer costs to Worksheet B in all
cases where expenses must be allocated between an OPO and a dialysis unit or kidney
foundation or any other activity other than kidney transplant services. It is also necessary to
allocate expenses if the OPO procures non-renal organs in addition to its renal organs. In the
case of a laboratory, it is necessary to transfer cost to Worksheet B when expenses must be
allocated between the tissue typing laboratory and clinical laboratory. It is also necessary to
transfer cost to Worksheet B when expenses must be allocated between the tissue typing lab and
a clinical lab. It is also necessary to transfer lab costs to Worksheet B where overhead cost must
be allocated between the lab and the blood bank.
2. If the OPO’s sole function is to provide the organ procurement services listed in
§3302.1, item 1, and costs do not need to be allocated to a tissue typing lab, non-reimbursable
cost center or non-renal organs, then total costs as shown on line 26, column 7, can be transferred
directly to Worksheet C, column 1, line 4. If any cost needs to be allocated to another cost
center, then the costs in column 7 need to be transferred to Worksheet B.
3. If the tissue typing lab’s sole function is that of tissue typing and the lab does not
provide clinical lab services and must not allocate costs to research or blood bank or any nonreimbursable cost center, then transfer the total cost as shown on column 7, line 26, to Worksheet
C, column 2, line 4. If any cost needs to be allocated to another cost center, then the cost in
column 7 needs to be transferred to Worksheet B.
3305.

WORKSHEET A-1 - ADMINISTRATIVE AND GENERAL EXPENSES

This worksheet provides for a detailed listed of administrative and general (A&G) expenses.
Columns 1, 2, and 3.--The same explanation applies as shown in §3304 for columns 1 2, and 3 of
Worksheet A.
Line 1.--Enter the salaries and other costs of the medical director who has responsibility for the
operation of the entire lab OPO or blood bank. Include salaries and other costs for medical
directors who have responsibilities for combined OPO/Labs or a tissue typing clinical lab and
blood bank. Costs for a medical director solely responsible for a tissue typing lab are shown on
Worksheet A-3, line 1. If the medical director performs actual testing (non-administrative
functions), allocate his/her salary between this line and the appropriate line on Worksheet A.
Line 2.--Enter the salaries and other costs of the administrator, executive director (not medical
director), officer, or individual who is responsible for the non-medical operation of the OPO/Lab.
If the medical director and administrator’s duties are performed by the same person, enter the
salary and other costs on line 1.

Rev. 1

33-11

3305 (Cont.)

FORM HCFA-216-94

06-95

Line 3.--Enter the total costs which were allocated and recorded on your books. Adjustments
resulting from the home office cost report are made on Supplemental Worksheet A-5-1 and
appear in column 6 of Worksheet A.
Line 4.--Enter the computer processing costs associated with the management and accounting
functions. Do not include the cost of registering potential recipients, maintaining and utilizing
the services of the United Network for Organ Sharing (UNOS) or a similar network, and time
sharing expenses on this line. Those costs are shown on Worksheet A-2, line 11.
Lines 5 through 8.--List the salaries and other costs related to these functions. Costs included in
line 6 for capital related leases and rent are reclassified on Worksheet A-4.
Line 9.--Enter the expenses of attending meetings and seminars which are administrative in
nature. Do not enter professional education costs for nurses and physicians or public awareness
costs.
Line 10.--Enter insurance expenses (e.g., auto, building, liability, and malpractice).
included that pertain to capital related costs are reclassified on Worksheet A-4.

Costs

Line 11.--Enter costs of travel, registration, and other expenses relating to the professional
education of employees.
Line 12.--Enter costs incurred for advertising and promotion of non-kidney related activities,
e.g., blood bank promotions and dialysis unit advertising.
Lines 13 through 19.--Costs included on these lines that pertain to capital costs are reclassified
on Worksheet A-4.
Line 20.--Transfer the totals of columns 1, 2, and 3 to Worksheet A, columns 1, 2, and 3, line 4.
3306.

WORKSHEET A-2 - ORGAN ACQUISITION COSTS (OPOs only)

This worksheet provides for a detailed listing of organ acquisition costs. Complete Worksheet
A-2 for each type of internal organ acquisition. This worksheet is only for internal organs and
does not apply to cornea and skin acquisitions. The top of the worksheet has six boxes. Place a
checkmark in the single appropriate box to which the worksheet corresponds. A separate
Worksheet A-2 must be completed for each type of internal organ acquisition performed by the
OPO.
Amounts Paid to Excision Hospitals.--A breakdown of hospital costs is necessary. If the donor
hospital does not sufficiently detail its bills, list available costs and show the balance on line 9.
Attempt to obtain detailed bills from the donor hospital. Where multiple types of organs are
billed by the excising hospital on a single bill, the bill must be split by type of organ procured.
Pediatric kidneys procured for transplantation "En Bloc" are to be counted as one kidney for
allocation purposes. If there are costs on the bill that are exclusively identifiable to a specific
organ, associate those costs directly to that type of organ. The remaining component costs of the
bill not specifically identified allocate to the proper component based on the number

33-12

Rev. 1

06-95

FORM HCFA-216-94

3306 (Cont.)

of organs retrieved. For each organ procurement, of both kidneys, count kidneys as two organs
for allocation purposes. If one is usable and one is not, they are still counted as two kidneys (one
viable and one nonviable). If a retrieval is known in advance to have only one potential kidney,
count one kidney for allocation purposes. Count a heart/lung procurement as one organ.
Lines 1 through 9.--These lines are self explanatory and detail the costs billed by the donor
hospitals to you.
Other Acquisition Costs
Line 11--Enter the cost of registering potential recipients, maintaining and utilizing the services
of the United Network for Organ Sharing (UNOS), or a similar network and time sharing
expenses. Do not enter computer costs associated with the management or accounting functions.
Those costs are entered on Worksheet A-1, line 4. Where computer registry costs apply to more
than one type of organ and it is indeterminable as to which organ type the costs are associated
with, place the costs on Worksheet A, line 12, and allocate to all organs on Worksheet B.
Line 12.--Enter costs incurred for the evaluation of potential donors.
Line 13.--Self explanatory.
Line 14.--Enter the costs associated with the perfusion lab, i.e., direct salaries and supplies.
Enter these costs regardless of whether the lab was a contracted or purchased service or an inhouse operation. When preservation applies to only one type of organ, enter the cost on line 14.
However, when preservation costs apply to several types of organs, it must be placed on
Worksheet A-2, line 14, for the appropriate organ.
Lines 15 and 16.--Use these lines only when services are purchased from an independent or
hospital-based lab. Show the cost for services provided by an in-house lab under tissue typing
costs on Worksheet A-3.
Line 17.--Enter the total direct costs of importing organs from another OPO. It includes any
transportation costs associated with the receipt of the organ.
Line 18.--Enter all costs associated with the transportation of organs retrieved locally and
exported outside of your retrieval area.
Line 19.--Enter costs of tissue typing purchased under agreement where the independent or
hospital-based lab bills you for the service. Exclude costs shown on lines 15 and 16. If the lab
bills the transplant hospital for the tests, do not complete this line.
Line 20--Enter all costs for anesthesiologist professional fees.
Line 21.--Enter all other acquisition costs that have not been provided for above. Identify the
costs included on this line. If more than one line is necessary, provide a separate schedule.
Line 22.--Enter the sum of the amounts on lines 11 through 21.
Line 23.--Transfer total costs to Worksheet A, columns 1, 2, and 3, lines 13 and 15 through 20,
as appropriate.

Rev. 1

33-13

3307
3307.

FORM HCFA-216-94

06-95

WORKSHEET A-3 - TISSUE TYPING LABORATORY COSTS

This worksheet provides for a detailed listing of tissue typing direct costs.
Line 1.--Enter the direct salary and other costs of the medical director of the laboratory.
If the medical director’s salary and other benefits are totally attributable to the tissue typing lab,
then include the entire cost on Worksheet A-3, line 1.
If the medical director has management responsibility in addition to the tissue typing lab, then
include all of the cost on Worksheet A-1, line 1.
If the Medical Director has management responsibility for both the tissue typing lab and clinical
lab, then utilize a time study to calculate the cost applicable to each lab. If a study is used, it
must detail the services performed for each lab and a realistic estimate of the effort involved.
Retain the study for future reference. Enter the actual reclassification on Worksheet A-4 and
transfer the amounts to Worksheet A, column 4, lines 14 and 23.
If a time study is not available, place the cost on Worksheet A, line 8, and allocate on Worksheet
B.
Line 2.--Enter the salaries and related cost of the technologist working in tissue typing only. If a
technologist works in both tissue typing and an area other than tissue typing, then a study can be
used to calculate the cost applicable to each cost center, or the cost can be placed on the blank
line, Worksheet A, line 8, and allocated on Worksheet B.
Line 3.--Enter the salaries and other costs associated with the ongoing development of reagents.
This includes local cell panel construction and maintenance, including freezing technique and
local reagent (antibody) characterization. Other expenses of this nature are also on this line.
Line 4.--Enter maintenance cost of equipment used only for tissue typing procedures. If
equipment is used for other than tissue typing, include the cost on Worksheet A, line 5. See
§3304, line 5 for details.
Lines 6 through 10.--Include any expenses which cannot properly be combined with lines 1
through 4. If additional lines are needed, detail the items below line 11 or on a separate page.
Line 11.--Total tissue typing costs (sum of columns 1, 2, and 3, lines 1 through 10) are
transferred to Worksheet A, columns 1, 2, and 3, line 14. Include on this line direct expenses
only attributable to tissue typing and not related to the clinical lab or any other cost center on
Worksheet A, lines 13 or 15 through 25.
3308.

WORKSHEET A-4 - RECLASSIFICATIONS

This worksheet provides for the reclassification of expenses needed to effectuate a proper
allocation of costs on Worksheet B.
The following are some examples of costs which must be reclassified on this worksheet.

33-14

Rev. 1

06-95

FORM HCFA-216-94

3309

1. Reclassify rental expense on a specific piece of movable equipment which was charged
directly to the appropriate cost center on this worksheet to the Capital Costs - Movable
Equipment cost center unless the OPO/Lab has identified and charged all depreciation and rental
expense for all movable equipment to the appropriate cost centers. The OPO or lab may not
direct cost individual pieces of equipment, unless all equipment can be direct costed.
2. The expenses related to medical directors in the A&G cost center and tissue typing
technologies in the tissue typing lab may be reclassified on this worksheet if a time study can
support the reclassification of costs between two different functions. Reclassification is also
applicable to the lab medical director (in the tissue typing cost center) if the director is
responsible for more than one type of lab.
3. Reclassify the costs of any other item which was posted to your accounting records,
but is more appropriately included in another cost center for cost finding, on Worksheet A-4.
For example, a procurement coordinator salary and other costs included with kidney acquisition
costs must be removed and allocated to all types of acquisition when non-renal organs are
processed.
4. Capital related costs of rental leases, taxes, insurance, and interest included in A&G
must be reclassified to the capital-related expense cost centers.
Columns 4 and 7.--Transfer the amounts shown in these columns to the appropriate lines of
Worksheet A, column 4.
3309.

WORKSHEET A-5 - ADJUSTMENTS TO EXPENSES

This worksheet provides for adjustments to the expenses listed on Worksheet A, column 5, and
are shown or summarized on Worksheet A, column 6. Make these required adjustments on the
basis of cost or amount received. Enter the amount received only if the costs (including direct
cost and all applicable overhead) cannot be determined. If the total direct and indirect cost can
be determined, enter the cost. If cost is used, retain the calculation of the cost for future
reference as long as the 3 year period for reopening cost reports has not expired. Once an
adjustment to an expense is made on the basis of cost, do not, in future periods, determine the
required adjustment on the basis of revenue. Enter the following symbols in column 1 to
indicate the basis for adjustment: A for cost and B for amount received. Line descriptions
indicate the more common activities which affect allowable cost or result in costs incurred for
reasons other than kidney transplantation and thus require adjustments.
Types of items to be entered on Worksheet A-5 are (1) items needed to adjust expenses to reflect
actual expenses incurred, (2) items which constitute recovery of costs through sales, charges , or
fees, (3) items needed to adjust expenses in accordance with the Medicare principles of
reimbursement, and (4)items which are provided for separately in the cost apportionment
process.
When an adjustment to an expense affects more than one cost center, either (1) record the
adjustment to each cost center on a separate line on Worksheet A-5 or (2) enter the total
adjustment on one line and attach a supporting worksheet showing the required adjustments to
the various cost centers affected. In this latter situation, enter on the appropriate line in column 3
of Worksheet A-5 the words "Supporting Worksheet Attached". For line 4, Supplemental
Worksheet A-5-1 is supporting documentation for any required entry.

Rev. 1

33-15

3309 (Cont.)

FORM HCFA-216-94

06-95

Lines 1 and 2.--Do not consider discounts, allowances, refunds, and rebates a form of income.
Use them to reduce the specific costs to which they apply in the accounting period in which the
purchase occurs. (See HCFA Pub. 15-I, chapter 8.)
Line 3.--Enter the allowable home office costs which have been allocated to the OPO/Lab. The
home office cost report on which the allocation is made must be submitted to the intermediary.
(See §112.)
Line 4.--Obtain the amount to be entered on this line from Supplemental Worksheet A-5-1, Part
B, column 6, total. Lines 1 through 4 of Supplemental Worksheet A-5-1, Part B, column 6,
represent the detail of various cost centers to be adjusted on Worksheet A. (See HCFA Pub. 15I, chapter 10.)
Line 5.--Enter the total amount received from the procurement of any tissues such as corneas,
bone, heart valves, pancreas islet, and skin. All internal organ acquisitions, such as livers hearts,
pancreas, and lungs, must go through cost finding on Worksheet B. Do not offset income
received from internal organs since these costs go through cost finding and all costs are removed
after stepdown.
Line 6.--Remove the direct cost plus applicable overhead of operating vending machines from
allowable cost. If cost cannot be calculated, then income received may be used.
Line 7.--Use income received from the rental or lease of equipment to reduce the cost of specific
equipment. When a building is owned or operated and space is leased or rented, the preferable
treatment is to establish a non-reimbursable cost center on Worksheet A, line 25. Record in this
cost center the direct cost plus all applicable overhead of the rented or leased space. A separate
calculation of the cost of leased space may be acceptable and the cost offset on line 7 of
Worksheet A-5 when the amount of the adjustment is minor. Only in rare situations is the rental
or lease income used as the offset on line 7 of Worksheet A-5. If space is leased or rented to an
outside organization for the provision of a service needed for kidney transplantation (such as a
perfusion lab), then the income received from the organization for rent must be offset on this
line.
Line 8.--Enter the amount of proceeds from the sale of organs which were sold for research.
Line 9.--Enter the costs incurred for public relations not related to organ procurement. See
HCFA Pub 15-I, §2136 for an explanation of this area.
Line 10.--If seminars and meetings grant continuing education credits, OPOs and labs charge a
fee to the attendees that is offset against A&G, using this line. If a good faith effort is made to
recover the costs in the form of fees, HCFA allows the costs not fully recovered.
Line 11.--The amount received from the sale of supplies to employees and others is a recovery of
cost and must be offset against the specific expenses.
Line 12.--Offset the amount received in investment income against interest expense.

33-16

Rev. 1

11-05

FORM CMS-216-94

3310

Lines 13 and 14.--If depreciation expense computed in accordance with Medicare principles of
reimbursement differs from the depreciation expenses shown on your books, enter the difference
on line 13 and/or 14. (See CMS Pub. 15-I, chapter 1.) Examples of possible situations are:
1. When the OPO/Lab utilizes the double declining balance method of depreciation on
assets purchased after August 1, 1970, the expense claimed on Worksheet A must be adjusted to
reflect the straight line method;
2. When the replacement cost method of accounting for fixed assets and depreciation has
been used, it must be adjusted to straight line;
3. When the 20 percent bonus depreciation has been used for book purposes, it must be
adjusted to straight line; and
4. When 150 percent declining balance has been used without approval, an adjustment is
required.
When adjustments are required due to differences in useful lives or depreciation methods,
maintain the fixed asset and depreciation records to support the depreciation expense allowed by
Medicare principles of reimbursement.
Line 17.--The total amount shown in column 2 must agree with Worksheet A, column 6, line 26.
Post the amounts shown in column 2 of Worksheet A-5 to the appropriate line of Worksheet A,
column 6.
3310.

WORKSHEET A-6 - CAPITAL EXPENDITURES AND DEPRECIATION
RECONCILIATION

Part I – Analysis Of Changes In Capital Asset Balances During The Cost Reporting Period
Complete the analysis of changes in capital asset balances during the cost reporting period. Do
not reduce the amount by accumulated depreciation. The beginning balance refers to the amount
as of the first day of the cost reporting period.
Part II – Analysis Of Changes In Accumulated Depreciation
The analysis of changes in is completed in a similar manner to the asset section in the first half of
the form.
Part III – Depreciation Recorded in Cost Statement
Lines 1, 2, and 3.--Enter on the appropriate line the amount of depreciation used during the cost
reporting period. The amounts shown are after any adjustments made to recognize the Medicare
principles of reimbursement relating to depreciation. (See CMS Pub. 15-I, chapter 1.)
Line 4.--Enter the total of lines 1 through 3. This amount equals the amount of allowable
depreciation expense that is included on Worksheet A, column 7, lines 1 and 2. The sum of the
amounts on lines 1 and 2 of Worksheet A may be an amount greater than line 4 of Worksheet A6. This is due to column 7 of Worksheet A having reclassified costs included with depreciation,
i.e., insurance and taxes.
Line 5.--Indicate whether a funded depreciation account was maintained during the period as
defined in CMS Pub. 15-I, §226. If a fund was maintained, list the ending balance of the fund.
Line 6.--Indicate whether there was a gain or loss on the sale of assets during the cost reporting
period. (See CMS Pub. 15-I, §132.)
Rev. 4

33-17

3311
3311.

FORM CMS-216-94

11-05

WORKSHEET B - COST ALLOCATION - GENERAL SERVICE COSTS AND
WORKSHEET B-1 COST ALLOCATION - STATISTICAL BASIS

Worksheet B provides for cost finding using a methodology which combines similar types of
costs and apportions the costs to those cost centers which receive the services. The cost centers
that are serviced include all reimbursable and nonreimbursable cost centers within the facility.
The total direct expenses are obtained from Worksheet A, column 7. Schedule B-1 provides the
statistics necessary to allocate the cost to the revenue producing cost centers on Worksheet B.
To facilitate the allocation process, the general format of Worksheets B and B-1 are identical.
The column and line numbers for the general service cost centers are identical on the two
worksheets.
The statistical allocation bases shown at the top of each column on Worksheet B-1 are the bases
of allocation of cost centers indicated. Certain centers are combined for cost allocation purposes.
OPOs and labs must combine and allocate these costs as shown on the worksheet. However,
deviations from the allocation statistics as well as the cost center combinations may be made
with approval from your intermediary prior to the start of the cost reporting period. The total
costs of each combined group of cost centers are allocated in one process to the revenue
producing and nonreimbursable cost centers.
The statistics shown on Worksheet B-1 are multiplied by the unit cost multiplier on line 18 of
Worksheet B-1. Place the result on the corresponding line of Worksheet B.
Column Descriptions
Column 1.--Enter the direct costs for allocation from Worksheet A, column 7. Column 1, line 1
must equal the sum of the amounts on Worksheet A, column 7, lines 1 through 8.
Column 2.--Enter all costs that are allocated on the statistical basis of square feet. Square feet
represents the actual square footage contained in each department or cost center. Include in the
organ acquisition cost center costs relating to the square footage for the coordinators, the direct
clerical staff, files, etc. Column 2, line 1, of Worksheet B equals the sum of the amounts on
Worksheet A, column 7, lines 1, 5, and 6.
Column 3.--Enter the costs from Worksheet A, column 7, line 2. The recommended statistical
basis is the dollar value of assets located in each department. Square footage is an alternative
basis which is acceptable to allocate movable equipment. However, where the facility has a
department that is equipment intensive, e.g., a dialysis unit, dollar value must be used rather than
square footage.
Column 4.--Enter the costs that are allocated on the statistical basis of direct salaries. The
amount in column 4, line 1, is transferred from Worksheet A, column 7, line 3. The direct
salaries on Worksheet B-1 generally are from Worksheet A, column 1. However, the salaries
need to be adjusted to reflect changes to salaries shown as reclassifications and adjustments in
columns 5 and 7 of Worksheet A. When a large number of changes to salaries are necessary,
attach a separate schedule to show the accumulation and reclassification of salaries by cost
center.

33-18

Rev. 4

11-05

FORM CMS-216-94

3311 (Cont.)

Column 5.--Medical supplies are allocated on costed requisitions. The cost to be allocated in
column 5, line 1, is from Worksheet A, column 7, line 7.
Column 8.--Enter the direct and indirect costs associated with internal organ acquisitions. The
direct costs in column 1 are added to the overhead costs allocated in columns 2-7 and
accumulated in column 8. After the total costs are accumulated in column 8, line 2, they are
allocated to the specific types of organ acquisition based on the number of organs procured.
Utilize the statistics (number of organs procured) on Worksheet B-1. The number of organs
procured means the total number of internal organs procured during the period including
imported organs as well as nonviable organs. For overhead allocation purposes, count a
heart/lung acquisition as one acquisition.
Column 10.--Allocate the A&G costs to revenue producing and nonreimbursable cost centers
based on accumulated costs. The accumulated costs used for allocation are the subtotals shown
on Worksheet B, column 9.
Column 11.--Total expenses in column 11 represent the full cost (direct and indirect) used for
settlement purposes. Column 11 is the sum of columns 9 and 10. Transfer only the reimbursable
cost centers to another worksheet in the cost report. Transfer kidney acquisition costs on line 3,
column 11 to Worksheet C, line 4, column 1. Transfer the tissue typing lab costs on line 5,
column 11 to Worksheet C, line 4, column 2.
Line Descriptions
Line 1.--Enter the general overhead costs that are allocated in columns 2 through 7 and 10. Line
1, column 1 must equal line 1, columns 2 through 7 and 10. Line 1, column 1 must also equal
lines 1 through 8, column 7 on Worksheet A. Allocate the costs in columns 2 through 7 of line 1
to the cost centers listed on lines 2 to 15.
Line 2.--Enter the costs of acquiring all organs. Line 2, column 1 is the direct cost of organ
acquisition and is transferred from Worksheet A, column 7, lines 9 through 12. Allocate
overhead costs applicable to organ acquisition in columns 2 through 7. After all overhead has
been allocated, allocate organ acquisition costs to the various types of organ acquisition in
column 8.
Line 3.--Enter the total cost for kidney acquisition. Transfer the cost in column 1, line 3 from
Worksheet A, column 7, line 13. After the completion of overhead allocations, transfer the total
costs on line 4, column 11 to Worksheet C, column 1, line 4.
Line 4.--Enter the total cost of the tissue typing laboratory. The costs on line 4, column 1 are
from Worksheet A, column 7, line 14. Transfer the total costs including overhead allocations in
column 11 to Worksheet C, column 2, line 4.
Lines 5 through 15.--Enter the total cost (direct and indirect) of the nonreimbursable cost centers.
These costs are not transferred to any other worksheet of the cost report since they are not
reimbursable costs under the Medicare program.
Line 16.--Enter total expenses. This figure must agree with Worksheet A, column 7, line 26.
Columns 2 to 8 and 10 are zero since the costs on line 1 are negative and are allocated to the cost
centers in lines 2 to 15, as appropriate.

Rev. 4

33-19

3312

FORM CMS-216-94

11-05

Line 17.--Enter on Worksheet B-1 the costs to be allocated from Worksheet B. Transfer these
costs from the appropriate column of Worksheet B, line 1. Transfer organ acquisition costs in
column 8 from Worksheet B, line 2, column 8.
Line 18.--Line 18 on Worksheet B-1 is the result of dividing line 17 by line 16. This unit cost
multiplier is then used by multiplying it by the statistics shown in each column of Worksheet B1. The result is placed on the corresponding line of Worksheet B. Round the unit cost multiplier
to four (4) decimal places.
3312.

WORKSHEET C - COMPUTATION OF MEDICARE COST

Part I - Kidney Acquisition
Line 1.--Enter the total number of viable kidneys procured from Worksheet S-1, Part I, line 3,
column 3.
Line 2.--These are kidneys sent to Medicare transplant centers or certified OPOs. It does not
include kidneys sent to foreign countries, DVA hospitals, or military hospitals. Kidneys sent to a
military transplant center that has a reciprocal sharing agreement with the OPO may be included
on this line. However, this agreement must be approved by the intermediary and have been in
effect prior to March 3, 1988.
Line 3.--Divide the amount on line 2 by the amount on line 1 and enter the result.
Line 4.--Obtain the total cost of kidney acquisition from Worksheet B, column 11, line 3 or
Worksheet A, column 7, line 13, as appropriate. (See instructions in §3304 for Worksheet A,
column 7, and Worksheet A, line 26, item 2.)
Line 5.--Determine Medicare kidney acquisition cost by multiplying the ratio of Medicare
kidneys to total kidneys times the kidney acquisition cost (the amount on line 4 times the ratio on
line 3). Transfer the amount on line 5 to Worksheet D, column 1, line 1.
Part II - Tissue Typing Lab
The gross ratio of Medicare charges to total charges applied to cost is the formula used to
calculate Medicare reimbursable cost for kidney transplant related tests (Gross RCCAC). This
formula requires that the amount charged for each test be the same for all types of payers for
similar services, e.g., Histocompatibility Locus Antigen (HLA) typing is charged at the same rate
for a kidney transplant patient, paternity, and bone marrow. The amount recorded as the charge
or revenue must be the gross charge prior to any discounts or contractual allowances.
Line 1.--Enter the gross revenue recorded for all tests (renal and non-renal) performed in the
tissue typing lab. The amount is prior to any discounts or contractual allowances. Base this
amount on the accrual basis of accounting.
Line 2.--Enter the gross revenue recorded for pre-transplant kidney related tissue typing tests.
This amount is prior to discounts or contractual allowances and is on the accrual basis of
accounting.

33-20

Rev. 4

4-13

FORM CMS-216-94

3313

NOTE: If the cost report is a partial year under the program (e.g., expenses are from July 1 June 30, but cost reimbursement is effective April 1 or three of the twelve months), show only on
line 2 the kidney related revenue since the effective date of cost reimbursement.
Line 3.--Divide the amount on line 2 by the amount on line 1 and enter the result.
Line 4.--Enter the amount from Worksheet B, column 11, line 4 or Worksheet A, column 7, line
14, as appropriate. (See instructions in §3304 for Worksheet A, column 7, and Worksheet A,
line 26, item 3.)
Line 5.--Multiply the ratio of kidney transplant tests to total tests by the total tissue typing lab
cost (the amount on line 4 times the ratio on line 3) and enter the result. Transfer the amount on
line 5 to Worksheet D, column 2, line 1.
3313.

WORKSHEET D - CALCULATION OF REIMBURSEMENT SETTLEMENT

Line 1, Column 1.--Enter the amount from Worksheet C, column 1, line 5.
Line 1, Column 2.--Enter the amount from Worksheet C, column 2, line 5.
Lines 2 through 8, Columns 1 and 2.-Line 2.--Enter the amount received for lab services furnished to transplant centers in foreign
countries, military hospitals, and DVA hospitals. Foreign transplant centers, military, and
veterans hospitals are not in the Medicare program. Use the amount received from them as a
reduction of cost.
Line 3.--Enter the amount of total cost reimbursable to OPO/Lab (the amount on line 1 minus the
amount on line 2).
Line 4.--Enter the amount of payments received or receivable from transplant hospitals or other
OPOs for furnishing organ procurement and tissue typing services for kidney transplant or tissue
typing laboratory services. It includes all payments received for furnishing kidneys to transplant
hospitals (non-military) and to other OPOs.
Line 5.--Enter the result of subtracting the amount on line 4 from the amount on line 3.
Line 6.-- For cost reports that overlap or begin on April 1, 2013, enter the result of (2 percent
times (total days in the cost reporting period that overlap April 1, 2013 through September 30,
2013, divided by total days in the entire cost reporting period, rounded to four decimal places))
times Medicare reimbursable costs, line 5.
Line 7.--Enter all payments received from the intermediary for furnishing organ procurement and
tissue typing services for kidney transplants (from intermediary records).
Line 8.--Enter the net amount due to the OPO/Lab or the net amount which must be repaid to the
Medicare program. Enter the amount on line 5 minus the sum of the amounts on lines 6 and 7.

Rev. 5
3314

33-21
FORM CMS-216-94

4-13

3314.

WORKSHEET E - BALANCE SHEET

Complete the balance sheet in a manner consistent with the financial statements of the OPO/Lab.
If fund type accounting records are maintained, combine and place all funds in the general fund
columns. Certified accounting statements by an independent certified public accounting firm are
acceptable if the detail is equal to that of Worksheet E.
3315.
WORKSHEET
REVENUES

E-1

-

STATEMENT

OF

OPERATING

EXPENSES

AND

This worksheet shows the revenues and expenses generated from the provision of services and
does not include other revenue or nonoperating revenue and expenses. This worksheet must be
completed by all OPOs/Labs.
3316.

WORKSHEET E-2 - STATEMENT OF REVENUES AND EXPENSES

This worksheet provides for the recording of other income and nonoperating revenues and
expense and all adjustments that are required to show the net income or loss for the period. The
net income or loss shown on line 29 must agree with the financial statements prepared under the
accrual basis of accounting.
3317.
SUPPLEMENTAL WORKSHEET A-5-1 - STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS
In accordance with 42 CFR 413.17, costs applicable to services, facilities, and supplies furnished
to an OPO or lab by organizations related by common ownership or control are includable in the
allowable cost of the facility at the cost to the related organization except for the exceptions
outlined in 42 CFR 413.17(d). This worksheet provides for the computation of any needed
adjustments to costs applicable to services, facilities, and supplies furnished to the facility by
related organizations. (See CMS Pub. 15-I, chapter 10.)
Part A.--This worksheet must be completed by all facilities. If the answer to Part A is "Yes",
complete Parts B and C.
Part B.--Costs applicable to services, facilities, and supplies furnished to you by organizations
related to you by common ownership or control, are includable in your allowable cost at the cost
to the related organization. However, such costs must not exceed the amount a prudent and cost
conscious buyer would pay for comparable services, facilities, and supplies that could be
purchased elsewhere.
Part C.--Use this part to show your interrelationship to organizations furnishing services,
facilities, and supplies to you. The requested data relative to all individuals, partnerships,
corporations or other organizations having either a related interest to you, a common ownership
of the facility, or control over you as defined in CMS Pub. 15-I, chapter 10, must be shown in
columns 1 through 6 as appropriate.
Complete only those columns which are pertinent to the type of relationship which exists.
Column 1.--Enter the appropriate symbol which describes your interrelationship to the related
organization.

33-22

Rev. 5

06-02

FORM CMS-216-94

3318

Column 2.--If the symbol A, D, E, F, or G is entered in column 1, enter the name of the related
individual in column 2.
Column 3.--If the individual indicated in column 2 or the organization indicated in column 4 has
a financial interest in the facility, enter the percent of ownership/control in such organization.
Column 4.--Enter the name of the related corporation, partnership, or other organization.
Column 5.--If the individual indicated in column 2 or the facility has a financial interest in the
related organizations, enter the percent of ownership/control in such organization.
Column 6.--Enter the type of business in which the related organization engages (e.g., medical
drugs and/or supplies, laundry and linen service).
3318.

KIDNEY PLACEMENT EFFORTS - DOCUMENTATION REQUIREMENTS

To ensure proper utilization and distribution of kidneys, organ procurement organizations
(OPOs) and certified transplant centers (CTCs) furnishing organ procurement services for kidney
transplants under the Medicare program must maintain adequate and verifiable records for each
kidney retrieved and furnished to a Medicare patient. Since it is not possible to determine at the
time of retrieval whether an individual kidney will be placed with a Medicare beneficiary, a
placement effort record must be maintained for every kidney.
A. For each kidney retrieved, independent and hospital-based OPOs and CTCs must
maintain a record (e.g., a log) showing the attempts to place the kidney with Medicare transplant
patients and the final disposition of the kidney. Include the following information:
o
Name of individual making calls;
o
Name of donor;
o
Time (date, hour, minute, e.g., 11/18/86, 9:45 p.m.) of retrieval;
o
Name of donor center;
o
Name and telephone number of each OPO/CTC contacted as a potential user, including
the name of the person talked to at the OPO/CTC and the time (date, hour, and minute) of
contact;
o
Name of OPO or CTC that accepts the kidney and time and date sent;
o
Disposition of the kidney if not placed, i.e., non-viable; and
o
Age of kidney when shipped.
Attach to the log a copy of their computer printout on the kidney.
B. Independent and hospital-based OPOs and CTCs that are offered kidneys must
maintain records (e.g., a log) containing the following information:
o
Name and telephone number of OPO or CTC offering the kidney;
o
Name of donor;
o
Time (date, hour, and minute) of retrieval or age of the organ at time of offering;
o
If accepted, indicate time accepted, name of recipient, and social security number (or
health insurance number), or other identifying information; and
o
Reason kidney not accepted (if applicable).
C.

Rev. 3

Furnish the information in subsections A and B to the intermediary upon request.

33-23

06-02

FORM CMS-216-94

3390

EXHIBIT 1- Form CMS-216-94
The following is a listing of the Form CMS –216-94 worksheets and the page number location.
Worksheets

Page(s)

Wkst. S ..................................................................................................... 33-303
Wkst. S-1.................................................................................................. 33-304
Wkst. A ................................................................................................... 33-305
Wkst. A-1 ................................................................................................. 33-306
Wkst. A-2 ................................................................................................ 33-307
Wkst. A-3 ................................................................................................ 33-308
Wkst. A-4 ................................................................................................ 33-309
Wkst. A-5 ................................................................................................. 33-310
Wkst. A-6 ................................................................................................. 33-311
Wkst. B ................................................................................................... 33-312
Wkst. B-1 ................................................................................................. 33-313
Wkst. C ................................................................................................... 33-314
Wkst. D ................................................................................................... 33-315
Wkst. E..................................................................................................... 33-316
Wkst. E-1 ................................................................................................. 33-317
Wkst. E-2 ................................................................................................. 33-318
Supp. Wkst. A-5-1 ................................................................................... 33-319

Rev. 3

33-301

11-05

FORM CMS 216-94

3395

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE OF CONTENTS
Topic

Page(s)

Table 1:

Record Specifications

33-503 - 33-508

Table 2:

Worksheet Indicators

33-509 - 33-511

Table 3:

List of Data Elements With Worksheet, Line, and
Column Designations

33-512 - 33-520

Table 3A:

Worksheets Requiring No Input

33-521

Table 3B:

Tables to Worksheet S-2

33-521

Table 3C:

Lines That Cannot Be Subscripted

Table 4:

Reserved for future use

Table 5:

Cost Center Coding

Table 6:

Edits:

Rev. 4

33-521 - 33-522
33-523 - 33-526

Level I Edits

33-527 - 33-529

Level II Edits

33-530 - 33-532

33-501

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 1 - RECORD SPECIFICATIONS
Table 1 specifies the standard record format to be used for electronic cost reporting. Each
electronic cost report submission (file) has three types of records. The first group (type one
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) is included in the type two records. Refer to Table 5 for cost center
coding. The data detailed in Table 3 are identified as type three 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"
diskette. These disks must be in IBM format. The character set must be ASCII. You must seek
approval from your fiscal intermediary regarding alternate methods of submission to ensure 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
123456789012345678901234567890123456779012345678901234567890
1
1
00P002200409120050907A99P00120051202005090
Record #1:

This is a cost report file submitted by Provider 00P002 for the period from April
1, 2004 (2004091) through March 31, 2005 (2005090). It is filed on FORM
CMS-216-94. It is prepared with vendor number A99's PC based system, version
number 1. Position 38 changes with each new test case and/or approval and is
alpha. Positions 39 and 40 remain constant for approvals issued after the first test
case. This file is prepared by the organ procurement organization on April 30,
2005 (2005120). The electronic cost report specification dated March 31, 2005
(2005090) is used to prepare this file.
FILE NAMING CONVENTION

Name each cost report file in the following manner:
OPNNPNNN.YYL, where
1.A. OP (OPO Electronic Cost Report Electronic Cost Report) is constant;
OPNNHLNN.YYL, where
1.B. OP (OPO Electronic Cost Report used for Histocompatibility Laboratories) is constant;
2.A. NNPNNN is the 6 digit Medicare OPO provider number consisting of two digits
followed by a P, followed three digits where the facility is an OPO or an OPO with an
OPO based Tissue Typing Laboratory.
2.B. NNHLNN is the 6 digit Medicare Histocompatibility Laboratory provider number
consisting of two digits followed by HL, followed two more digits.
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 OPO/HL
with two or more cost reporting periods ending in the same calendar year.
Rev. 4

33-503

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Number 1
Size Usage
Loc.
Remarks
1.

Record Type

1

X

1

Constant "1"

2.

NPI

10

9

2-11

Numeric only

3.

Spaces

1

X

12

4.

Record Number

1

X

13

5.

Spaces

3

X

14-16

6.

HHA
Number

6

9

17-22

Field must have 6 alphanumeric
characters.

7.

Fiscal Year
Beginning Date

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

Constant "7" (for FORM CMS-21694)

10.

Vendor Code

3

X

38-40

To be supplied upon approval. Refer
to page 32-503.

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 2004366 (12/31/2004).

33-504

Provider

Constant "1"

P = PC; M = Main Frame

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size Usage
Loc.
Remarks
1.

Record Type

1

9

1

2.

Spaces

3.

Constant "1"

10

X

2-11

Record Number

2

9

12-13

#2-99 - Reserved for future use.

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.
Remarks
1.

Record Type

1

9

1

Constant "2"

2.

Wkst. 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

4

9

21-24

Numeric.
Refer to Table 5 for
appropriate cost center codes.

9.

Labels/Headings
a. Line Labels

36

X

25-60

Alphanumeric, left justified

b. Column Headings
Statistical Basis
& Code

10

X

21-30

Alphanumeric, left justified

Alphanumeric. Refer to Table 2.

The type 2 records contain both the text that appears on the pre-printed cost report and any labels
added by the preparer. 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.
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.

Rev. 4

33-505

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 1 - RECORD SPECIFICATIONS
Column headings for the General Service cost centers on Worksheets B and B-1 are supplied
once. They consist of one to three records. Each statistical basis shown on Worksheet B-1 is
also to be reported. The statistical basis consists of one or two records (lines 4-5). Statistical
basis code is supplied only to Worksheet B-1 columns and is recorded as line 6. The statistical
code must agree with the statistical bases 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.
The following type 2 cost center descriptions are to be used for all Worksheet A standard cost
center lines.
Line
1
2
3
4
5
6
7
9
10
11
13
14
15
16
17
18
21
22
23
24

33-506

Description
CAPITAL COSTS-BLDG & FIXT
CAPITAL COSTS-MVBLE EQUIPMENT
EMPLOYEE BENEFITS
ADMINISTRATIVE & GENERAL
OPERATION AND MAINTENANCE OF PLANT
HOUSEKEEPING
MEDICAL SUPPLIES
PROCUREMENT COORDINATORS
PROFESSIONAL EDUCATION
PUBLIC EDUCATION
KIDNEY ACQUISITIONS
TISSUE TYPING LABORATORY
LIVER ACQUISITIONS
HEART ACQUISITIONS
PANCREAS ACQUISITIONS
LUNG ACQUISITIONS
RESEARCH
BLOOD BANK
LABORATORY-NON-TISSUE TYPING
DIALYSIS UNITS

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 1 - RECORD SPECIFICATIONS
Type 2 records for Worksheet B-1, columns 1-8, and 10 for lines 1-6 are listed below. The
numbers running vertical to line 1 descriptions are the general service cost center line
designations.

2
3
4
5
8
10

1

2

CAP BLDG
CAP COSTS
EMPLOYEE
MEDICAL
ORGAN
ADMIN &

OP PLANT &
MOVABLE
BENEFITS
SUPPLIES
ACQUISITN
GENERAL

LINE
3
HOUSEKEEP
EQUIPMENT
COSTS

4
SQUARE
DOLLAR
ADJUST
COSTED
NUMBER
ACCUM

5
FEET
VALUE
SALARIES
REQUISIT
ORGANS
COSTS

6
1
2
3
3
3
3

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). However, spaces are preferred. Refer
to Table 5 and 6 for additional cost center code requirements.
Examples:
Worksheet A line labels with embedded cost center codes:
2A000000
2A000000
2A000000
2A000000
2A000000
2A000000

1
2
3
5
6
7

0100CAPITAL COSTS-BLDG & FIXT
0200CAPITAL COSTS-MVBLE EQUIP
0300EMPLOYEE BENEFITS
0500OPERATION & MAINT OF PLANT
0600HOUSEKEEPING
0700MEDICAL SUPPLIES

Examples of column headings for Worksheets B-1 and B ; statistical bases used in cost allocation
on Worksheet B-1 ; and statistical codes used for Worksheet B-1 (line 6) are displayed below
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*
2B10000*

Rev. 4

1 3
2 3
3 3
4 3
5 3
6 3

CAP COSTS
MOVABLE
EQUIPMENT
DOLLAR
VALUE
2

33-506.1

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Nonlabel Data
Size

Usage

Loc.

Remarks

1.

Record Type

1

9

1

2.

Wkst. 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
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).

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.
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. Alpha Data

b. Numeric Data

Constant "3"
Alphanumeric. Refer to Table 2.

A sample of type 3 records are below.
3A000000
3A000000
3A000000

Rev. 4

9
10
11

1
2
2

283833
50644
122693

33-507

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 1 - RECORD SPECIFICATIONS
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.
Worksheet A-4, columns 3 and 6
Worksheet A-5, column 4
Supplemental Worksheet A-5-1, Part B, column 1
Examples of records (*) with a Worksheet A line number as data are below.

*
*

*
*

3A400001
3A400001
3A400001
3A400001
3A400001
3A400001

1
1
1
1
1
1

0
1
3
4
6
7

TO RECLASS TISSUE TYPING
A
13
345632
14
434711

3A500000
3A500000
3A500000
3A500000

15
15
15
15

0
1
2
4

RCH & ISLETS
A
-3900
9

3A510000
3A510000
3A510000
3A510000

1
3
4
5

1
1
1
1

7
MEDICAL SUPPLIES
5000
4000

RECORD NAME: Type 4 Records - File Encryption
This type 4 record consists of 3 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 and insures the integrity of the file.

33-508
11-05

FORM CMS-216-94

Rev. 4
3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94

TABLE 2 - WORKSHEET INDICATORS
This table contains the worksheet indicators that are used for electronic cost reporting. A
worksheet indicator is provided for only those worksheets for which data are to be provided.
The worksheet indicator consists of seven digits in positions 2-8 of the record identifier. The
first two digits of the worksheet indicator (positions 2 and 3 of the record identifier) always show
the worksheet. The third digit of the worksheet indicator (position 4 of the record identifier) is
used to identify Supplemental Worksheet A-5-1. For Worksheets A-4 and A-5, if there is a need
for extra lines on multiple worksheets, the fifth and sixth digits of the worksheet indicator
(positions 6 and 7 of the record identifier) identify the page number. The seventh digit of the
worksheet indicator (position 8 of the record identifier) represents the worksheet or worksheet
part.
Worksheet
S, Part I
S, Part III
S-1, Part I
S-1, Part II
S-1, Part III
A
A-1
A-2
A-3
A-4
A-5
A-6, Part A
A-6, Part B
A-6, Part C
B-1 (For use in
column headings)
B
B-1
C, Part I
C, Part II
D
E
E-1, Part I
E-1, Part II
E-2
Rev. 4
3395 (Cont.)

Worksheet Indicator
S000001
S000003
S100001
S100002
S100003
A000000
A100000
A200000
A300000
A400010
A500010
A60000A
A60000B
A60000C
B10000*

(b)
(a)

B000000
B100000
C000001
C000002
D000000
E000000
E100001
E100002
E200000

FORM CMS-216-94

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 2 - WORKSHEET INDICATORS

33-509
11-05

Worksheet
A-5-1, Part A
A-5-1, Part B
A-5-1, Part C

33-510

Worksheet Indicator
A51000A
A51000B
A51000C

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 2 - WORKSHEET INDICATORS
FOOTNOTES:
(a) Multiple Worksheets for Reclassifications Before 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-4. For
reports that do not need additional worksheets, the default is 01. For reports that do need
additional worksheets, the first page is numbered 01. The number for each additional page of
the worksheet is incremented by 1.
(b) Multiple Worksheets A-2
This worksheet is used for kidney, liver, heart, pancreas, lung and other organ acquisition
costs. The fourth digit of the worksheet indicator (position 5 of the record) is an alpha
character of K for kidney, L for liver, H for heart, P for pancreas, U for lung and O for other.

Rev. 4

33-511

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
This table identifies those data elements necessary to calculate an OPO or HL cost report. It also
identifies some figures from a completed cost report. These calculated fields (e.g., Worksheet B,
column 11) are needed to verify the mathematical accuracy of the raw data elements and to
isolate differences between the file submitted by the OPO or HL 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 adjustments 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, less than, or equal to 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.
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" (with a space preceding the 1) in field locations 14-15. It is
unacceptable to format in a 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., Worksheet settlement series, all subscripted lines should
be in sequence and consecutively numbered beginning with subscripted line number 01.
Automated systems should reorder these numbers where providers skip or delete a line 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 that are specified in Table 3 with a usage of "-9". Amounts that are within
preprinted parentheses on the worksheets, indicating the reduction of another number, are
reported as positive values.

33-512

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE
WORKSHEET S
Part I
OPO or LAB Identification Data:
Name

1

1

36

X

Medicare Provider Number

1

2

6

X

Street

1.01

1

36

X

P.O. Box

1.01

2

9

X

City

1.02

1

36

X

State

1.02

2

2

X

1.02

3

10

X

Name

2

1

36

X

Medicare Provider Number

2

2

6

X

Street

2.01

1

36

X

P.O. Box

2.01

2

9

X

City

2.02

1

36

X

State

2.02

2

2

X

Zip Code

2.02

3

10

X

date

3

1

10

X

date

3

2

10

X

Type of control (See Table 3B.)

4

1

2

9

Type of Provider (See Table 3B.)

4

3

2

9

Participation Date (MM/DD/YYYY)

4

4

10

X

1-2

9

-9

1-3

9

9

Zip Code
OPO based LAB Identification Data:

Cost reporting period
(MM/DD/YYYY)
Cost reporting period
(MM/DD/YYYY)

beginning
ending

Part III
Balances due provider or program:

1
WORKSHEET S-1

Part I
Total number of kidneys retrieved (viable
and non viable)
Rev. 4

1

33-513

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE
WORKSHEET S-1 (Continued)
Total number of kidneys included in line 1
2
1-3
9
9
that were non-viable
Total number of kidneys included in line 3,
column 3 that were exported out of local
retrieval area

4

1-3

9

9

5

1-3

9

9

6

1-3

9

9

Was payment received for kidneys
furnished to foreign countries and included
on line 4, column 2. (Y/N)

7

1

1

X

If yes, total number of kidneys and amount
received.

7

2-3

9

9

Total number of organs/tissue other than
kidneys retrieved and administratively
processed.

8-8.19

1

9

9

Nonviable Organs

8-8.19

2

9

9

Enter the amount of payment received for
each type of organ.

8-8.19

3

9

9

Total number of tests performed- all
laboratory.

1

1

9

9

Total number of tests performed-tissue
typing laboratory.

2

1

9

9

Total number of pre-transplant tests
performed for kidney transplantation that
are included in line 2.

3

1

9

9

Test Name

4-4.19

1

36

X

Number

4-4.19

2

9

9

1.03-1.19

1,3,5

36

X

Total Full time equivalent employees

1-1.19

2,4,6

6

9(3).99

Total Full time equivalent employees
33-514

2

1

6

9(3).99
Rev. 4

Total number of kidneys sent to military or
DVA hospitals that were included in line 3,
column 3
Amount received for kidneys listed in line 5

Part II

Tissue typing pre-transplant tests performed
for kidney transplant:

Part III
Text as needed for blank line

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE
WORKSHEET A
2-3,5-8,912,21-25

1

9

-9

26

1

9

9

1-3,5-8,912,21-25

2

9

-9

26

2

9

9

1-3,5-8,912,21-25

7

9

-9

26

7

9

9

17-19

0

36

X

1-2,4-5,8,
11-12,15,
17-19

1

9

-9

1-15,17-19

2

9

-9

1-2

9

9

11-21

1

9

-9

All other organ acquisition costs by
position.

1-9,11-21

2

9

-9

Total salaries and other organ acquisition
costs

23

1-2

9

9

6-10

0

36

X

Salaries and wages by position

1-4,6-10

1

9

-9

All other tissue typing laboratory costs by
position.

1-4,6-10

2

9

-9

1-2

9

9

Direct salaries by department
Total direct salaries
Other direct costs by department
Total other direct costs
Net expense for allocation
Total expenses for allocation

WORKSHEET A-1
Other administrative and general (specify)
Salaries and wages by position

All other administrative and general costs
by position.
Total salaries
general costs.

and

administrative

and

20

WORKSHEET A-2
Salaries and wages by position.

WORKSHEET A-3
Other administrative and general (specify)

Total salaries and tissue typing costs.
Rev. 4

11

33-515

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET A-4
For each expense reclassification:
Explanation

1-35

0

36

X

Reclassification identification code

1-35

1

2

X

Worksheet A line number

1-35

3

6

9(3).99

Reclassification amount

1-35

4

9

9

Worksheet A line number

1-35

6

6

9(3).99

Reclassification amount

1-35

7

9

9

15-16

0

36

X

Basis (A or B)

1-3,5-16

1

1

X

Amount

1-3,5-16

2

9

-9

Worksheet A line number

1-3,5-16

4

6

9(3).99

1

1

1

X

Worksheet A line number

1-4

1

6

9(3).99

Expense item(s)

1-4

3

36

X

Amount included in Worksheet A

1-4

4

9

-9

Amount allowable in reimbursable
cost

1-4

5

9

-9

Increases:

Decreases:

WORKSHEET A-5
Description of adjustment

SUPPLEMENTAL WORKSHEET A-5-1
Part A - Are there any related organization
costs included on Worksheet A? (Y/N)
Part B - For costs incurred and adjustments
required as a result of transactions with
related organization(s):

33-516

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

SUPPLEMENTAL WORKSHEET A-5-1 (Continued)
Part C - For each related organization:
Type of interrelationship (A
through G)

1-4

1

1

X

If type is G, specify description of
relationship

1-4

0

36

X

Name of related individual

1-4

2

36

X

Percent owned by provider

1-4

3

6

9(3).99

1-4

4

36

X

Percent ownership of provider

1-4

5

6

9(3).99

Type of business

1-4

6

15

X

7

0

36

X

Beginning balances

1-7

1

9

9

Purchases

1-7

2

9

9

Donations

1-7

3

9

9

Disposals and retirements

1-7

5

9

9

Name of
partnership or other

related

corporation,

WORKSHEET A-6
Part A
Other (specify)
Analysis of changes in capital assets
balances during cost reporting period for
land, land improvements, buildings and
fixtures, fixed auto, truck and van, and
other movable equipment, and in total:

Part B
Analysis of changes in Accumulated
depreciation for land, land improvements,
buildings
and
fixtures,
building
improvements, fixed and moveable
equipment, auto, truck, van, and other
assets

Rev. 4

32-517

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET A-6 (Continued)
Other (specify)

8

0

36

X

Beginning balances

1-8

1

9

9

Additions

1-8

2

9

9

Deletions

1-8

3

9

9

Straight Line

1

1

9

9

Declining Balance

2

1

9

9

Sum of Years Digits

3

1

9

9

Total Depreciation reported on
W/S-A, column 7

4

1

9

9

Is depreciation funded (Y/N)

5

1

1

X

If yes, balance in fund at end of
period

5

2

9

9

Was there a gain or loss on sale of
assets
during
the
cost
reporting
period? (Y/N)

6

1

1

X

WORKSHEETS B and B-1
1-3 *

1-10

10

X

4, 5 *

1-10

10

X

Part C
Depreciation Reported

Column heading (cost center name)
Statistical basis
*

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 that has less than five type 2
record entries, blank records or the word blank is not required to maximize each column
record count.

33-518

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
FIELD
DESCRIPTION
LINE(S) COLUMN(S)
USAGE
SIZE
WORKSHEET B
Costs after cost finding by department
Total costs after cost finding

All cost allocation statistics

3-15

11

9

-9

16

11

9

9

2-8,10

9

9

WORKSHEET B-1
2-15
WORKSHEET C

Parts 1–Kidney Acquisition
Total number of viable kidneys procured

1

1

11

9

Total number of kidneys

2

1

11

9

Gross revenues-tissue typing laboratory-all
tests

1

1

11

9

Gross revenues-tissue typing laboratorykidney transplant related tests only

2

1

11

9

2

11

9

Parts 2-Tissue Typing Laboratory

WORKSHEET D
Total revenues received for laboratory
services furnished to foreign countries,
2
military and DVA hospitals.
Total payments received and receivable from
OPOs and transplant hospitals for kidneys
furnished or laboratory services provided for
kidney transplantation

4

1-2

11

9

Sequestration adjustment

6

1-2

11

9

Interim payments

7

1-2

11

-9

Balance due provider or Medicare

8

1-2

11

9

Rev. 4

33-519

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION
LINE(S) COLUMN(S) FIELD
USAGE
SIZE

Balance sheet account balances

WORKSHEET E
1-10, 12-26,
28-31, 3341, 43-48,
51- 57, 59
9, 26, 31, 39,
41, 46-48

Text as needed for blank lines

1

9

-9

0

36

X

WORKSHEET E-1
Part I
Total revenues by department

1-11

1-2

9

9

Text as needed for blank lines

6-9

0

36

X

Increases to operating expenses reported on
Worksheet A

2-5

1

9

9

Decreases to operating expenses reported
on Worksheet A

7-10

1

9

9

2-5, 7-10

0

36

X

2

9

-9

Part II

Text as needed for blank lines

Contract
services

allowance

and

WORKSHEET E-2
discount on
2

Other income

7-23

1

9

9

Other expenses

26-27

1

9

9

29

2

9

-9

15-23,
26-27

0

36

X

Net income
Text as needed for blank lines

33-520

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3A - WORKSHEETS REQUIRING NO INPUT
Worksheet B
TABLE 3B - TABLES TO WORKSHEET S, Part I
Type of Control
1
2
3
4
5
6
7
8
9
10
11
12

=
=
=
=
=
=
=
=
=
=
=
=

Type of Provider

Proprietary, Individual
Proprietary, Corporation
Proprietary, Partnership
Proprietary, Other
Voluntary Non-Profit, Church
Voluntary Non-Profit, Corporation
Voluntary Non-Profit, Foundation
Voluntary Non-Profit, Other
Governmental, Federal
Governmental, State
Governmental, County
Governmental, Other

1
2

=
=

OPO
LAB

TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet

Lines

S

1-3,5

S-1, Part I

1-7

S-1, Part II

1-3

S-1, Part III

2

A
A-1

1-18,20

A-2

1-8,10-20,22,23

A-3

1-5,11

A-4

1-34,36

A-5

1-14,17

A-6, Part A

1-6, 8

A-6, Part B

1-7, 9

A-6, Part C

All

B
B-1

Rev. 4

1-7,9-11,13-24,26

1-8, 10-13
1-8,10-13,16-18

C, Part I

All

C, Part II

All

33-521

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 3C - LINES THAT CANNOT BE SUBSCRIPTED (BEYOND THOSE PREPRINTED)
(CONTINUED)
Worksheet

33-522

Lines

D

All

E

All

E-1, Part I

All (except line 9)

E-1, Part II

All (except lines 5 and 10)

E-2

All (except line 23 and 27)

A-5-1, Part A

All

A-5-1, Part B

1-3,5

A-5-1, Part C

1-3

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 5 - COST CENTER CODING
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. Using codes to standardize meanings makes practical data
analysis possible. The method to accomplish this must be rigidly controlled to assure accuracy.
For any added cost center names (the preprinted cost center labels must be precoded), preparers
must be presented with the allowable choices for that line or range of lines from the lists of
standard and nonstandard descriptions. They 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:
•
•
•
•
•
•
•
•

Do not allow any pre-existing codes for the line to be carried over.
Do not precode all Other lines.
For cost centers, the order of choice must be standard first, then specific nonstandard, and
finally the nonstandard AOther . . ."
For the nonstandard "Other . . .", prompt the preparers with, “Is this the most appropriate
choice?," and then offer the chance to answer yes or to select another description.
Allow the preparers to invoke the cost center coding process again to make corrections.
For the preparers’ review, provide a separate printed list showing their added cost center
names on the left with the chosen standard or nonstandard descriptions and codes on the
right.
On the screen next to the description, display the number of times the description can be
selected on a given report, decreasing this number with each usage to show how many
remain. The numbers are shown on the cost center tables.
Do not change standard cost center lines, descriptions and codes. The acceptable formats for
these items are listed on page 33-525 & 33-526 of the Standard Cost Center Descriptions and
Codes. The proper line number is the first two digits of the cost center code.
INSTRUCTIONS FOR PREPARERS

Coding of Cost Center Labels
Cost center coding standardized the meaning of cost center labels used by health care providers
on the Medicare cost reporting forms. 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 four digit codes that are required to be associated with each label provide standardized
meaning for data analysis. Normally, it is necessary to code only added labels because the
preprinted standard labels are automatically coded by CMS approved cost report software.
When additional cost center descriptions have been identified, these additional descriptions are
hereafter referred to as the nonstandard labels. Included with the nonstandard descriptions is an
"Other . . ." designation to provide for situations where no match in meaning can be found.

Rev. 4

33-523

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 5 - COST CENTER CODING
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 tables for purposes of selecting a code.
Most CMS-approved software provides an automated process to present you with the allowable
choices for the line/column being coded, and automatically associates the code for the selected
matching description with your label.
Additional Guidelines
Categories
Make a selection from the proper category such as general service description for general service
lines, organ acquisition overhead cost center descriptions for organ acquisition overhead cost
center lines, etc.
Use of a 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 or changed 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. Most approved software
systems 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
Use cost center codes only in designated lines in accordance with the classification of cost
center(s), e.g., cost center codes within the nonreimbursable services cost center category of both
standard and nonstandard coding.

33-524

Rev. 4

11-05

FORM CMS 216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 5 - COST CENTER CODING
STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE

USE

Capital Costs - Buildings and Fixtures

0100

(01)

Capital Costs - Movable Equipment

0200

(01)

Employee Benefits

0300

(01)

Administration and General

0400

(01)

Operation and Maintenance of Plant

0500

(01)

Housekeeping

0600

(01)

Medical Supplies

0700

(01)

Other Overhead

0800

(20)

Procurement Coordinators

0900

(01)

Professional Education

1000

(01)

Public Education

1100

(01)

Other Acquisition

1200

(20)

Kidney Acquisition

1300

(01)

Tissue Typing Laboratory

1400

(01)

Liver Acquisitions

1500

(01)

Heart Acquisitions

1600

(01)

Pancreas Acquisitions

1700

(01)

Lung Acquisitions

1800

(01)

Other Acquisitions

1900

(10)

Other Acquisitions

2000

(10)

Research

2100

(01)

Blood Bank

2200

(01)

GENERAL SERVICE COST CENTERS

ORGAN ACQUISITION OVERHEAD

REIMBURSABLE COST CENTERS

NON REIMBURSABLE COST CENTERS

Rev. 4

33-525

3395 (Cont.)

FORM CMS 216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 5 - COST CENTER CODING
STANDARD COST CENTER DESCRIPTIONS AND CODES (CONTINUED)
CODE

USE

Laboratory-Non-Tissue Typing

2300

(01)

Dialysis Units

2400

(01)

Other Non-Reimbursable

2500

(10)

NON-REIMBURSABLE COST CENTERS (Continued)

NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
GENERAL SERVICE COST CENTERS
Other Overhead

0800

(10)

1200

(10)

2500

(10)

ORGAN ACQUISITION OVERHEAD
Other Acquisition
NONREIMBURSABLE COST CENTERS
Other Nonreimbursable

33-526

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 6 - EDITS
Medicare cost reports submitted electronically must be subjected to various edits, which are
divided into two categories: Level I and level II edits. These include mathematical accuracy
edits, certain minimum file requirements, and other data edits. Any vendor software that
produces an electronic cost report file for Medicare OPOs and/or HLs 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 OPO or HL of the cause of every exception. The edit
message generated by the vendor systems must contain the related 4 digit and 1 alpha character,
and where indicated, the reject/edit code specified below. Any file containing a level I edit will
be rejected by your fiscal intermediary without exception.
Level I edits (1000 series reject codes) test that the file conforms to processing specifications,
identifying error conditions that would 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 (2000 series edit
codes) identify potential inconsistencies and/or missing data items that may have exceptions and
should not automatically cause a cost report rejection. Resolve these items and submit
appropriate worksheets and/or data supporting the exceptions 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 intermediary processing time
and unnecessary rejections. Vendors should develop their programs to prevent their client OPOs
and/or HLs from generating either a hard copy substitute cost report or electronic cost report file
where level I edits exist. Ample warnings should be given to the provider where level II edit
conditions are violated.
NOTE: Dates in brackets [ ] at the end of an edit indicate the 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 the specified date. Dates followed by an “s”
are for services rendered on or after the specified date unless otherwise noted.
[10/31/2000]
I. Level I Edits (Minimum File Requirements)
Reject Code

Condition

1000

The first digit of every record must be either 1, 2, 3, or 4 (encryption code only).
[3/31/2005]

1005

No record may exceed 60 characters. [3/31/2005]

1010

All alpha characters must be in upper case. This is exclusive of the encryption code,
type 4 record, record numbers 1, 1.01, and 1.02. [3/31/2005]

1015

For micro systems, the end of record indicator must be a carriage return and line feed,
in that sequence. [3/31/2005]

1020

The organ procurement organization provider number (record #1, positions 17-22)
must be valid and may be alphanumeric. [3/31/2005]

1025

All dates (record #1, positions 23-29, 30-36, 45-51, and 52-58) must be in Julian
format and legitimate. [3/31/2005]

1030

The fiscal year beginning date (record #1, positions 23-29) must be less than or equal
to the fiscal year ending date (record #1, positions 30-36). [3/31/2005]

Rev. 4

33-527

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 6 - EDITS
Reject Code Condition
1035

The vendor code (record #1, positions 38-40) must be a valid code. [3/31/2005]

1055

All record identifiers (positions 1-20) must be unique. [3/31/2005]

1060

Only a Y or N is valid for fields which require a Yes/No response. [3/31/2005]

1065

Variable column (Worksheet B and Worksheet B-1) must have a corresponding type 2
record (Worksheet A label) with a matching line number. [3/31/2005]

1075

Cost center integrity must be maintained throughout the cost report. For subscripted
lines, the relative position must be consistent throughout the cost report. [3/31/2005]

1080

For every line used on Worksheets A and B there must be a corresponding type 2
record. [3/31/2005]

1090

Fields requiring numeric data (numbers, tests, costs, FTEs, etc.) may not contain any
alpha character. [3/31/2005]

1100

In all cases where the file includes both a total and the parts that comprise that total,
each total must equal the sum of its parts. [3/31/2005]

1005S

The cost report ending date (Worksheet S, Part I, column 2, line 3) must be on or after
December 31, 2004. [3/31/2005]

1015S

The cost report period beginning date (Worksheet S, Part I, column 1, line 3) must
precede the cost report ending date (Worksheet S, Part I, column 2, line 3). [3/31/2005]

1020S

The organ procurement organization or histocompatibility lab name, provider number,
and participation date (Worksheet S, Part I, lines 1, 2, 4 columns 1, 2, and 4,
respectively) must be present and valid (the appropriate provider number range).
[3/31/2005]

1000A

All amounts reported on Worksheet A, columns 1-2, line 26, must be greater than or
equal to zero. [3/31/2005]

1020A

For reclassifications reported on Worksheet A-4, the sum of all increases (column 4)
must equal the sum of all decreases (column 7). [3/31/2005]

1025A

For each line on Worksheet A-4, if there is an entry in columns 3, 4, 6, or 7, there must
be an entry in column 1. There must be an entry on each line of column 4 for each
entry in column 3 (and vice versa), and there must be an entry on each line of column 7
for each entry in column 6 (and vice versa). [3/31/2005]

1040A

For Worksheet A-5 adjustments on lines 1-3, and 5-14, if either column 2 or 4 has an
entry, then both columns 2 and 4 must have entries, and if any one of columns 0, 1, 2,
or 4 for lines 15-16 and subscripts thereof has an entry, then all columns 0, 1, 2, and 4
must have entries. Only valid line numbers may be used in column 4. [3/31/2005]

1045A

If there are any transactions with related organizations or home offices as defined in
CMS Pub. 15-I, chapter 10 ( Supplemental Worksheet A-5-1, Part A, column 1, line 1
is "Y"), Supplemental Worksheet A-5-1, Part B, columns 4 or 5, sum of lines 1-4 must
be greater than zero; and Part C, column 1, any one of lines 1-4 must contain any one
of alpha characters A through G. Conversely, if Supplemental Worksheet A-5-1, Part
A, column 1, line 1 is "N", Supplemental Worksheet A-5-1, Parts B and C must not be
completed. [3/31/2005]

33-528

Rev. 4

11-05

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 6 - EDITS
Reject Code
Condition
1000B

On Worksheet B-1, all statistical amounts must be greater than or equal to zero.
[3/31/2005]

1005B

Worksheet B, column 11, line 16 must be greater than zero. [3/31/2005]

1000C

Worksheet C, line 2 must be greater than or equal to Worksheet C, line 1. [3/31/2005]

Rev. 4

33-529

3395 (Cont.)

FORM CMS-216-94

11-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 6 – EDITS
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 (FI). Failure to clear these errors in a timely fashion, as determined by your
FI, may be grounds for withholding payments.
Edit
Condition
2000

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).
[3/31/2005]

2005

Only elements set forth in Table 3, with subscripts as appropriate, are required in the ECR file.
[3/31/2005]

2010

The cost center codes (positions 21-24) (type 2 records) must be a code from Table 5, and
each cost center code must be unique. [3/31/2005]

2015

Standard cost center lines, descriptions, and codes should not be changed. (See Table 5.) This
edit applies to the standard line only and not subscripts of that code. [3/31/2005]

2020

All standard cost center codes must be entered on the designated standard cost center line and
subscripts thereof as indicated in Table 5. [3/31/2005]

2025

Only nonstandard cost center codes within a cost center category may be placed on standard
cost center lines of that cost center category. [3/31/2005]

2030

The 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.
[3/31/2005]
Cost Center

33-530

Line

Code

Cap Costs-Bldg & Fixt

1

0100

Cap Costs-Mvble Equip

2

0200

Employee Benefits

3

0300

Administrative and General

4

0400

Operation and Maintenance of Plant

5

0500

Housekeeping

6

0600

Medical Supplies

7

0700

Other Overhead

8

0800-0819

Procurement Coordinators

9

0900

Professional Education

10

1000

Public Education

11

1100

Other Acquisitions

12

1200-1219

Kidney Acquisition

13

1300

Rev. 4

11-05

Edit

FORM CMS-216-94

3395 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-216-94
TABLE 6 - EDITS
Condition
Cost Center

Line

Code

Tissue Typing Laboratory

14

1400

Liver Acquisition

15

1500

Heart Acquisition

16

1600

Pancreas Acquisition

17

1700

Lung Acquisition

18

1800

Other Acquisition

19

1900-1909

Other Acquisition

20

2000-2009

Research

21

2100

Blood Bank

22

2200

Laboratory

23

2300

Dialysis Unit

24

2400

Other Non-Reimbursable

25

2500-2509

2035

The administrative and general standard cost center code (0400) may appear only on line 4.
[3/31/2005]

2040

All calendar format dates must be edited for 10 character format, e.g., 01/01/1996
(MM/DD/YYYY). [3/31/2005]

2045

All dates must be possible, e.g., no "00", no "30", or "31" of February. [3/31/97]

2005S

The combined amount due the provider or program (Worksheet D, line 8, columns 1 and 2)
should not equal zero. [3/31/2005]

2015S

The organ procurement organization participation date and the histocompatibility laboratory
participation date (see cost report instructions) (Worksheet S, column 4, line 4) should be on
or before the cost report beginning date (Worksheet S, column 1, line 3). [3/31/2005]

2020S

The length of the cost reporting period should be greater than 27 days and less than 459 days.
[3/31/2005]

2045S

Worksheet S, line 4, column 1 (type of control) must have a value of 1 through 12. (See Table
3B.) [3/31/2005]

2100S

The following statistics from Worksheet S-1, Part I should be greater than zero:
a. Total number of kidneys retrieved for organ procurement organization (column 3, line 1)
[3/31/2005]

2110S

The following statistics from Worksheet S-1, Part II should be greater than zero:
a. Total number of tests performed by histocompatibility laboratory (column 1, line 1)
[3/31/2005]

Rev. 4
3395 (Cont.)

FORM CMS-216-94

33-531
11-05

Edit
2120S

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 216-94
TABLE 6 - EDITS
Condition
The following statistics from Worksheet S-1, Part III should be greater than zero:
a. Total number of full time equivalents (column 1, line 2) [3/31/2005]

2000A

Worksheet A-4, column 1 (reclassification code) must be alpha characters. [3/31/2005]

2005A

If worksheet A-2 (when completed for kidneys), line 18, sum of columns 1 and 2 is greater
than zero, then each worksheet A-2 (when completed for liver, heart, pancreas, lung, & other
organs, respectively), line 18, sum of columns 1 and 2 must also be greater than zero.
[3/31/2005]

2020A

Supplemental Worksheet A-5-1, Part A, must contain a "Y" or "N" response. [3/31/2005]

2000B

At least one cost center description (lines 1-3), at least one statistical basis label (lines 4-5),
and one statistical basis code (line 6) must be present for each general service cost
center. This edit applies to all general service cost centers required and/or listed.
[3/31/2005]

2005B

b. The column numbering among these worksheets must be consistent. For example, data

2000F

Total assets on Worksheet E (line 33, sum of column 1) must equal total liabilities and fund
balances (line 59, sum of columns 1). [3/31/2005]

2005F

Net income or loss (Worksheet E-2, column 2, line 29) should not equal zero. [3/31/2005]

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.

33-532

Rev. 4

in capital related costs - buildings and fixtures is identified as coming from column 1
on all applicable worksheets. [3/31/2005]