Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24 (CMS-222-92)

Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24

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Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24 (CMS-222-92)

OMB: 0938-0107

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CHAPTER 29
INDEPENDENT RURAL HEALTH CLINIC AND
FREESTANDING FEDERALLY QUALIFIED HEALTH CENTER
COST REPORT
FORM CMS-222-92
Section
General.......................................................................................................
Rounding Standards for Fractional Computations............................
Recommended Sequence For Completing Form CMS-222-92...................
Sequence of Assembly................................................................................
Sequence of Assembly - Worksheets................................................
Worksheet S - Independent Rural Health Clinic/Federally
Qualified Health Center Statistical Data and
Certification Statement..........................................................................
Part I - Statistical Data.....................................................................
Part II - Certification Statement........................................................
Worksheet A - Reclassification and Adjustment of Trial
Balance of Expenses..............................................................................
Worksheet A-1 - Reclassification.................................................................
Worksheet A-2 - Adjustments to Expenses..................................................
Worksheet B - Visits and Overhead Cost For RHCs/FQHCs........................
Part I - Visits and Productivity.........................................................
Part II - Determination of Total Allowable Cost
Applicable To RHC/FQHC Services...........................................
Worksheet C - Determination of Medicare Payment.....................................
Part I - Determination of Rate For RHC/FQHC
Services......................................................................................
Part II - Determination of Total Payment.........................................
Supplemental Worksheet A-2-1 - Statement of Costs of
Services From Related Organizations.....................................................
Part I - Introduction.........................................................................
Part II - Costs Incurred and Adjustments
Required.....................................................................................
Part III - Interrelationship of Facility to
Related Organization(s)..............................................................
Supplemental Worksheet B-1 - Computation of
Pneumococcal and Influenza Vaccine Cost............................................
Exhibit 1-Form CMS-222-92 Worksheets....................................................
Electronic Cost Reporting Specifications for Form CMS 222-92................

Rev. 7

2900
2900.1
2901
2902
2902.1
2903
2903.1
2903.2
2904
2905
2906
2907
2907.1
2907.2
2908
2908.1
2908.2
2909
2909.1
2909.2
2909.3
2910
2990
2995

29-1

05-13
2900.

FORM CMS-222-92

2901

GENERAL

These forms must be used by all independent rural health clinics (RHCs) and freestanding
Federally qualified health centers (FQHCs). These forms are required for determining Medicare
payment for RHC and FQHC services under 42 CFR 405, Subpart X.
An RHC/FQHC must complete all applicable items on the worksheets. For its initial reporting
period, the facility completes these worksheets with estimates of costs and visits and other
information required by the reports. The contractor uses the estimates to determine an interim
rate of payment for the facility. Following the end of the facility’s reporting period, the facility is
required to submit its worksheets using data based on its actual experience for the reporting
period. This information is used by the contractor for determining the total Medicare payment
due the RHC/FQHC for services furnished Medicare beneficiaries.
2900.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost
report, required computations result in the use of fractions. Use the following rounding standards
for such computations:

2901.

Round to 2 decimal places:
a. Rates
b. Cost per visit
c. Cost for pneumococcal vaccine

Round to 6 decimal places:
a. Ratios
b. Limit adjustments

RECOMMENDED SEQUENCE FOR COMPLETING FORM CMS-222-92
Part I - General Statistics and Expense Reclassification
and Adjustments

Step
No. Worksheet

Page(s)

S, Part I

Read §§2903 and 2903.1. Complete Part
I.

3&4

Read §2904. Complete columns 1
through 3, lines 1 through 62.

A-1

Read §2905. Complete entire worksheet
if applicable.

3&4

Read §2904. Complete columns 4 and 5,
lines 1 through 62.

Supp. A-2-1

Read §2909. Complete entire Parts I-III
worksheet as applicable.

A-2

Read §2906. Complete entire worksheet.

3&4

Read §2904. Complete columns 6 and
7, lines 1 through 62.

Rev. 11

29-3

2901 (Cont.)

FORM CMS-222-92

05-13

Part II - Computation of Medicare Cost
Step
No.

Worksheet

Page(s)

Supp. B-1

Read §2910. Complete if applicable.

B, Parts I-II

Read §§2907 through 2907.2.
Complete entire worksheet.

Part III - Calculation of Reimbursement Settlement
Step
No.

Worksheet

Page(s)

C, Parts I-III

Read §§2908 through 2908.3.
Complete entire worksheet.

S, Part II

Read §2903.2. Complete
certification statement.

2902.

SEQUENCE OF ASSEMBLY

The following list of assembly of worksheets is provided so all facilities are consistent in the
order of submission of their annual cost report. All facilities using Form CMS-222-92 are to
adhere to this sequence. Where worksheets are not completed because they are not applicable,
blank worksheets are not included in the assembly of the cost report.
2902.1

Sequence of Assembly - Worksheets.--

Worksheet

Part(s)

I & II

N/A

A-1

N/A

A-2

N/A

Supp. A-2-1

I, II, & III

I & II

B-1

N/A

I, II, & III

2903.

WORKSHEET S - INDEPENDENT RURAL HEALTH CLINIC/FEDERALLY
QUALIFIED HEALTH CENTER STATISTICAL DATA AND CERTIFICATION
STATEMENT

2903.1 Part I - Statistical Data.--At the top of the worksheet, indicate by checking the
appropriate box whether the cost report being filed is a projected or an actual/final cost report.

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Rev. 11

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FORM CMS-222-92

2903.1 (Cont.)

Line 1.--Enter the full name of the RHC/FQHC. If the cost report is for multiple sites, see
worksheet S, Part III.
Line 1.01.--Enter the street address and P.O. Box (if applicable) of the RHC/FQHC.
Line 1.02.--Enter the city, state and zip code of the RHC/FQHC.
Line 1.03.--Enter the county of the FQHC.
Line 2.--Enter the RHC/FQHC identification number that was provided by CMS.
Line 3.--For FQHCs only, enter your appropriate designation (“U” for urban or “R” for rural).
See IOM 100-04, chapter 9, section 20.6.2 of the RHC/FQHC Claims Processing Manual for
information regarding urban and rural designations. If you are uncertain of your designation,
contact your contractor. Do not complete this line for RHCs.
Line 4.--Enter on the appropriate lines the inclusive dates covered by these worksheets. A
reporting period is a period of 12 consecutive months for which a clinic must report its costs and
utilization. The first and last reporting periods may be less than 12 months but not less than one
month or greater than 13. A cost reporting period exceeding 13 months is subject to the
provisions of CMS Pub. 15-2, section 102.1A.
Line 5.-Column 1.--Type of Control--Indicate the ownership or auspices of the RHC/FQHC by entering
the number below that corresponds to the type of control of the RHC/FQHC.
Voluntary Non Profit
1=Corporation
2=Other (specify)

Proprietary
3=Individual
4=Corporation
5=Partnership
6=Other ( specify)

Government
7=Federal
8=State
9=County
10=City
11=Other (specify)

Column 2.-- If item 2, 6, or 11 is selected, “Other (specify)” category, specify the type of
ownership or auspices in column 2.
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 a RHC and 2 for a FQHC.
Column 4.--Date Certified--Enter the date the RHC/FQHC was certified for participation in the
Medicare program.
Line 6.-Column 1--Source of Federal Funds--Indicate the source of federal funds by entering the number
below that corresponds to the applicable source.
1=Community Health Center (Section 330(d), Public Health Service Act)
2=Migrant Health Center (Section 329 (d), Public Health Service Act)
3=Health Services for the Homeless (Section 340 (d), Public Health Service Act)
4=Appalachian Regional Commission
5=Look-Alikes
6=Other (Specify)
If item 6 is selected, “Other (Specify)” category, specify the source in column 2 of the worksheet.
Column 3--Enter the grant award number.
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29-4.1

2903.3

FORM CMS-222-92

05-13

Column 4--Enter the date the grant was awarded.
Line 7.--In column 1, list all physicians furnishing services at the RHC/FQHC and in column 2
list the physician’s Medicare billing number. Also in column 2, list any other Medicare Part B
billing number used by the RHC/FQHC. This line is not applicable for cost reporting periods
ending on or after May 31, 2009.
Line 8.--In column 1, enter the name of all supervisory physicians and in column 2, enter the
number of hours spent in supervision. This line is not applicable for cost reporting periods
ending on or after May 31, 2009.
Line 8.50-- If this facility is claiming allowable Graduate Medical Education (GME) costs as a
result of substantial payment for interns and residents, enter “Y” for yes or “N” for no in
column 1. Enter the number of Medicare visits performed by interns and residents in column 2
and total visits in column 3 performed by interns and residents. Complete Worksheet A, lines
20.50 and 53.50 as applicable. (See 42 CFR 405.2468 (f)(2).)
Line 8.51.--Have you received an approval for an exception to the productivity standards? Enter
Y” for yes or “N” for no.
Line 9.--Does the facility operate as other than a RHC or FQHC? Enter “Y” for yes or “N” for
no.
Line 10.--If the answer on line 9 is yes, enter the type of operation (i.e., laboratory or physicians
services).
Line 11.--Enter the hours of operation (from/to) based on a 24 hour clock next to the appropriate
day that the facility is available to provide RHC/FQHC services. For example 8:00 am is 0800
and 5:30 pm is 1730.
Line 12.--If the answer on line 9 is yes, enter the hours of operation (from/to) next to the
appropriate day that the facility is available to provide other than RHC/FQHC services.
Line 13.--Indicate whether this is a low or no Medicare utilization cost report, enter an “L” for
low Medicare utilization or “N” for no Medicare utilization. If “L” is selected you must meet
your contractor’s criteria for filing a low Medicare utilization cost report. (See 42 CFR 413.24
(h)).
Line 14.--Indicate whether this facility is filing a consolidated cost report under CMS Pub. 10004, chapter 9, section 30.8. Enter “Y” for yes or “N” for no. If yes, complete a separate
Worksheet S, Part III for each clinic filing on the consolidated cost report.
2903.2 Part II - Certification Statement.--The certification statement must be prepared and signed
after the worksheets have been completed. The individual signing this statement must be an
officer or other administrator.
2903.3 Part III - Statistical Data for Clinics Filing Under Consolidated Cost Reporting.--This
worksheet must be completed by each clinic filing under consolidated cost reporting. Indicate on
each worksheet the corresponding clinic identification number under which the facility is
certified to furnish Medicare services. Do not re-enter clinic information already entered on
Worksheet S, Part I for the primary clinic.
Line 1.--Enter the full name of the RHC/FQHC.
Line 2.--Enter the street address and P.O. Box (if applicable) of the RHC/FQHC.
Line 3.--Enter the city, state and zip code of the RHC/FQHC.
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FORM CMS-222-92

2903.3 (Cont.)

Line 4.--Enter the county of the FQHC. RHCs are not required to provide this information.
Line 5.--Enter the RHC/FQHC identification number that was provided by CMS.
Line 6.--For FQHCs only, enter your appropriate designation (urban or rural). See IOM 100-04,
chapter 9, section 20.6.2 for information regarding urban and rural designations. If you are
uncertain of your designation, contact your contractor. Do not complete this line for RHCs.
Line 7.--On subscripts of line 7, in column 1, list all physicians furnishing services at the
RHC/FQHC and in Column 2 list the physician’s Medicare billing number. Also in Column 2,
list any other Medicare Part B billing number used by the RHC/FQHC. This line is not
applicable for cost reporting periods ending on or after May 31, 2009.
Line 8.--On subscripts of line 8, in column 1, enter the name of all supervisory physicians and in
Column 2, enter the number of hours spent in supervision. This line is not applicable for cost
reporting periods ending on or after May 31, 2009.
Line 9.--Does the facility operate as other than a RHC or FQHC? Enter “Y” for yes or “N” for
no.
Line 10.--If the answer on line 9 is yes, enter the type of operation (i.e., laboratory or physicians
services).
Line 11.--Enter the hours of operation (from/to) next to the appropriate day that the facility is
available to provide RHC/FQHC services.
Line 12.--If the answer on line 9 is yes, enter the hours of operation (from/to) next to the
appropriate day that the facility is available to provide other than RHC/FQHC services.

Rev. 11

29-4.3

2904

FORM CMS-222-92

05-13

2904. WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL
BALANCE OF EXPENSES
Use Worksheet A to record the trial balance of expense accounts from your books and records.
The worksheet also provides for the necessary reclassification and adjustments to certain
accounts. All cost centers listed do not apply to all RHCs/FQHCs using this worksheet. For
example, a facility might not employ laboratory technicians and does not, in that case, complete
line 8. In addition to those lines listed, the worksheet also provides blank lines for other facility
cost centers.
If the cost elements of a cost center are maintained separately on your books, a reconciliation of
costs per the accounting books and records to those on this worksheet must be maintained by you
and are subject to review by your contractor.
Under certain conditions, a provider may elect to use different cost centers for allocation
purposes. These conditions are stated in CMS Pub. 15-1, §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.
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. The Form CMS 222-92 provides for
preprinted cost center descriptions that may apply to RHC/FQHC 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, 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 9.
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.
Column Descriptions
Columns 1 through 3.--The expenses listed in these columns must be in accordance with your
accounting books and records.
Enter on the appropriate lines in columns 1 through 3 the total expenses incurred during the
reporting period. Detail the expenses as Compensation (column 1) and Other (column 2). The
sum of columns 1 and 2 must equal column 3. Record any needed reclassification and
adjustments in columns 4 and 6, as appropriate.

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FORM CMS-222-92

2904 (Cont.)

Column 4.--Enter any reclassification among cost center expenses which are needed to effect
proper cost allocation.
Worksheet A-1 is provided to compute the reclassification affecting the expenses specified
therein. This worksheet need not be completed by all facilities but must be completed only to the
extent that the reclassification is needed and appropriate in the facility’s circumstances.

Rev. 11

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FORM CMS-222-92

05-13

NOTE: The net total of the entries in column 4 must equal zero on line 62.
Column 5.--Adjust the amounts entered in column 3 by the amounts in column 4 (increase or
decrease) and extend the net balances to column 5. The total of column 5, line 62, must equal the
total of column 3, line 62.
Column 6.--Enter on the appropriate lines the amounts of any adjustments to expenses indicated
on Worksheet A-2, column 2. The total on Worksheet A, column 6, line 62, must equal the
amount on Worksheet A-2, column 2, line 12.
Column 7.--Adjust the amounts in column 5 by the amounts in column 6 (increases or decreases)
and extend the net balances to column 7.
Transfer the amounts in column 7 to the appropriate lines on Worksheet B and Supplemental
Worksheet B-1.
Line Descriptions
Lines 1 through 11.--Enter the costs of your health care staff on the appropriate line by type of
staff.
Line 12.--Enter the sum of the amounts on lines 1 through 11.
Line 13.--Enter the cost of physician medical services furnished under agreement.
Line 14.--Enter the expenses of physician supervisory services furnished under agreement.
Line 16.--Enter the sum of the amounts on lines 13 through 15.
Lines 17 through 20.--Enter the expenses of other health care costs.
Line 20.50.--Enter the total allowable interns and residents costs.
Lines 21 through 23.--Enter the expenses of other health care costs.
Line 24.--Enter the sum of the amounts on lines 17 through 23.
Line 25.--Enter the sum of the amounts on lines 12, 16, and 24. Transfer this amount to
Worksheet B, Part II, line 10.
Lines 26 through 36.--Enter the overhead expenses related to the facility.
Line 37.--Enter the sum of the amounts on lines 26 through 36.
Lines 38 through 48.--Enter the expenses related to the administration and management of the
clinic.
Line 49.--Enter the sum of the amount on lines 38 through 48.
Line 50.--Enter the sum of lines 37 and 49. Transfer the total amount in column 7 to Worksheet
B, Part II, line 14.
Lines 51 through 53.--Enter the cost applicable to services other than RHC/FQHC services
(excluding overhead).
Line 53.50.--If the clinic does not provide all or substantially all training costs, enter the total
non-allowable GME cost.
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2906

Lines 54 through 56.--Enter the cost applicable to services other than RHC/FQHC services
(excluding overhead).
Line 57.--Enter the sum of the amounts on lines 51 through 56.
Lines 58 through 60.--Enter the cost of services that are not reimbursable under Medicare.
Line 61.--Enter the sum of the amounts on lines 58 through 60.
Line 62.--This is the total cost of the facility. It is the sum of the amounts on lines 25, 50, 57, and
61.
2905. WORKSHEET A-1 - RECLASSIFICATION
This worksheet provides for the reclassification of certain amounts to effect the proper cost
allocation. The cost centers affected must be specifically identifiable in your accounting records.
Use reclassifications in instances in which the expenses applicable to more than one of the cost
centers listed on Worksheet A are maintained in your accounting books and records in one cost
center. For example, if a physician performs administrative duties, the appropriate portion of
his/her compensation, payroll taxes and fringe benefits must be reclassified from "Facility Health
Care Staff Cost" to "Facility Overhead", line 38 for the office salaries and line 45 for the benefits
and taxes.
2906. WORKSHEET A-2 - ADJUSTMENTS TO EXPENSES
This worksheet provides for adjusting the expenses listed on Worksheet A, column 5. Make
these adjustments, which are required under the Medicare principles of reimbursement, on the
basis of cost, or amount received. Enter the total amount received (revenue) only if the cost
(including the direct cost and all applicable overhead) cannot be determined. However, if total
direct and indirect cost can be determined, enter the cost. Once an adjustment to an expense is
made on the basis of cost, you may not, in future cost reporting periods determine the required
adjustment to the expense on the basis of revenue. Enter the following symbols in column 1 to
indicate the basis for adjustments: "A" for costs and "B" for amount received. Line descriptions
indicate the more common activities which affect allowable costs or result in costs incurred for
reasons other than patient care and, thus, require adjustments.
Types of items to be entered on this worksheet are (1) those needed to adjust expenses incurred,
(2) those items which constitute recovery of expenses through sales, charges, fees, etc, and (3)
those items needed to adjust expenses in accordance with the Medicare principles of
reimbursement. (See CMS Pub. 15-1, §2328.)
If an adjustment to an expense affects more than one cost center, record the adjustment to each
cost center on a separate line on this worksheet.
Line Descriptions
Line 1.--Investment income on restricted and unrestricted funds which are commingled with
other funds must be applied together against the total interest expense included in allowable
costs. (See CMS Pub. 15-1, §202.2.)
Apply the investment income on restricted and unrestricted funds which are commingled with
other funds against the Administrative, Depreciation - Buildings and Fixtures, Depreciation Equipment, and any other appropriate cost centers on the basis of the ratio that interest expense
charged to each cost center bears to the total interest expense charges to all of your cost centers.

Rev. 11

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2907

FORM CMS-222-92

05-13

Line 5.--Enter the allowable home office costs which have been allocated to the facility. Use
additional lines to the extent that various facility cost centers are affected. (See CMS Pub. 15-1,
chapter 21.)
Line 6.--Obtain the amount to be entered on this line from Supplemental Worksheet A-2-1, Part
II, column 6, line 5. Note that Worksheet A-2-1, Part II, lines 1 through 4, represent the detail of
the various cost centers to be adjusted on Worksheet A.
Line 8.--Enter the amount which represents the allowable cost of the services furnished by
National Health Service Corp (NHSC) personnel. Obtain this amount from your contractor.
Lines 9 and 10.--If depreciation expense computed in accordance with Medicare principles of
reimbursement differs from depreciation expenses per your books, enter the difference on lines 9
and/or 10.
2907. WORKSHEET B - VISITS AND OVERHEAD COST FOR RHCs/FQHCs
Worksheet B is used by the RHC/FQHC to summarize (1) the visits furnished by your health care
staff and by physicians under agreements with you, and (2) the overhead costs incurred by you
which apply to RHC/FQHC services.
2907.1 Part I - Visits and Productivity.--Use Part I to summarize the number of facility visits
furnished by the health care staff and to calculate the number of visits to be used in the rate
determination. Productivity standards established by CMS are applied as a guideline that reflects
the total combined services of the staff. Apply a level of 4200 visits for each physician and a
level of 2100 visits for each nonphysician practitioner.
Lines 1 through 9 (and applicable subscripts) of Part I list the types of practitioners (positions)
for whom facility visits must be counted and reported.
Line 1--Enter the number of FTEs and total visits furnished to facility patients by staff physicians
working at the facility on a regular ongoing basis. Also include on this line, physician data
(FTEs and visits) for services furnished to facility patients by staff physicians working under
contractual agreement with you on a regular ongoing basis in the RHC/FQHC facility. These
physicians are subject to productivity standards. See 42 CFR 405.2468(d)(2)(v).
Column 1.--Record the number of all full time equivalent (FTE) personnel in each of the
applicable staff positions in the facility practice. (See IOM 100-04, chapter 9, section 40.3 for a
definition of FTEs.)
Column 2.--Record the total visits actually furnished to all patients by all personnel in each of the
applicable staff positions in the reporting period. Count visits in accordance with instructions in
42 CFR 405.2401(b) defining a visit.
Column 3.--Productivity standards established by CMS are guidelines that reflect the total
combined services of the staff. Apply a level of 4200 visits for each physician and 2100 visits for
each nonphysician practitioner. However, if you were granted an exception to the productivity
standards (answered yes to question 8.51 of Worksheet S, Part I), enter on lines 1-3 the number
of productivity visits approved by the contractor.
Contractors have the authority to waive productivity guidelines in cases where you have
demonstrated reasonable justification for not meeting the standard. In such cases, the
contractor may set any number of visits as reasonable (not just actual visits) if an exception is
granted. For example, if the guideline is 4200 visits and you furnished only 1000 visits, the
contractor may permit 2500 visits to be used in the calculation.
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FORM CMS-222-92

2907.2

Column 4.--This is the minimum number of facility visits the personnel in each staff position are
expected to furnish. Enter the product of column 1 and column 3.
Column 5.--Enter the greater of the visits from column 2 or column 4. Contractors have the
authority to waive the productivity guideline in cases where you have demonstrated reasonable
justification for not meeting the standard. In such cases, the contractor could set any number of
visits as reasonable (not just your actual visits) if an exception is granted. For example, if the
guideline number is 4200 visits and you have only furnished 1000 visits, the contractor need not
accept the 1000 visits but could permit 2500 visits to be used in the calculation.
Line 4.--Enter the total of lines 1 through 3.
Line 8.--Enter the total of lines 4 through 7.
Line 9.--Enter the number of visits furnished to facility patients by physicians under agreement
with you who do not furnish services to patients on a regular ongoing basis in the RHC/FQHC
facility. Physicians services under agreements with you are (1) all medical services performed at
your site by a nonstaff physician who is not the owner or an employee of the facility, and (2)
medical services performed at a location other than your site by such a physician for which the
physician is compensated by you. While all physician services at your site are included in
RHC/FQHC services, physician services furnished in other locations by physicians who are not
on your full time staff are paid to you only if your agreement with the physician provides for
compensation for such services.
2907.2 Part II - Determination of Total Allowable Cost Applicable To RHC/FQHC Services.-Use Part II to determine the amount of overhead cost applicable to RHC/FQHC services.
Line 10.--Enter the cost of RHC/FQHC services (excluding overhead) from Worksheet A,
column 7, line 25 less the amount on Worksheet A, column 7, line 20.5
Line 11.--Enter the cost of services (other than RHC/FQHC services) excluding overhead from
Worksheet A, column 7, sum of lines 57 and 61.
Line 12.--Enter the cost of all services (excluding overhead). It is the sum of lines 10 and 11.
Line 13.--Enter the percentage of RHC/FQHC services. This percentage is determined by
dividing the amount on line 10 (the cost of RHC/FQHC services) by the amount on line 12 (the
cost of all services, excluding overhead).
Line 14.--Enter the total overhead costs incurred from Worksheet A, column 7, line 50. It is the
sum of facility costs and administrative overhead costs.
Line 14.01.--Enter the amount of GME overhead costs. To determine the amount of GME
overhead multiply the amount of facility overhead (from line 14) by the ratio of intern and
resident visits (from Worksheet S, Part I, column 3, line 8.50) to total visits (from Worksheet C,
Part I, line 6 ).
Line 14.02.--Enter the net facility overhead costs by subtracting line 14.01 from line 14.
Line 15.--Enter the overhead amount applicable to RHC/FQHC services. Multiply the amount on
line 13 (the percentage of RHC/FQHC services) by the amount on line 14 (total overhead). When
an amount is entered on line14.01, enter the result of multiplying the amount on line 13 (the
percentage of RHC/FQHC services) by the amount on line 14.02 (net facility overhead).
Line 16.--Enter the total allowable cost of RHC/FQHC services. It is the sum of line 10 (cost of
RHC/FQHC services other than overhead services) and line 15 (overhead services applicable to
RHC/FQHC services).
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29-9

2908
2908.

FORM CMS-222-92

05-13

WORKSHEET C - DETERMINATION OF MEDICARE PAYMENT

Use this worksheet to determine the interim all inclusive rate of payment and the total Medicare
payment due you for the reporting period.
2908.1 Part I - Determination of Rate For RHC/FQHC Services.--Use Part I to calculate the cost
per visit for RHC/FQHC services and to apply the screening guideline established by CMS on
your health care staff productivity.
Line 1.--Enter the total allowable cost from Worksheet B, Part II, line 16.
Line 2.--Enter the total cost of pneumococcal and influenza vaccine from Supplemental
Worksheet B-1, line 15.
Line 3.--Subtract the amount on line 2 from the amount on line 1 and enter the result.
Line 4.--Enter the greater of the minimum or actual visits by the health care staff from Worksheet
B, Part I, column 5, line 8.
Line 5.--Enter the visits made by physicians under agreement from Worksheet B, Part I, column
5, line 9.
Line 6.--Enter the total adjusted visits (sum of lines 4 and 5).
Line 7.--Enter the adjusted cost per visit. This is determined by dividing the amount on line 3 by
the visits on line 6.
Lines 8 through 18.--Complete columns 1 and 2 of lines 8 through 18 to identify costs and visits
affected by different payment limits during a cost reporting period. For lines 11 through 18,
enter in column 3 the sum of columns 1 and 2 (and 2.01, if applicable). Enter the rates and the
corresponding data chronologically in the appropriate column as they occur during the cost
reporting period. For example, if only one payment limit is applicable during the cost reporting
period complete column 1 only. Column 2 can be subscripted to accommodate the possibility of
three per visit limits during a cost reporting period.
For services rendered from January 1, 2010, through December 31, 2013, the maximum rate per
visit entered on line 8 and the outpatient mental health treatment service limitation applied on
line 15 both correspond to the same time period (partial calendar year). Consequently, both are
entered in the same column and no further subscripting of the columns are necessary.
Line 8.--Enter the maximum rate per visit that can be received by you. Obtain this amount from
PM A-03-21 or from your contractor.
Line 9.--Enter the lesser of the amount on line 7 or line 8.
2908.2 Part II - Determination of Total Payment.--Use Part II to determine the total Medicare
payment due you for covered RHC/FQHC services furnished to Medicare beneficiaries during
the reporting period.
Line 10.--Enter the rate for Medicare covered visits from line 9.
Line 11.--Enter the number of Medicare covered visits excluding visits subject to the outpatient
mental health services limitation from your contractor records.
Line 12.--Enter the subtotal of Medicare cost. This cost is determined by multiplying the rate per
visit on line 10 by the number of visits on line 11 (the total number of covered Medicare
beneficiary visits for RHC/FQHC services during the reporting period).
29-10

Rev. 11

05-13

FORM CMS-222-92

2908.2 (Cont.)

Line 13.--Enter the number of Medicare covered visits subject to the outpatient mental health
services limitation from your contractor records.
Line 14.--Enter the Medicare covered cost for outpatient mental health services by multiplying the
rate per visit on line 10 by the number of visits on line 13.
Line 15.--Enter the limit adjustment. In accordance with MIPPA 2008, section 102, the outpatient
mental health treatment service limitation applies as follows: For services rendered through
December 31, 2009, the limitation is 62.50 percent; services from January 1, 2010, through
December 31, 2011, the limitation is 68.75 percent; services from January 1, 2012, through
December 31, 2012, the limitation is 75 percent; services from January 1, 2013, through December
31, 2013, the limitation is 81.25 percent; and services on or after January 1, 2014, the limitation is
100 percent. This is computed by multiplying the amount on line 14 by the corresponding
outpatient mental health treatment service limit percentage. This limit applies only to therapeutic
services not initial diagnostic services.
Line 15.10.--Enter the total allowable GME pass-through costs determined by dividing Medicare
visits performed by interns and residents (from Worksheet S, Part I, column 2, line 8.50) by the
total intern and resident visits (from Worksheet S, Part I, column 3, line 8.50) and multiply that
result by (the sum of the total allowable GME cost reported on Worksheet A, column 7, line 20.50
and allowable GME overhead reported on Worksheet B, Part II, line 14.01). NOTE: If
Worksheet S, Part I, line 8.50, column 1 is “N”, GME pass-through costs on this line must be
zero.
Line 16.--Enter the total Medicare cost. This is equal to the sum of the amounts on lines 12, 15,
and 15.10.
Line 17.--Enter the amount credited to the RHC’s Medicare patients to satisfy their deductible
liabilities on the visits on lines 11 and 13 as recorded by the contractor from clinic bills processed
during the reporting period. RHCs determine this amount from the provider statistical and
reimbursement (PS&R) report. FQHCs enter zero on this line as deductibles do not apply.
Line 18.--Enter the net Medicare cost. This is equal to the result of subtracting the amount on line
17 from the amount on line 16. Enter in column 3 the sum of the amounts in columns 1 and 2.
NOTE: Section 4104 of ACA eliminates coinsurance and deductible for preventive services,
effective for dates of service on or after January 1, 2011. RHCs and FQHCs must provide detailed
healthcare common procedure coding system (HCPCS) coding for preventive services to ensure
coinsurance and deductible are not applied. Providers must maintain this documentation in order
to apply the appropriate reductions on lines 18.03 and 18.04. For cost reporting periods that
overlap or begin on or after January 1, 2011, providers must complete lines 18.01 through 18.06.
Line 18.01.--Enter the total Medicare charges from the contractor’s records (PS&R report). For
cost reporting periods that overlap January 1, 2011, do not complete the column associated with
services rendered prior to January 1, 2011, and enter total program charges in the column
associated with services rendered on or after January 1, 2011. For cost reporting periods
beginning on or after January 1, 2011, enter total program charges in each column, as applicable.
Line 18.02.--Enter the total Medicare preventive charges from the provider’s records. For cost
reporting periods that overlap January 1, 2011, do not complete the column associated with
services rendered prior to January 1, 2011, and enter total program preventive charges in the
column associated with services rendered on or after January 1, 2011. For cost reporting periods
beginning on or after January 1, 2011, enter total program preventive charges in each column, as
applicable.
Line 18.03.--Enter the total Medicare preventive costs. For cost reporting periods that overlap
January 1, 2011, do not complete the column associated with services rendered prior to January 1,
2011, and enter the total program preventive costs ((line 18.02 divided by line 18.01) times line
16)) in the column associated with services rendered on or after January 1, 2011. For cost
reporting
Rev. 11
29-11

2908.2 (Cont.)

FORM CMS-222-92

05-13

periods beginning on or after January 1, 2011, enter the total program preventive costs ((line
18.02 divided by line 18.01) times line 16)) in each column, as applicable.
Line 18.04.--Enter the total Medicare non-preventive costs. For cost reporting periods that
overlap January 1, 2011, do not complete the column associated with services rendered prior to
January 1, 2011, and enter the total program non-preventive costs ((line 18 minus line 18.03)
times .80)) in the column associated with services rendered on or after January 1, 2011. For cost
reporting periods beginning on or after January 1, 2011, enter the total program non-preventive
costs ((line 18 minus line 18.03) times .80)) in each column, as applicable.
Line 18.05.--Enter the net Medicare costs. For cost reporting periods that overlap January 1,
2011, enter total program costs (line 18 times .80) in column 1, and enter the sum of lines 18.03
and 18.04, in column 2, as applicable. For cost reporting periods beginning on or after January 1,
2011, enter the sum of lines 18.03 and 18.04, in each column, as applicable.
Line 18.06.--Enter the coinsurance amount applicable to the RHC or FQHC for program patient
visits on lines 11 and 13 as recorded by the contractor from clinic bills processed during the
reporting period. This line is captured for informational and statistical purposes only. This line
does not impact the settlement calculation.
Line 19.--Enter 80 percent of the amount on line 18, column 3. Do not use this line for cost
reporting periods that overlap or begin on or after January 1, 2011.
Line 20.--Enter the Medicare cost of pneumococcal and influenza vaccines and their
administration from Worksheet B-1, line 16.
Line 20.50.--Enter any other adjustment. Specify the adjustment in the space provided.
Line 21.--Enter the total reimbursable Medicare cost. For cost reporting periods ending before
January 1, 2011, enter the sum of the amounts on lines 19 and 20. For cost reporting periods that
overlap or begin on or after January 1, 2011, enter the sum of the amounts on lines 18.05, column
3, plus, 20 and 20.50.
Line 22.--Enter the total payments made to you for covered services furnished to Medicare
beneficiaries during the reporting period (from contractor records).
Line 23.--This is equal to the result of subtracting the amount on line 22 from the amount on line
21.
Line 24.--Enter your total reimbursable bad debts, net of recoveries, from your records.
Line 24.01.--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount
is reported for statistical purposes only. These amounts also are included on line 24. (4/1/2004b)
Line 24.02.--FOR CONTRACTOR USE ONLY--Enter contractor/contractor tentative and final
settlements on this line.
Line 24.10.--For cost reporting periods that begin prior to October 1, 2012, enter the amount
from line 24. For cost reporting periods that begin on or after October 1, 2012, enter the result
of line 24 (including negative amounts) times 88 percent, 76 percent for cost reporting periods
that begin on or after October 1, 2013, and 65 percent for cost reporting periods that begin on
or after October 1, 2014.
Line 24.11--For cost reporting periods that overlap or begin on or after April 1, 2013, enter the
sequestration adjustment amount as (2 percent times (total days in the cost reporting period that
occur during the sequestration period beginning on or after April 1, 2013, divided by total days
in the entire cost reporting period, rounded to four decimal places)) times the sum of lines 21
and 24.10.
29-11.1
Rev. 11

05-13

FORM CMS-222-92

2908.2 (Cont.)

Line 25.--Enter the total amount due to/from the Medicare program (sum of lines 23 and 24.10
minus lines 24.02 and 24.11). This is the amount of the payment reconciliation.

Rev. 11

29-11.2

2908.3 (Cont.)

FORM CMS-222-92

05-13

This page is reserved for future use.

29-11.3

Rev. 11

2908.2 (Cont.)

FORM CMS-222-92

11-11

Line 18.04.--Enter the total Medicare non-preventive costs. For cost reporting periods that
overlap January 1, 2011, do not complete the column associated with services rendered prior to
January 1, 2011, and enter the total program non-preventive costs ((line 18 minus line 18.03)
times .80)) in the column associated with services rendered on or after January 1, 2011. For cost
reporting periods beginning on or after January 1, 2011, enter the total program non-preventive
costs ((line 18 minus line 18.03) times .80)) in each column, as applicable.
Line 18.05.--Enter the net Medicare costs. For cost reporting periods that overlap January 1,
2011, enter total program costs (line 18 times .80) in column 1, and enter the sum of lines 18.03
and 18.04, in column 2, as applicable. For cost reporting periods beginning on or after January 1,
2011, enter the sum of lines 18.03 and 18.04, in each column, as applicable.
Line 18.06.--Enter the coinsurance amount applicable to the RHC or FQHC for program patient
visits on lines 11 and 13 as recorded by the contractor from clinic bills processed during the
reporting period. This line is captured for informational and statistical purposes only. This line
does not impact the settlement calculation.
Line 19.--Enter 80 percent of the amount on line 18, column 3. Do not use this line for cost
reporting periods that overlap or begin on or after January 1, 2011.
Line 20.--Enter the Medicare cost of pneumococcal and influenza vaccines and their
administration from Worksheet B-1, line 16.
Line 21.--Enter the total reimbursable Medicare cost. For cost reporting periods ending before
1/1/2011, enter the sum of the amounts on lines 19 and 20. For cost reporting periods that
overlap or begin on or after January 1, 2011, enter the sum of the amounts on lines 18.05 and 20.
Line 22.--Enter the total payments made to you for covered services furnished to Medicare
beneficiaries during the reporting period (from intermediary records).
Line 23.--This is equal to the result of subtracting the amount on line 21 from the amount on line
22.
Line 24.--Enter your total reimbursable bad debts, net of recoveries, from your records.
Line 24.01.--Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount
is reported for statistical purposes only. These amounts also are included on line 24. (4/1/2004b)
Line 24.02.--FOR INTERMEDIARY/CONTRACTOR USE ONLY--Enter
intermediary/contractor tentative and final settlements on this line.
Line 25.--Enter the total amount due to/from the Medicare program (sum of lines 23 and 24 plus
or minus line 24.02). This is the amount of the payment reconciliation.

29-11.1

Rev. 10

2909
2909.

FORM CMS-222-92

03-10

SUPPLEMENTAL WORKSHEET A-2-1 - STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS

In accordance with 42 CFR 413.17, cost 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 subject to 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 you by organizations related to you. In
addition, certain information concerning the related organizations with which you have
transacted business is shown. (See CMS Pub. 15-1, chapter 10.)
2909.1 Part I - Introduction.--If there are any costs included in Worksheet A which resulted
from transactions with related organizations as defined in CMS Pub. 15-I, chapter 10, check the
"Yes" box and complete Parts II and III.
If there are no costs included in Worksheet A which resulted from transactions with related
organizations as defined in CMS Pub. 15-1, chapter 10, check the "No" box and do not complete
the rest of the form.
2909.2 Part II - Costs Incurred and Adjustments Required.--Cost 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 organizations. However,
such cost must not exceed the amount a prudent and cost conscious buyer pays for comparable
services, facilities, or supplies that are purchased elsewhere.
Complete each line as necessary and complete all columns for each of those lines.
Column 1.--Enter the line number from Worksheet A which corresponds to the cost center for
which the adjustment is being made.
Column 2.--Enter the cost center from Worksheet A for which the adjustment is being made.

29-12

Rev. 9

01-10

FORM CMS-222-92

2910

Column 3.--Enter the item of service, facility, or supplies which you obtained from the related
organization.
Column 4.--Enter the cost to your organization for the service, facility, or supplies which were
obtained from the related organization.
Column 5.--Enter the allowable cost of the service, facility, or supplies which were obtained
from the related organization. The allowable cost is the lesser of the cost of the service, facility,
or supplies to the related organization or the amount a prudent and cost conscious buyer pays for
a comparable service, facility or supply purchased elsewhere.
Column 6.--Enter the amount in column 4 minus the amount in column 5. Transfer the(se)
amount(s) to the corresponding line of Worksheet A, column 6.
2909.3 Part III - Interrelationship of Facility to Related Organization(s).-Use this part to show
your interrelationship to organizations furnishing services, facilities, or 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 with you, or control over you as defined in
CMS Pub. 15-1, chapter 10, is 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.
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 you, enter the percent of ownership.
Column 4.--Enter the name of the related organization, partnership or other organization.
Column 5.--If you or the individual indicated in column 2 has a financial interest in the related
organization, enter the percent of ownership 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.)
2910.

SUPPLEMENTAL WORKSHEET B-1 - COMPUTATION OF PNEUMOCOCCAL
AND INFLUENZA VACCINE COST

The cost and administration of pneumococcal and influenza vaccine to Medicare beneficiaries
are 100 percent reimbursable by Medicare. This worksheet provides for the computation of the
cost of the pneumococcal vaccine.
Effective for services rendered on or after September 1, 2009, the administration of influenza
H1N1 vaccines furnished by RHCs and FQHCs are cost reimbursed. However, no cost will be
incurred for the influenza H1N1 vaccine as this is provided free of charge to providers/suppliers.

Rev. 8

29-13

2910 (Cont.)

FORM CMS-222-92

01-10

To account for the cost of administering seasonal influenza vaccines, influenza H1N1 vaccines,
and/or both vaccines administered during the same patient visit, column 2 is subscripted adding
column 2.01 (administration of only H1N1 vaccines) and 2.02 (administration of both the
seasonal influenza and H1N1 vaccines during the same patient visit). The data entered in all
columns (1, 2, and applicable subscripts) for lines 4, 11, and 13 are mutually exclusive. That is,
the vaccine costs, the total number of vaccines administered, and the total number of Medicare
covered vaccines shall only be represented one time in the appropriate column. Columns 2.01
and 2.02 will not reflect the cost of H1N1 vaccines as it is furnished at no cost to the provider.
However, the cost of seasonal influenza vaccines are required in columns 2 and 2.02, line 4.
Line 1.--Enter the health care staff cost from Worksheet A, column 7, line 12.
Line 2.--Enter the ratio of the estimated percentage of time involved in administering
pneumococcal and influenza vaccine injections to the total health care staff time. Do not include
physician service under agreement time in this calculation.
Line 3.--Multiply the amount on line 1 by the amount on line 2 and enter the result.
Line 4.--Enter the cost of pneumococcal and influenza vaccine medical supplies from your
records.
Line 5.--Enter the sum of lines 3 and 4.
Line 6.--Enter the amount on Worksheet A, column 7, line 25. This is your total direct cost of
the facility.
Line 7.--Enter the amount from Worksheet A, column 7, line 50.
Line 8.--Divide the amount on line 5 by the amount on line 6 and enter the result.
Line 9.--Multiply the amount on line 7 by the amount on line 8 and enter the result.
Line 10.--Enter the sum of the amounts on lines 5 and 9. Transfer this amount to Worksheet C,
Part I, line 2.
Line 11.--Enter the total number of pneumococcal and influenza vaccine injections from your
records.
Line 12.--Enter the cost per pneumococcal and influenza vaccine injection by dividing the
amount on line 10 by the number on line 11 and entering the result.
Line 13.--Enter the number of pneumococcal and influenza vaccine injections from your records.
Line 14--Enter the cost per pneumococcal and influenza vaccine injection by multiplying the
amount on line 12 by the amount on line 13.
Line 15--Enter the total cost of pneumococcal and influenza vaccine and its (their) administration
and the administration of H1N1 vaccines by entering the sum of the amount in column 1, line 10
and the amount in column 2 (and applicable subscripts), line 10. Transfer this amount to
Worksheet C, Part I, line 2.
Line 16--Enter the Medicare cost of pneumococcal and influenza vaccine and its (their)
administration and the administration of H1N1 vaccines. This is equal to the sum of the amount
in column 1, line 14 and column 2 (and applicable subscripts), line 14. Transfer the result to
Worksheet C, Part II, line 20.

29-14

Rev. 8

01-05

FORM CMS-222-92

2990

EXHIBIT 1- Form CMS-222-92
The following is a listing of the Form CMS –222-92 worksheets and the page number location.
Worksheets
Wkst. S, Part I
Wkst. S, Parts I (Cont.) & II
Wkst. S, Part III
Wkst. A, Page 1
Wkst. A, Page 2
Wkst. A-1
Wkst. A-2
Wkst. B, Parts I & II
Wkst. C, Part I
Wkst. C, Part II
Supp. Wkst. A-2-1, Parts I-III
Supp. Wkst. B-1

Rev. 7

Page(s)
29-303
29-304
29-304.1
29-305
29-306
29-307
29-308
29-309
29-310
29-311
29-312
29-313

29-301

01-05

FORM CMS 222-92

2995

EXHIBIT 2-ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE OF CONTENTS
Topic

Page(s)

Table 1:

Record Specifications

29-503 - 29-509

Table 2:

Worksheet Indicators

29-510 - 29-511

Table 3:

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

29-512 - 29-518

Table 3A:

Worksheets Requiring No Input

29-518

Table 3B:

Lines That Cannot Be Subscripted

29-518

Table 3C:

Table to Worksheet S

29-519

Table 3D:

Table to Worksheet S

29-519

Table 4:

Reserved for future use

Table 5:

Cost Center Coding

Table 6:

Edits:

Rev. 7

29-520 - 34-524

Level I Edits

29-525 - 29-527

Level II Edits

29-528 - 29-529

29-501

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
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) 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 contractors is a 3½”
diskette, compact diskettes (CDs), or a flash drive. 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
123456789012345678901234567890123456789012345678901234567890
1
1
213975200909120100904A99P00120101202009274
1
2
14:30
Record #1:
This is a cost report file submitted by Provider 213975 for the period from April 1,
2009 (2009091) through March 31, 2010 (2010090). It is filed on FORM CMS-222-92. 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 independent rural health
clinic facility on April 30, 2010 (2010120). The electronic cost report specification dated
October 1, 2009 (2009274) is used to prepare this file.
FILE NAMING CONVENTION
Name each cost report file in the following manner:
RFNNNNNN.YYL, where
1. RF (Independent Rural Health Clinic or Federally Qualified Health Center Electronic Cost
Report) is constant;
2. NNNNNN is the 6 digit Medicare independent rural health clinic or federally qualified health
center provider number;
3. YY is the year in which the provider's cost reporting period ends; and
4. L is a character variable (A-Z) to enable separate identification of files from independent
RHC/FQHC facility with two or more cost reporting periods ending in the same calendar year.

Rev. 11

29-503

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Number 1
Size Usage
Loc.
Remarks
1.

Record Type

Constant "1"

NPI

2-11

Numeric only

Spaces

Record Number

Spaces

14-16

RHC/FQHC
Provider Number

17-22

Field must have 6 numeric characters.

Fiscal Year
Beginning Date

23-29

YYYYDDD - Julian date; first day
covered by this cost report

Fiscal Year
Ending Date

30-36

YYYYDDD - Julian date; last day
covered by this cost report

MCR Version

Constant "4" (for FORM CMS-22292)

10.

Vendor Code

38-40

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

11.

Vendor Equipment

P = PC; M = Main Frame

12.

Version Number

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

45-51

YYYYDDD – Julian date; date on
which the file was created (extracted
from the cost report)

14.

ECR Spec. Date

52-58

YYYYDDD – Julian date; date of
electronic cost report specifications
used in producing each file. Valid for
cost reporting periods beginning on or
after 2012275 (10/1/2012). Prior
approval(s) 2005090, 2009274 and
2011001.

29-504

Constant "1"

Rev. 11

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 1 Records - Record Numbers 2 - 99
Size Usage
Loc.
Remarks
1.

Record Type

Constant "1"

Spaces

2-11

Record Number

Spaces

14-20

Spaces (optional)

ID Information

21-60

Left justified to position 21.

#2 - The time that the ECR file is
created. This is represented in military
time as alpha numeric. Use positions
21-25. Example 2:30 PM is expressed
as 14:30.
#3-99 - Reserved for future use.

RECORD NAME: Type 2 Records for Labels
Size Usage

Loc.

Remarks

Record Type

Constant "2"

Wkst. Indicator

2-8

Alphanumeric. Refer to Table 2.

Spaces

9-10

Line Number

11-13

Numeric

Subline Number

14-15

Numeric

Column Number

16-18

Alphanumeric

Subcolumn Number

19-20

Numeric

Cost Center Code

21-24

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

Labels/Headings
a. Line Labels

25-60

Alphanumeric, left justified

b. Column Headings
Statistical Basis
& Code

21-30

Alphanumeric, left justified

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); and (2) 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. 11

29-505

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 1 - RECORD SPECIFICATIONS
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
8
13
14
17
18
19
20
20.50
26
27
28
29
30
31
32
33
38
39
40
41
42
43
44
45
51
52
53
53.50

29-506

Description
PHYSICIAN
PHYSICIAN ASSISTANT
NURSE PRACTITIONER
VISITING NURSE
OTHER NURSE
CLINICAL PSYCHOLOGIST
CLINICAL SOCIAL WORKER
LABORATORY TECHNICIAN
PHYSICIAN SERVICES UNDER AGREEMENT
PHYSICIAN SUPERV UNDER AGREEMENT
MEDICAL SUPPLIES
TRANSPORTATION (HEALTH CARE STAFF)
DEPRECIATION-MEDICAL EQUIPMENT
PROFESSIONAL LIABILITY INSURANCE
ALLOWABLE GME PASS THROUGH COSTS
RENT
INSURANCE
INTEREST ON MORTGAGE OR LOANS
UTILITIES
DEPRECIATION-BUILDINGS AND FIXTURES
DEPRECIATION-EQUIPMENT
HOUSEKEEPING AND MAINTENANCE
PROPERTY TAX
OFFICE SALARIES
DEPRECIATION-OFFICE EQUIPMENT
OFFICE SUPPLIES
LEGAL
ACCOUNTING
INSURANCE
TELEPHONE
FRINGE BENEFITS AND PAYROLL TAXES
PHARMACY
DENTAL
OPTOMETRY
NON-ALLOWABLE GME PASS THROUGH COSTS

Rev. 11

01-05

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 1 - RECORD SPECIFICATIONS
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

Rev. 7

1
2
8
17
19
26

0100PHYSICIAN
0200PHYSICIAN ASSISTANT
0800LABORATORY TECHNICIAN
1700MEDICAL SUPPLIES
1900DEPRECIATION-MEDICAL EQUIPMENT
2600RENT

29-507

2995 (Cont.)

FORM CMS 222-92

01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 1 - RECORD SPECIFICATIONS
RECORD NAME: Type 3 Records for Nonlabel Data
Size

Usage

Loc.

Remarks

Record Type

Wkst. Indicator

2-8

Spaces

9-10

Line Number

11-13

Numeric

Subline Number

14-15

Numeric

Column Number

16-18

Alphanumeric

Subcolumn
Number

19-20

Numeric

Field Data
36

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.

57-60

Spaces (optional).

21-36

Right justified. May contain
embedded decimal point. Leading
zeros are suppressed; trailing zeros to
the right of the decimal point are not.
(See example below.) Positive values
are presumed; no “+” signs are
allowed. Use leading minus to specify
negative values unless the field is
defined as negative on the form.
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

29-508

5
8
17

1
1
2

20502
46347
469

Rev. 7

01-05

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
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-1, columns 3 and 6
Worksheet A-2, column 4
Worksheet A-2-1, Part II, column 1
Examples of records (*) with a Worksheet A line number as data are below.
3A100010
3A100010
3A100010
3A100010
3A100010
3A100010

1
1
1
1
1
1

0
1
3
4
6
7

NON-RHC PHYSICIAN COMPENSATION
AA
58.00
121656
1.00
121656

7
7
7

1
2
4

3A200000
3A200000
3A200000

3A210002
3A210002
3A210002
3A210002

1
1
1
1

1
3
4
5

17.00
LATEX GLOVES
325
280

*
*

-1993
26.00

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.

Rev. 7

29-509

2995(Cont.)

FORM CMS 222-92

01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
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-2-1. For Worksheet A-1, 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.
Worksheets That Apply to the Rural Health Clinic/Federally Qualified Health Center Cost
Report
Worksheet
S, Part I
S, Part III
A
A-1
A-2
B, Part I
C, Part I
A-2-1, Part 1
A-2-1, Part 2
A-2-1, Part 3
B-1

29-510

Worksheet Indicator
S000001
S000013
A000000
A100010
A200000
B000001
C000001
A210001
A210002
A210003
B100000

(a)
(a)

(b)
(b)

Rev. 7

01-05

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 2 - WORKSHEET INDICATORS
FOOTNOTES:
(a) Multiple Worksheets for Reclassifications and Consolidated Cost Reports
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 S, Part III and
A-1. 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) Worksheets With Multiple Parts Using Identical Worksheet Indicator
Although some worksheets have multiple parts, the lines are numbered sequentially. In these
instances, the same worksheet identifier is used with all lines from this worksheet regardless
of the worksheet part. This differs from the Table 3 presentation, which still identifies each
worksheet and part as they appear on the printed cost report. This affects Worksheets B and
C.

Rev. 7

29-511

2995 (Cont.)

FORM CMS 222-92

01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
This table identifies those data elements necessary to calculate a independent renal dialysis cost
report. It also identifies some figures from a completed cost report. These calculated fields (e.g.,
Worksheet B, column 8) are needed to verify the mathematical accuracy of the raw data elements
and to isolate differences between the file submitted by the independent renal dialysis facility 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.

29-512

Rev. 7

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET S, PART I
Name
Street
P.O. Box
City
State
Zip Code
County
Provider Number (999999)
Designation (R for Rural or U for Urban)
Cost reporting period beginning date
(MM/DD/YYYY)
Cost reporting period ending date (MM/DD/YYYY)
Type of control (See Table 3C)
Type of Provider
Date Certified (MM/DD/YYYY)
Source of Federal Funds (See Table 3D)
Grant Award Number
Date of Grant (MM/DD/YYYY)
Name of Physicians Furnishing Services
Name of Physician
Billing Number
Supervisor Physician
Name
Hours of Supervision For Reporting Period
Are you claiming allowable GME costs? Y or N.
If yes, enter the number of Medicare visits in column
2 and total visits in column 3
Have you received an approval for an exception to
the productivity standard? Enter Y or N.
Does the facility operate as other than a RHC or
FQHC? Enter “Y” for yes or “N” for no.
If yes, specify what type of operation, (i.e. physicians
office, independent laboratory).
Identify days and hours of operation (from/to) by
listing the time the facility operates as an RHC or
FQHC next to the applicable day. *
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Rev. 11

1
1.01
1.01
1.02
1.02
1.02
1.03
2
3

1
1
2
1
2
3
1
1
1

36
36
9
36
2
10
36
6
1

X
X
X
X
X
X
X
9
X

4
5
5
5
6
6
6

2
1
3
4
1
3
4

10
2
1
10
1
20
10

X
9
X
X
9
X
X

7.01-7.30
7.01-7.30

1
2

36
36

X
X

8.01-8.30
8.01-8.30
8.50

1
2
1

36
6
1

X
9
X

8.50

2,3

8.51

1,2
1,2
1,2
1,2
1,2
1,2
1,2

4
4
4
4
4
4
4

9
9
9
9
9
9
9

11.01
11.02
11.03
11.04
11.05
11.06
11.07

29-513

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET S, PART I (Continued)
Identify days and hours (from/to) by listing the time
the facility operates as other than an RHC or FQHC
next to the applicable day. *
Sunday

12.01

1,2

Monday

12.02

1,2

Tuesday

12.03

1,2

Wednesday

12.04

1,2

Thursday

12.05

1,2

Friday

12.06

1,2

Saturday

12.07

1,2

If this is a low or no Medicare utilization cost report,
enter “L” for low or “N” for no Medicare utilization
(L/N).

Is this facility filing a consolidated cost report? Enter
“Y” for yes or “N” for no.

If “Y” for question 14, then enter the number of
additional providers filing under the consolidated
cost report option (excluding the main provider).

1
2
2
3
3
3
4
5
6
6

1
1
2
1
2
3
1
1
1
2

36
36
9
36
2
10
36
6
1
10

X
X
X
X
X
X
X
X
X
X

7.01-7.30
7.01-7.30

1
2

36
36

X
X

8.01-8.30
8.01-8.30

1
2

36
6

X
9

WORKSHEET S, PART III
Name
Street
P.O. Box
City
State
Zip Code
County
Provider Number (xxxxxx)
Designation (R for Rural or U for Urban)
Date Certified (MM/DD/YYYY)
Name of Physicians Furnishing Services
Name of Physician
Billing Number
Supervisor Physician
Name
Hours of Supervision For Reporting Period
Does the facility operate as other than a RHC or
FQHC? Enter “Y” for yes or “N” for no.

29-514

Rev. 11

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

FIELD
SIZE

USAGE

11.01
11.02
11.03
11.04
11.05
11.06
11.07

1,2
1,2
1,2
1,2
1,2
1,2
1,2

4
4
4
4
4
4
4

9
9
9
9
9
9
9

12.01
12.02
12.03
12.04
12.05
12.06
12.07

1,2
1,2
1,2
1,2
1,2
1,2
1,2

4
4
4
4
4
4
4

9
9
9
9
9
9
9

LINE(S)

COLUMN(S)

WORKSHEET S, PART III (Continued)
If yes, specify what type of operation, (i.e. physicians
office, independent laboratory).
Identify days and hours (from/to) by listing the time
the facility operates as an RHC or FQHC next to the
applicable day.*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Identify days and hours (from/to) by listing the time
the facility operates as other than an RHC or FQHC
next to the applicable day.*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

* Enter the time based on a 24 hour clock. For example 8:30 am is 0830 and 5:00 pm is 1700.

WORKSHEET A
Physicians salaries by department
Total compensation
Other costs by department
Total other costs
Net expenses by department
Total expenses

Rev. 11

1-11,13-15,1723,20.50,26-36,3848,51-56, 53.50,58-60

-9

1-11,13-15,17-23,
20.50,26-36,38-48,5156,53.50,58-60

-9

62
1-11,13-15,17-23,
20.50,26-36,38-48,5156, 53.50,58-60
62

29-515

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET A-1
For each expense reclassification:
Explanation

1-35

Reclassification identification code

1-35

Worksheet A line number

1-35

9(3).99

Reclassification amount

1-35

Worksheet A line number

1-35

9(3).99

Reclassification amount

1-35

4,7

Increases:

Decreases:

Total increases and decreases

36
WORKSHEET A-2

Description of adjustment
Basis (A or B)
Amount
Worksheet A line number

1,4,5,7-11

1-5,7-11

-9

1-5,7,8,11

9(3).99

SUPPLEMENTAL WORKSHEET A-2-1
Part I - Are there any related organization costs
included on Worksheet A? (Y/N)

Worksheet A line number

1-4

9(3).99

Expense item(s)

1-4

Amount included in Worksheet A

1-4

-9

Amount allowable in reimbursable
cost

1-4

-9

1-4

Part II - For costs incurred and adjustments required
as a result of transactions with related
organization(s):

Part III - For each related organization:
Type of interrelationship (A
through G)

29-516

Rev. 11

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

SUPPLEMENTAL WORKSHEET A-2-1 (Continued)
If type is G, specify description of
relationship

1-4

Name of related individual or
organization

1-4

Percentage of ownership

1-4

9 (3).99

1-4

Percentage of ownership of provider

1-4

9(3).99

Type of business

1-4

1
2
3
5

6
11
11
11

9(3).99
9
9
9

1,2,2.01

9(3).99

Name of related individual or
organization

WORKSHEET B-PART I
Position by department:
Number of Full Time Equivalent Personnel
Total Visits
Productivity Standard (see instructions)
Greater of columns 2 or 4

1-3,5-7
1-3,5-7,9
1-3
4

WORKSHEET C-PART I
Maximum Rate Per Visit

WORKSHEET C-PART II
Medicare Covered Visits Excluding Mental
Health Services

1,2,2.01

Medicare Covered Visits For Mental Health
Services

1,2,2.01

Beneficiary Deductibles

1,2,2.01

Total Program Cost

1,2,2.01

Total Program Charges

18.01

1,2,2.01

Total Program Preventative Charges

18.02

1,2,2.01

Total Net Program Cost

18.05

1,2,2.01

Beneficiary Coinsurance

18.06

1,2,2.01

Rev. 11

29-517

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
DESCRIPTION

LINE(S)

COLUMN(S)

FIELD
SIZE

USAGE

WORKSHEET C-PART II
Payments to RHC/FQHC during Reporting
Period

Total Reimbursable Bad Debts, Net of
Recoveries

-9
9

Total Gross Reimbursable Bad Debts for Dual
Eligible Beneficiaries

24.01

Adjusted reimbursable bad debts (see
instructions)

24.10

-9

Sequestration adjustment amount

24.11

Total Amount Due To/From The Medicare
Program

29-518

Rev. 11

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 3 - LIST OF DATA ELEMENTS WITH WORKSHEET, LINE, AND COLUMN
DESIGNATIONS
SUPPLEMENTAL WORKSHEET B-1
Ratio of Pneumococcal and Influenza
Vaccine Staff Time to Total Health Care
2
1,2,2.01,2.02
Staff Time

9.9(6)

Medicare supplies cost-Pneumococcal and
Influenza Vaccine (From Your Records)

1,2,2.02

Total Number of Pneumococcal and
Influenza injections (From Provider
Records)

1,2,2.01,2.02

Number of Pneumococcal and Influenza
Vaccine Injections Administered to
Medicare Beneficiaries allowable cost

1,2,2.01,2.02

TABLE 3A - WORKSHEETS REQUIRING NO INPUT
Worksheet B, Part II
TABLE 3B - LINES THAT CANNOT BE SUBSCRIPTED
(BEYOND THOSE PREPRINTED)
Worksheet
S, Part I
S, Part III
A

1-5,8.50,8.51,9,10,13,14
1-6,9,10
1-8,12-14,16-20,20.50,24-33,3742,44,49-53,53.50,57,61,62

A-1

ALL

A-2

1-10

A-2-1, Part I

A-2-1, Part II

1-3,5

A-2-1, Part III

1-3

B-Part I

1-9

B-Part II

10-14,14.01,14.02,15,16

C, Part I

1-9

C, Part II

10-15,15.10,1624,24.01,24.02,24.10,24.11,25 (except
20.50)

B-1
Rev. 11

Lines

1-16
29-518.1

2995 (Cont.)

FORM CMS-222-92

05-13

This page is reserved for future use.

29-518.2

Rev. 11

01-05

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 3C -TABLE TO WORKSHEET S
Type of Control
1 = Voluntary Nonprofit, Corporation
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Government, Federal
8 = Government, State
9 = Government, County
10 = Government, City
11 = Government, Other

Type of Provider
1= RHC
2= FQHC
TABLE 3D-TABLE TO WORKSHEET S
Source of Federal Funds
1=
2=
3=
4=
5=
6=

Rev. 7

Community Health Center(Section 330 (d), Public Health Service Act)
Migrant Health Center (Section 329 (d), Public Health Service Act)
Health Services for the Homeless (Section 340 (d), Public Health Service Act)
Appalachian Regional Commission
Look-Alikes
Other

29-519

2995 (Cont.)

FORM CMS 222-92

01-05

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
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), prepares
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:
Χ
Χ
Χ
Χ
Χ
Χ
Χ
Χ

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 29-521 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.
Additional cost center descriptions have been identified. These additional descriptions are
hereafter referred to as the nonstandard labels. Included with the some nonstandard descriptions
is an "Other . . ." designation to provide for situations where no match in meaning can be found.
Refer to Worksheet A, line 9 or 21.

29-520

Rev. 7

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
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, special purpose cost center descriptions for special purpose 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. Now, most approved
software associate the proper code, including increments as required, once a matching description
is selected. Remember to use your label. You are matching to CMS’s description only for
coding purposes.
Cost Center Coding and Line Restrictions
Use cost center codes only in designated lines in accordance with the classification of cost
center(s), e.g., lines 58 through 60 may only contain cost center codes within the
nonreimbursable services cost center category of both standard and nonstandard coding.

Rev. 11

29-521

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 5 - COST CENTER CODING
STANDARD COST CENTER DESCRIPTIONS AND CODES
CODE

USE

Physician

0100

(01)

Physician Assistant

0200

(01)

Nurse Practitioner

0300

(01)

Visiting Nurse

0400

(01)

Other Nurse

0500

(01)

Clinical Psychologist

0600

(01)

Clinical Social Worker

0700

(01)

Laboratory Technician

0800

(01)

Physician Services Under Agreement

1300

(01)

Physician Superv Under Agreement

1400

(01)

Medical Supplies

1700

(01)

Transportation (Health Care Staff)

1800

(01)

Depreciation-Medical Equipment

1900

(01)

Professional Liability Insurance

2000

(01)

Allowable GME Pass Through Costs

2050

(01)

Rent

2600

(01)

Insurance

2700

(01)

Interest on Mortgage or Loans

2800

(01)

Utilities

2900

(01)

Depreciation-Building and Fixtures

3000

(01)

Depreciation-Equipment

3100

(01)

Housekeeping and Maintenance

3200

(01)

Property Tax

3300

(01)

FACILITY HEALTH CARE STAFF COSTS

COSTS UNDER AGREEMENT

OTHER HEALTH CARE COSTS

FACILITY OVERHEAD-FACILITY COST

29-522

Rev. 11

05-13

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 5 - COST CENTER CODING-CONTINUED
STANDARD COST CENTER DESCRIPTIONS AND CODES (Continued)
CODE

USE

Office Salaries

3800

(01)

Depreciation-Office Equipment

3900

(01)

Office Supplies

4000

(01)

Legal

4100

(01)

Accounting

4200

(01)

Insurance

4300

(10)

Telephone

4400

(01)

Fringe Benefits and Payroll Taxes

4500

(01)

Pharmacy

5100

(01)

Dental

5200

(01)

Optometry

5300

(01)

Non-allowable GME Pass Through Costs

5350

(01)

FACILITY OVERHEAD-ADMINISTRATIVE COSTS

COSTS OTHER THAN RHC/FQHC SERVICES

NONSTANDARD COST CENTER DESCRIPTIONS AND CODES
CODE

USE

Other Facility Health Care Staff Costs

0900

(10)

Other Facility Health Care Staff Costs

1000

(10)

Other Facility Health Care Staff Costs

1100

(10)

1500

(10)

Other Health Care Costs

2100

(10)

Other Health Care Costs

2200

(10)

Other Health Care Costs

2300

(10)

FACILITY HEALTH CARE STAFF COSTS

COSTS UNDER AGREEMENT
Other Costs Under Arrangement
OTHER HEALTH CARE COSTS

Rev. 11

29-523

2995 (Cont.)

FORM CMS-222-92

05-13

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS 222-92
TABLE 5 - COST CENTER CODING-CONTINUED
NONSTANDARD COST CENTER DESCRIPTIONS AND CODES (Continued)
CODE

USE

Other Facility Overhead-Facility Costs

3400

(10)

Other Facility Overhead-Facility Costs

3500

(10)

Other Facility Overhead-Facility Costs

3600

(10)

Other Facility Overhead-Administrative Costs

4600

(10)

Other Facility Overhead-Administrative Costs

4700

(10)

Other Facility Overhead-Administrative Costs

4800

(10)

Other Than RHC/FQHC Service Costs

5400

(10)

Other Than RHC/FQHC Service Costs

5500

(10)

Other Than RHC/FQHC Service Costs

5600

(10)

Other Non-reimbursable Costs

5800

(10)

Other Non-reimbursable Costs

5900

(10)

Other Non-reimbursable Costs

6000

(10)

FACILITY OVERHEAD-FACILITY COSTS

FACILITY OVERHEAD-ADMINISTRATIVE COSTS

COSTS OTHER THAN RHC/FQHC SERVICES

NON-REIMBURSABLE COSTS

29-524

Rev. 11

03-10

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
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 RHC/FQHCs 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 RHC/FQHC of the cause of every exception. The edit message
generated by the vendor systems must contain the related 4 digit and 1 alpha character, where
indicated, 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
RHC/FQHCs 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. [3/31/2005]
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 independent RHC/FQHC facility provider number (record #1, positions 1722) must be valid and numeric (issued by the applicable certifying agency and
falls within the specified range). [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 the
fiscal year ending date (record #1, positions 30-36). [3/31/2005]

Rev. 9

29-525

03-10

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 6 – EDITS
Reject Code

Condition

1035

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

1050

The type 1 record #1 must be correct and the first record in the file. [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]

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 Worksheet A, there must be a corresponding type 2 record.
[3/31/2005]

1090

Fields requiring numeric data (charges, treatments, 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 4) must be on or
after March 31, 2005. [3/31/2005]

1015S

The cost report period beginning date (Worksheet S, Part I, column 1, line 4)
must precede the cost report ending date (Worksheet S, Part I, column 2, line 4).
[3/31/2005]

1020S

The independent RHC/FQHC facility name, address, provider number, and
certification date (Worksheet S, line 1, column 1(name); line 1.01, column 1
(street address); line 1.02, columns 1 (city), 2 (State), and 3 (ZIP code); line 1.03,
column 1 (county); line 2, column 1 (provider number); and line 5, column 4
(certification date), respectively) must be present and valid. [3/31/2005]

1025S

If the response to Worksheet S, Part I, line 14, column 1 is “Y”, then the facility
name, address, provider number, designation (applicable for FQHCs only,
(Worksheet S, Part I, line 5, column 3 = “2”)), and certification date (Worksheet
S, Part III, line 1, column 1; line 2, column 1; line 3, columns 1, 2, and 3; line 4,
column 1; line 5, column 1; and line 6, columns 1 and 2, respectively) must be
present and valid. [3/31/2005]

1030S

If the response to Worksheet S, Part I, line 14, column 1 is “Y”, then Worksheet
S, Part I , line 14, column 2 must be greater than 0 (zero), but if Worksheet S, Part
I, line 14, column 1 is “N”, then Worksheet S, Part I , line 14, column 2 must
equal 0 (zero). Additionally, if line 14, column 2, is greater than zero, this
number must reflect the number of consolidated facilities (Worksheet S, part III),
excluding the main provider. [12/31/2006]

1000A

All amounts reported on Worksheet A, columns 1-2, line 62, must be greater than
or equal to zero. [3/31/2005]

1020A

For reclassifications reported on Worksheet A-1 the sum of all increases (column
4) must equal the sum of all decreases (column 7). [3/31/2005]

29-526

Rev. 9

11-11

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 6 – EDITS
Reject Code

Condition

1025A

For each line on Worksheet A-1, 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-2 adjustments on lines 1-5, and 7-10, if either columns 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 line 11 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 as defined in CMS Pub.
15-I, chapter 10 (Worksheet A-2-1, Part I, column 1, line 1 is "Y"), Worksheet
A-2-1, Part II, 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 Worksheet A-2-1, Part I, column 1, line 1 is "N",
Worksheet A-2-1, Parts II and III must not be completed. [3/31/2005]

1050A

If the following amounts on Worksheet A are greater than zero, then the
corresponding FTEs and total visits on worksheet B, Part I must also be greater
than zero and vise versa:
Worksheet A, column 7,
Worksheet B, Part I, columns 1& 2,
Line:
Line:
1
1
2
2
3
3
4
5
6
6
7
7
[3/31/2005]

1055A

If the amount on Worksheet A, column 7, line 13 (Physician Services Under
Agreement) is greater than zero, then the corresponding total visits on
worksheet B, Part I, column 2, line 9 must also be greater than zero and vise
versa. [3/31/2005]

1000B

Total visits on Worksheet B, Part I (sum of column 2, lines 1-3, 5-7, & 9), must
be greater than or equal to the sum of the total Medicare covered visits on
Worksheet C, Part II, lines 11 &13, columns 1, 2, & 2.01. [3/31/2005]

1000C

The sum of Worksheet C, Part II, line 18.02, columns 1 and 2, must be less than
or equal to the sum of line 18.01, columns 1 and 2. [1/1/2011s].

Rev. 10

29-527

11-11

FORM CMS-222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
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
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

29-528

Line

Physician

Code
0100

Physician Assistant

0200

Nurse Practitioner

0300

Visiting Nurse

0400

Other Nurse

0500

Clinical Psychologist

0600

Clinical Social Worker

0700

Laboratory Technician

0800

Physician Services Under Agreement

1300

Physician Supervision Under Agreement

1400

Medical Supplies

1700

Transportation (Health Care Staff)

1800
Rev. 10

03-10

FORM CMS 222-92

2995 (Cont.)

ELECTRONIC REPORTING SPECIFICATIONS FOR FORM CMS-222-92
TABLE 6 – EDITS
Edit

Condition
Cost Center

Line

Code

Depreciation-Medical Equipment

1900

Professional Liability Insurance

2000

Rent

2600

Interest on Mortgage or Loans

2800

Utilities

2900

Depreciation-Building & Fixtures

3000

Depreciation-Equipment

3100

Housekeeping and Maintenance

3200

Property Tax

3300

Office Salaries

3800

Depreciation-Office Equipment

3900

Office Supplies

4000

Legal

4100

Accounting

4200

Insurance

4300

Telephone

4400

Fringe Benefits and Payroll Taxes

4500

Pharmacy

5100

Dental

5200

Optometry

5300

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. [3/31/2005]

2020S

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

2020A

Worksheet A-2-1, Part I, must contain a "Y" or "N" response. [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.
29-529

Rev. 9

File Type	application/pdf
File Modified	2014-08-08
File Created	2013-05-24